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Patients With Femoroacetabular Impingement Obtain Information From Low-Quality Sources Online and Are Most Interested in Conservative Treatment and Expected Recovery

Open AccessPublished:December 16, 2022DOI:https://doi.org/10.1016/j.asmr.2022.09.011

      Purpose

      To investigate the type of questions patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) are searching online and determine the type and quality of the online sources from the top results to each query by the “people also ask” Google algorithm.

      Methods

      Three search strings pertaining to FAI were carried out through Google. The webpage information was manually collected from the “People also ask” Google algorithm. Questions were categorized using Rothwell’s classification method. Each website was assessed using Journal of the American Medical Association Benchmark Criteria for source quality.

      Results

      A total of 286 unique questions were collected with their associated webpages. The most common questions included: “How do you treat femoroacetabular impingement and labral tears without surgery?” “What is the recovery process after hip arthroscopy and are there limitations after surgery?” and “How do you diagnose hip impingement and differentiate from other causes of hip pain?” The Rothwell Classification of questions were fact (43.4%), policy (34.3%), and value (20.6%). The most common webpage categories were Medical Practice (30.4%), Academic (25.8%), and Commercial (20.6%). The most common subcategories were Indications/Management (29.7%) and Pain (13.6%). Government websites had the highest average Journal of the American Medical Association score (3.42), whereas Single Surgeon Practice websites had the lowest (1.35). Conclusions: Commonly asked questions on Google regarding FAI and labral tears pertain to the indications and management of pathology as well as pain control and restrictions in activity. The majority of information is provided by medical practice, academic, and commercial sources, which have highly variable academic transparency.

      Clinical Relevance

      By better understanding which questions patients ask online, surgeons can personalize patient education and enhance patient satisfaction and treatment outcomes after hip arthroscopy.
      The sources of medical information continue to expand, and patients increasingly are using the internet with greater frequency to access information related to their health status.
      • Silver M.P.
      Patient perspectives on online health information and communication with doctors: A qualitative study of patients 50 years old and over.
      In addition to the information provided by physicians, patients are using videos, multimedia presentations, and other internet-based searches to access information about their diagnosis, prognosis, and treatment.
      • Fasulo S.M.
      • Testa E.J.
      • Lawler S.M.
      • Fitzgerald M.
      • Lowe J.T.
      • Jawa A.
      A preoperative educational video improves patient satisfaction and perceived knowledge, but not patient understanding for total shoulder arthroplasty: A randomized, surgeon-blinded study.
      While patients search through internet-based platforms for information on their orthopaedic conditions, some patients will ask their surgeon questions about the data they encounter online.
      • Fraval A.
      • Ming Chong Y.
      • Holcdorf D.
      • Plunkett V.
      • Tran P.
      Internet use by orthopaedic outpatients—current trends and practices.
      ,
      • Koenig S.
      • Nadarajah V.
      • Smuda M.P.
      • Meredith S.
      • Packer J.D.
      • Henn 3rd, R.F.
      Patients' use and perception of internet-based orthopaedic sports medicine resources.
