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Resúmenes Epistemonikos
Medwave 2018;18(5):e7258 doi: 10.5867/medwave.2018.05.7258
¿Cuáles son los beneficios y riesgos de la artroplastia total en rodillas artrodesadas?
What are the benefits and risks of total arthroplasty in arthrodesed knees?
Martín de Amesti, Luis Ortiz-Muñoz, Sebastián Irarrázaval
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Palabras clave: Artroplastia total, rodillas artrodesadas, Epistemonikos, GRADE.

Abstract

INTRODUCTION
The conversion of a previously arthrodesed knee to a total knee arthroplasty is an alternative seldom used. However, arthroplasty would provide greater functionality to the arthrodesed joint. Since it is a technically demanding procedure, not exempt from complications, there is controversy about the role of this intervention.

METHODS
To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS
We identified two systematic reviews including 10 studies overall, none of which corresponded to a randomized trial. We concluded the conversion of knee arthrodesis to total knee arthroplasty could increase the functionality, but it is not clear whether it increases the complications or if it has any impact on pain or patient satisfaction because the certainty of the evidence is very low.


 
Problem

Arthrodesis is a salvage surgical procedure, whose objective is to achieve fusion between two bones and eliminate movement of the joint between them. It is used as the last surgical option in different articular conditions, usually in the knee and hip, in order to decrease pain and to improve satisfaction. Some examples are advanced inflammatory arthritis,  tuberculosis sequelae, hemophilic arthropathies, tumoral lesions, among others. However, immobility secondary to the fusion and the subsequent overload of the adjacent joints, can lead to serious physical and psychosocial limitations.

On the other hand, total knee arthroplasty is a surgical procedure in which the damaged joint surfaces are replaced by modular prosthetic components. This procedure is currently recognized as the first option to treat severe knee osteoarthritis, with good results both in functionality and quality of life.

The objective of the arthrodesis to arthroplasty conversion is to restore the range of movement in the joint, leading to an improvement in the functionality of the patient. However, it is not a procedure that is performed frequently, since it is technically demanding and has a high rate of complications.

It is currently unclear what is the role of the conversion of arthrodesis to total knee arthroplasty.

Methods

To answer the question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others, to identify systematic reviews and their included primary studies. We extracted data from the identified reviews and reanalyzed data from primary studies included in those reviews. With this information, we generated a structured summary denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos) using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies when it is possible, a summary of findings table following the GRADE approach and a section of other considerations for decision-making. 

Key messages

  • Conversion of knee arthrodesis to arthroplasty could increase functionality, but the certainty of the evidence is low.
  • It is not clear whether conversion of knee arthrodesis to arthroplasty increases patient satisfaction or impacts on perceived pain, because the certainty of the evidence is very low.
  • It is not clear what is the frequency or magnitude of complications after conversion of knee arthrodesis to arthroplasty because the certainty of the evidence is very low.
About the body of evidence for this question

What is the evidence.
See evidence matrix  in Epistemonikos later

We found two systematic reviews [1],[2] including 10 primary studies [3],[4],[5],[6],[7],[8],[9],[10],[11],[12], none of which corresponded to a randomized trial. All primary studies were retrospective cohorts.

What types of patients were included*

All studies included patients with knee arthrodesis.The average age ranged between 39 and 68.5 years in the different studies.

The reason for arthrodesis varied between studies, predominating infectious causes and osteoarthritis.

Knees remained arthrodesed prior to arthroplasty for 9 to 25 years in average.

Eight studies exclusively included patients with surgical arthrodesis, in which an intervention is performed to produce the arthrodesis [3],[4],[5],[7],[8],[9],[11],[12] and two also included non-surgical arthrodesis, which occur as a result of joint disease (i.e. ankylosis) [6],[10].

We excluded case reports that included only one patient and studies that only considered non-surgical arthrodesis (ankylosis).

What types of interventions were included*

Different types of prosthesis were used: non-constrained [9], semiconstrained [5],[11], with posterior stabilization [5],[8],[10], constrained [9] and hinge (rotational true hinge) [5],[12], among others.

All studies compared under the assumption that each patient could be considered its own control.

What types of outcomes
were measured

The studies reported multiple outcomes, which were grouped by the systematic reviews as follows:

  • Functionality, measured with the Hospital for Special Surgery (HSS) functionality score.
  • Range of movement (degrees).
  • Satisfaction.
  • Pain.
  • Complications.

The average follow-up of the studies was 4.8 years, with a range between two and eight years.

* The information about primary studies is extracted from the systematic reviews identified, unless otherwise specified.

Summary of findings

The information on the effects of the conversion of knee arthrodesis to total knee arthroplasty is based on ten primary studies including 143 patients.

Five studies reported postoperative functionality (27 patients) [4],[8],[9],[10],[12]; five studies reported satisfaction (40 patients) [5],[6],[8],[9],[12]; four studies reported postoperative pain (88 patients) [6],[9],[10],[11] and eight studies reported complications (70 patients) [3],[4],[5],[7],[8],[9],[11],[12]. None of the reviews presented data that could be re-analyzed or pooled in a meta-analysis, so the conclusions are presented as they were presented by the systematic reviews identified.

The summary of findings is as follows:

  • The conversion of knee arthrodesis to arthroplasty might increase functionality, but the certainty of the evidence is low.
  • It is not clear what is the effect of the conversion of knee arthrodesis to arthroplasty on patient satisfaction because the certainty of the evidence is very low.
  • It is not clear what is the effect of the conversion of knee arthrodesis to arthroplasty on postoperative pain because the certainty of the evidence is very low.
  • It is not clear what is the frequency or magnitude of the complications of knee arthrodesis to arthroplasty because the certainty of the evidence is very low.

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)

Other considerations for decision-making

To whom this evidence does and does not apply

  • The evidence presented in this summary applies to patients with knee arthrodesis.
  • It does not apply to patients with arthrodesis of other joints, since the results probably differ in different joints.
About the outcomes included in this summary
  • The outcomes selected are those considered critical for decision-making according to the opinion of the authors of the summary. They coincide in general terms with those presented in the systematic reviews identified.
  • The outcome of increase in joint range was not included because it is considered as a component of functionality.
Balance between benefits and risks, and certainty of the evidence
  • It is important to emphasize that the certainty of the evidence is low or very low for all outcomes evaluated, especially because they come from observational, mostly retrospective studies. For this reason, it is not possible to make an adequate balance between benefits and risks.
Resource considerations
  • The reviews did not address the costs associated with performing the surgical procedure.
  • It is not possible to make an adequate balance between benefits and costs, due to the uncertainty associated with the former.
What would patients and their doctors think about this intervention
  • Due to the limitations of the available information, it is unlikely that the existing evidence will significantly influence the surgical decision. Although the decision must be made in a case by case basis, it is particularly important to convey this uncertainty to the patient.
  • Although the certainty of the evidence is very low, it is interesting to note that the  functional results and patient’s perception contrast with the high rate of complications reported.

Differences between this summary and other sources

  • The conclusions of this summary are consistent with those of the systematic reviews identified [1],[2].
  • No international clinical guidelines were found that addressed the question of this summary.
Could this evidence change in the future?
  • The probability that future research changes the conclusions of this summary is high, due to the existing uncertainty.
  • We did not identify ongoing trials answering this question in the International Clinical Trials Registry Platform of the World Health Organization, or systematic reviews in progress in the International Prospective Register of Systematic Reviews (PROSPERO).
How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.

Follow the link to access the interactive version: Conversion of knee arthrodesis to arthroplasty.

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier.