      Across specialties, patients are increasingly using online resources to gather information. Previous research has reported that in both neurosurgery and plastic surgery, patients conducted internet searches before their surgical appointments.
      • Janik P.E.
      • Charytonowicz M.
      • Szczyt M.
      • Miszczyk J.
      Internet and social media as a source of information about plastic surgery: Comparison between public and private sector, a 2-center study.
      • Parmeshwar N.
      • Reid C.M.
      • Park A.J.
      • Brandel M.G.
      • Dobke M.K.
      • Gosman A.A.
      Evaluation of information sources in plastic surgery decision-making.
      • Samuel N.
      • Alotaibi N.M.
      • Lozano A.M.
      YouTube as a source of information on neurosurgery.
      • Alotaibi N.M.
      • Samuel N.
      • Wang J.
      • et al.
      The use of social media communications in brain aneurysms and subarachnoid hemorrhage: A mixed-method analysis.
      As these internet searches have increased in frequency, several studies have evaluated the quality of information available to patients from large online search engines.
      • Houck D.A.
      • Kraeutler M.J.
      • Belk J.W.
      • McCarty E.C.
      • Bravman J.T.
      Evaluation of information available on the internet regarding reverse total shoulder arthroplasty.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      These methods have been used to analyze the questions patients have regarding shoulder arthritis, anatomic and reverse shoulder arthroplasty,
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      • Matthews J.R.
      • Harrison C.M.
      • Hughes T.M.
      • Dezfuli B.
      • Sheppard J.
      Web page content and quality assessed for shoulder replacement.
      • Monroe E.J.
      • Selley R.S.
      • Gombera M.M.
      • et al.
      The quality and accuracy of online resources for total and reverse shoulder replacement.
      as well as hip and knee arthroplasty.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      Femoroacetabular impingement (FAI) represents a complex combination of static and dynamic changes in the biomechanics and anatomy of the hip joint resulting in loss of femoral head–neck offset (cam lesion), acetabular overcoverage (pincer lesion), or combined impingement. All of these anatomical variants can be associated with labral tears.
      • Bedi A.
      • Kelly B.T.
      Femoroacetabular impingement.
      Given the diversity of patients’ medical and educational literacy, patients may not remember to ask many of their questions during an initial clinic evaluation. Previous studies have also found that 40% to 80% of medical information provided to patients is forgotten immediately after leaving the office, and nearly 50% of retained information is incorrect.
      • Kessels R.P.
      Patients' memory for medical information.
      In these situations, patients often turn to the internet and search engines for answers. It is important for hip arthroscopists to understand the type of questions and resources that patients are using online so that they can effectively anticipate these questions in the clinical setting. Currently, there is a lack of literature highlighting the type of online information patients who are undergoing FAI are searching for regarding their condition and associated medical or surgical management.
      The purposes of this study were to investigate the type of questions patients undergoing hip arthroscopy for FAI are searching online and determine the type and quality of the online sources from the top results to each query by the “people also ask” Google algorithm. We hypothesized that patients searching for information online regarding FAI would look for information regarding disease management from low evidence-based quality websites.