After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

This article is part of the Epistemonikos Evidence Synthesis project. It is elaborated with a pre-established methodology, following rigorous methodological standards and internal peer review process. Each of these articles corresponds to a summary, denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos), whose main objective is to synthesize the body of evidence for a specific question, with a friendly format to clinical professionals. Its main resources are based on the evidence matrix of Epistemonikos and analysis of results using GRADE methodology. Further details of the methods for developing this FRISBEE are described here (http://dx.doi.org/10.5867/medwave.2014.06.5997)

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

Potential conflicts of interest

The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

INTRODUCTION
The conversion of a previously arthrodesed knee to a total knee arthroplasty is an alternative seldom used. However, arthroplasty would provide greater functionality to the arthrodesed joint. Since it is a technically demanding procedure, not exempt from complications, there is controversy about the role of this intervention.

METHODS
To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS
We identified two systematic reviews including 10 studies overall, none of which corresponded to a randomized trial. We concluded the conversion of knee arthrodesis to total knee arthroplasty could increase the functionality, but it is not clear whether it increases the complications or if it has any impact on pain or patient satisfaction because the certainty of the evidence is very low.

Autores: Martín de Amesti[1,2], Luis Ortiz-Muñoz[2,3], Sebastián Irarrázaval[2,4]

Filiación:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Proyecto Epistemonikos, Santiago, Chile
[3] Centro Evidencia UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[4] Departamento de Ortopedia y Traumatología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile

E-mail: sirarraz@med.puc.cl

Correspondencia a:
[1] Centro Evidencia UC
Pontificia Universidad Católica de Chile
Diagonal Paraguay 476
Santiago
Chile

Citación: de Amesti M, Ortiz-Muñoz L, Irarrázaval S. What are the benefits and risks of total arthroplasty in arthrodesed knees?. Medwave 2018;18(5):e7258 doi: 10.5867/medwave.2018.05.7258

Fecha de envío: 10/4/2018

Fecha de aceptación: 6/9/2018

Fecha de publicación: 28/9/2018

Origen: Este artículo es producto del Epistemonikos Evidence Synthesis Project de la Fundación Epistemonikos, en colaboración con Medwave para su publicación.

Tipo de revisión: Con revisión por pares sin ciego por parte del equipo metodológico del Epistemonikos Evidence Synthesis Project.

Ficha PubMed

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  1. Jauregui JJ, Buitrago CA, Pushilin SA, Browning BB, Mulchandani NB, Maheshwari AV. Conversion of a Surgically Arthrodesed Knee to a Total Knee Arthroplasty-Is it Worth it? A Meta-Analysis. J Arthroplasty. 2016 Aug;31(8):1736-41. | CrossRef | PubMed |
  2. Kernkamp WA, Verra WC, Pijls BG, Schoones JW, van der Linden HM, Nelissen RG. Conversion from knee arthrodesis to arthroplasty: systematic review. Int Orthop. 2016 Oct;40(10):2069-2074. | PubMed |
  3. Holden DL, Jackson DW. Considerations in total knee arthroplasty following previous knee fusion. Clin Orthop Relat Res. 1988 Feb;227:223-8. | PubMed |
  4. Mahomed N, McKee N, Solomon P, Lahoda L, Gross AE. Soft-tissue expansion before total knee arthroplasty in arthrodesed joints. A report of two cases. J Bone Joint Surg Br. 1994 Jan;76(1):88-90. | PubMed |
  5. Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty. 1996 Sep;11(6):732-7. | PubMed |
  6. Naranja RJ Jr, Lotke PA, Pagnano MW, Hanssen AD. Total knee arthroplasty in a previously ankylosed or arthrodesed knee. Clin Orthop Relat Res. 1996 Oct;(331):234-7. | PubMed |
  7. Kreder HJ, Williams JI, Jaglal S, Axcell T, Stephen D. A population study in the Province of Ontario of the complications after conversion of hip or knee arthrodesis to total joint replacement. Can J Surg. 1999 Dec;42(6):433-9. | PubMed | PMC |
  8. Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty. 2000 Jun;15(4):453-60. | PubMed |
  9. Henkel TR, Boldt JG, Drobny TK, Munzinger UK. Total knee arthroplasty after formal knee fusion using unconstrained and semiconstrained components: a report of 7 cases. J Arthroplasty. 2001 Sep;16(6):768-76. | PubMed |
  10. Kim YH, Oh SH, Kim JS. Conversion of a fused knee with use of a posterior stabilized total knee prosthesis. J Bone Joint Surg Am. 2003 Jun;85-A(6):1047-50. | PubMed |
  11. Clemens D, Lereim P, Holm I, Reikerås O. Conversion of knee fusion to total arthroplasty: complications in 8 patients. Acta Orthop. 2005 Jun;76(3):370-4. | PubMed |
  12. Cho SH, Jeong ST, Park HB, Hwang SC, Kim DH. Two-stage conversion of fused knee to total knee arthroplasty. J Arthroplasty. 2008 Apr;23(3):476-9. | CrossRef | PubMed |
Jauregui JJ, Buitrago CA, Pushilin SA, Browning BB, Mulchandani NB, Maheshwari AV. Conversion of a Surgically Arthrodesed Knee to a Total Knee Arthroplasty-Is it Worth it? A Meta-Analysis. J Arthroplasty. 2016 Aug;31(8):1736-41. | CrossRef | PubMed |