      Methods

      The current study was exempt from institutional review board review at our institution. The methods for this study have been adopted from 2 previous studies, by Shen et al.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      and Sudah et al.
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      To avoid bias from personalized search results based on previous web browser history, a new Google Chrome application (Google, Inc., Mountain View, CA) with no cookies or previous queries was installed before inputting the search terms. The following search strings were then individually searched in Google: “Femoroacetabular Impingement,” “Hip Labral Tear,” and “Hip Cam Impingement.” For each of the 3 previously mentioned search queries, the “People also ask” tab was expanded by selecting the auto-generated questions in order, which leads to generation of more questions below, until approximately 100 suggested search questions appeared on the page, as previously reported to be the average number of queries needed to assess online health information with a similar protocol.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      ,
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      A freely available online program (Google Chrome Extension Scrapper, Version 1.7) was used to extract the approximately 100 questions from each search string, including the question asked and the associated website link providing the explanation. Questions that were clearly unrelated to the topic of FAI and associated pathology were excluded from the data set (i.e., “how do I treat my shoulder labral tear”). In addition, any repeat questions with the exact same phrasing and website link were eliminated to ensure there was not overcounting of the most-asked questions.
      The questions were classified based on a modified version of Rothwell’s classification system using 1 of the 3 following themes: policy, fact, or value.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      ,
      • Rothwell J.
      Mixed company: Communicating in small groups and teams.
      Questions were further categorized into 10 topics related to FAI and hip arthroscopy: Specific Activities, Timeline for Recovery, Restrictions, Technical Details, Cost, Indications/Management, Risks/Complications, Pain, Longevity, and Evaluation of Surgery (Table 1). Similar to the methodology of previous studies, the associated website for each individual question was categorized into one of the following: Commercial, Academic, Medical Practice, Single Surgeon Practice, Government, and Social Media.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      ,
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      A description and example of each website classification is illustrated in Table 2. Initial data collection was conducted by 2 independent reviewers (T.A.T and A.J.H). Discrepancies were addressed between the 2 reviewers and a third-party reviewer (B.K.) after fully and independently completing the initial data query. Interobserver reliability for question categorization and website classification was determined utilizing Cohen’s kappa coefficient.
      Table 1Rothwell’s Classification System With Subcategorization Breakdown, Definitions, and Examples of Questions That Are Asked Regarding Femoroacetabular Impingement and Hip Arthroscopy Procedures
      Type SubcategoryDefinition/Example
      FactAsk whether something is true, and to what extent,
      e.g., Where do they cut for hip arthroscopy surgery?
       Specific ActivitiesCan I drive after hip labral repair surgery?
       Timeline of RecoveryWhat is the average recovery time for hip arthroscopy surgery?
       Technical DetailsHow long does an arthroscopic hip surgery take?
       RestrictionsWhat can you not do after hip arthroscopy?
       CostHow much does femoroacetabular impingement surgery cost?
      PolicyAsk whether a certain course of action should be taken to solve a problem,
      e.g., How can I speed up recovery after hip labral repair surgery?
       Indications/ManagementWhat happens if a torn hip labrum goes untreated?
       Risks/ComplicationsCan you wait too long for arthroscopic femoroacetabular impingement surgery?
      ValueAsk for evaluation of an idea, object, or event
      e.g., Is hip arthroscopy and labral repair surgery considered a major surgery?
       PainWhy is hip impingement surgery so painful?
       LongevityHow long does a hip arthroscopy and labral repair last?
       Evaluation of SurgeryIs surgery for femoroacetabular impingement worth it?
      Table 2Website Categorization Breakdown With Definitions of Each Website Type and Associated Examples
      Website TypeExample
      AcademicWebpage hosted by an academic institution or organization
      e.g., dukehealth.org, orthoinfo.aaos.org
      CommercialWebpage hosted by a for-profit company
      e.g., orthopedia.com, athletico.com
      JournalAcademic journal publication, may be hosted by third-party site
      e.g., pubmed.com, arthroscopyjournal.com
      GovernmentGovernmental hosted webpage
      e.g., myhealth.alberta.ca, medlineplus.gov
      LegalSingle attorney, law firm, or legal advice webpage
      e.g., rosenfeldinjurylawyers.com, rossfellercasey.com
      Medical Information SiteCompany or organization for the purpose of medical information reviewed by medical professionals
      e.g., WebMD.com, healthline.com
      Medical PracticeMedical or Surgical practice of physicians
      e.g., rothmanortho.com, orthobethesda.com
      Non-medical Media SiteWebpages not specializing in medical information such as general news and social media sites
      e.g., wikipedia.com, abcnews.com
      Single Surgeon PracticeSingle surgeon practice or personal webpage
      e.g., rachelfrankmd.com
      In addition, each website was scored based on information quality using the Journal of the American Medical Association (JAMA) Benchmark Criteria.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      One point was awarded for the presence of each of the following: authorship, attribution, currency, and disclosure (Table 3). A maximum score of 4 was possible for each website. Initial data collection for the JAMA criteria was conducted by the same 2 independent reviewers (T.A.T. and A.J.H.). Any discrepancies were evaluated by the third-party reviewer (B.K.) who acted as a tiebreaker.
      Table 3Journal of American Medical Association (JAMA) Benchmark Criteria for Classifying Websites Based on Quality of Information
      Criteria(Each Criterion Receives 1 Point for a Maximum of 4 Points)
      AuthorshipClearly identifiable author and contributors with affiliations and relevant credentials present
      AttributionReferences and sources clearly listed with any copyright information disclosed
      CurrencyClearly identifiable posting date of any content as well as date of any revisions
      DisclosureWebsite ownership clearly disclosed along with any sponsorship, advertising, underwriting, and financial support
      NOTE. Definitions of each criterion are provided in the right column. One point for the presence of each of the following was determined for each website link: authorship, attribution, currency, and disclosure. A maximum score of 4 is possible for each website.