Kernkamp WA, Verra WC, Pijls BG, Schoones JW, van der Linden HM, Nelissen RG. Conversion from knee arthrodesis to arthroplasty: systematic review. Int Orthop. 2016 Oct;40(10):2069-2074. | PubMed |

Holden DL, Jackson DW. Considerations in total knee arthroplasty following previous knee fusion. Clin Orthop Relat Res. 1988 Feb;227:223-8. | PubMed |

Mahomed N, McKee N, Solomon P, Lahoda L, Gross AE. Soft-tissue expansion before total knee arthroplasty in arthrodesed joints. A report of two cases. J Bone Joint Surg Br. 1994 Jan;76(1):88-90. | PubMed |

Cameron HU, Hu C. Results of total knee arthroplasty following takedown of formal knee fusion. J Arthroplasty. 1996 Sep;11(6):732-7. | PubMed |

Naranja RJ Jr, Lotke PA, Pagnano MW, Hanssen AD. Total knee arthroplasty in a previously ankylosed or arthrodesed knee. Clin Orthop Relat Res. 1996 Oct;(331):234-7. | PubMed |

Kreder HJ, Williams JI, Jaglal S, Axcell T, Stephen D. A population study in the Province of Ontario of the complications after conversion of hip or knee arthrodesis to total joint replacement. Can J Surg. 1999 Dec;42(6):433-9. | PubMed | PMC |

Kim YH, Kim JS, Cho SH. Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion. J Arthroplasty. 2000 Jun;15(4):453-60. | PubMed |

Henkel TR, Boldt JG, Drobny TK, Munzinger UK. Total knee arthroplasty after formal knee fusion using unconstrained and semiconstrained components: a report of 7 cases. J Arthroplasty. 2001 Sep;16(6):768-76. | PubMed |

Kim YH, Oh SH, Kim JS. Conversion of a fused knee with use of a posterior stabilized total knee prosthesis. J Bone Joint Surg Am. 2003 Jun;85-A(6):1047-50. | PubMed |

Clemens D, Lereim P, Holm I, Reikerås O. Conversion of knee fusion to total arthroplasty: complications in 8 patients. Acta Orthop. 2005 Jun;76(3):370-4. | PubMed |

Cho SH, Jeong ST, Park HB, Hwang SC, Kim DH. Two-stage conversion of fused knee to total knee arthroplasty. J Arthroplasty. 2008 Apr;23(3):476-9. | CrossRef | PubMed |