      Results

      After we removed any repeat questions, a total of 286 questions were obtained from the following search strings: 86 unique questions for “femoroacetabular Impingement,” 92 unique questions for “hip labral tear,” and 108 unique questions for “hip cam impingement.” The 3 most common asked questions were the following: How do you treat femoroacetabular impingement and labral tears without surgery? What is the recovery process after hip arthroscopy and are there limitations after surgery? How do you diagnose hip impingement and differentiate from other causes of hip pain?
      The most common questions based on Rothwell classification were “fact” (43.4%), followed by “policy” (34.3%), “value” (20.6%), and “other” (2.1%) (Table 4). When we evaluated the breakdown of each question by topic, the most common questions were “Indications/Management” (29.7%), “Other” (23.1%), “Pain” (13.6%), and “Restrictions” (8.0%) (Table 5). When we evaluated the questions based on website type, the most frequently observed were “Medical Practice” (30.4%), “Academic” (25.8%), and “Commercial” (20.6%) websites (Table 6).
      Table 4Total Number of Questions and Associated Percentage Breakdown of the 3 Main (Fact, Value, Policy) Rothwell’s Classification Groups
      Distribution of Questions by Rothwell’s Classification
      FactValuePolicyOtherTotal
      Count (%)124 (43.4)59 (20.6)98 (34.3)6 (2.1)286
      NOTE. When a question did not clearly fit into any of the 3 main categories, the “Other” option was used.
      Table 5Breakdown of Each Rothwell Subcategory With the Number of Questions in Each Category and Their Relative Percentage Presence
      Distribution of Questions by Topic
      TopicCount (%)
      Cost3 (1.0)
      Evaluation of Surgery13 (4.5)
      Indications/Management85 (29.7)
      Longevity2 (0.7)
      Pain39 (13.6)
      Restrictions23 (8.0)
      Risks/Complications14 (4.9)
      Specific Activities18 (6.3)
      Technical Details8 (2.8)
      Timeline of Recovery15 (5.2)
      Other66 (23.1)
      Total286
      NOTE. When a question did not clearly fit into any of the 10 main categories, the “Other” option was used.
      Table 6Breakdown of Each Website Type With the Number of Questions in Each Category and Their Relative Percentage Presence
      Distribution of Questions by Website Type
      TopicCount (%)
      Commercial59 (20.6)
      Academic74 (25.8)
      Medical Practice87 (30.4)
      Single-Surgeon Practice26 (9.1)
      Government19 (6.6)
      Social Media6 (2.1)
      Other15 (5.2)
      Total286
      NOTE. When a website did not clearly fit into any of the 6 main categories, the “Other” option was used.
      The mean JAMA Benchmark Criteria score for all websites was 2.15 with a standard deviation (SD) of 1.36 (Table 7). The highest mean JAMA score based on Rothwell classification was “value” 2.83 (SD = 1.17) and the lowest mean score was for “fact” 1.98 (SD = 1.29). When evaluating JAMA criteria based off website type, the highest mean scores were observed in “Government” websites 3.42 (SD = 1.07) and “Commercial” websites 3.20 (SD = 1.13), whereas the lowest scores were seen in “Medical Practice” websites 1.43 (SD = 1.11) and “Single-Surgeon” websites 1.35 (SD = 1.13) (Table 8). Cohen’s kappa coefficient for interobserver reliability showed a high level of agreement for question categorization (0.82) and for website categorization (0.90).
      Table 7Journal of American Medical Association (JAMA) Benchmark Criteria Scores Based on Rothwell’s Classification Type
      JAMA Benchmark Scores by Rothwell’s Classification
      JAMA Score
      Total websites2.15 (1.36)
      Rothwell’s Classification
       Fact1.98 (1.29)
       Value2.83 (1.17)
       Policy2.40 (1.30)
       Other2.02 (1.59)
      NOTE. One point for the presence of each of the following was determined for each website link: authorship, attribution, currency, and disclosure. A maximum score of 4 could be attained for each website. Scores listed are presented as a mean (standard deviation). When a question did not clearly fit into any of the 3 main categories, the “Other” option was used.
      Table 8Journal of American Medical Association (JAMA) Benchmark Criteria Scores Based on Website Type
      JAMA Benchmark Scores by Website Type
      TopicJAMA Score
      Commercial3.20 (1.13)
      Academic2.03 (1.30)
      Medical Practice1.43 (1.11)
      Single-Surgeon Practice1.35 (1.13)
      Government3.42 (1.07)
      Social Media2.83 (0.75)
      Other2.33 (0.82)
      NOTE. One point for the presence of each of the following was determined for each website link: authorship, attribution, currency, and disclosure. A maximum score of 4 could be attained for each website. Scores listed are presented as a mean (standard deviation). When a website did not clearly fit into any of the 6 main categories, the “Other” option was used.

      Discussion

      This study found that patients with FAI and hip labrum disease generally obtain online information from sources with poor academic reporting, most commonly hosted by medical practices, and regarding questions about indications/management of their pathology. The key findings of this study were as follows: (1) the most common question type by Rothwell classification is fact (43.4%); (2) the most common subcategories of questions are related to indications/management (29.7%), followed by pain (13.6%) and restrictions (8.0%); (3) the most frequently asked question is “How do you treat FAI and labral tears without surgery?” (4) answers to patients’ questions are most commonly found on websites hosted by medical practices (30.4%); and (5) the overwhelming majority of websites scored relatively poorly on the JAMA benchmark criteria (average = 2.15), with government sites scoring the highest (3.42) and single-surgeon practices and medical practices scoring the lowest (1.35 and 1.43, respectively).
      The majority of questions posed by patients with FAI online are classified as fact (aiming to answer if something is true, and if so, to what extent) by Rothwell (43.4%). This indicates patients are interested in obtaining objective information on their diagnosis and treatment options. The fact subcategories pertain to specific activities, the timeline of recovery, restrictions, cost, and technical details. Restrictions themselves composed 8.0% of all total questions. These results show patients are concerned about how FAI or labral tear and potential surgical intervention will affect their day-to-day lives and other practical minutiae. Arthroscopic labral repair continues to rapidly evolve since its introduction in 1986 by Suzuki et al.
      • Suzuki S.
      • Awaya G.
      • Okada Y.
      • Maekawa M.
      • Ikeda T.
      • Tada H.
      Arthroscopic diagnosis of ruptured acetabular labrum.
      There is variability in published surgical techniques and rehabilitation protocols, which can result in patient uncertainty.
      • Cvetanovich G.L.
      • Lizzio V.
      • Meta F.
      • et al.
      Variability and comprehensiveness of north american online available physical therapy protocols following hip arthroscopy for femoroacetabular impingement and labral repair.
      Patients may discover information that does not apply to their condition or is incorrect, which leads to time spent in clinic clarifying misconceptions that could be otherwise be spent explaining pertinent material. It is important for hip arthroscopists to provide patients with detailed restrictions and rehabilitation protocols following a diagnosis of FAI/labral to negate the need for patients to search online for answers, particularly given the mismatch between patient expectations of postoperative rehabilitation and their actual therapy protocol.
      • Jones D.M.
      • Kemp J.L.
      • Crossley K.M.
      • Hart H.F.
      • Ackerman I.N.
      Mismatch between expectations and physical activity outcomes at six months following hip-arthroscopy: A qualitative study.
      This is especially important for patients undergoing arthroscopic labral repair, as it has been shown that greater preoperative expectations are correlated with improved patient-reported outcomes at 1-year postoperatively.
      • Chahla J.
      • Beck E.C.
      • Nwachukwu B.U.
      • Alter T.
      • Harris J.D.
      • Nho S.J.
      Is there an association between preoperative expectations and patient-reported outcome after hip arthroscopy for femoroacetabular impingement syndrome?.
      The question category most frequently asked by patients was indications/management (29.7%). Two of the 3 most asked questions pertained to diagnosing (“How do you diagnose hip impingement and differentiate it from other causes of hip pain?”) and managing FAI/labral tears (“How do you treat femoroacetabular impingement and labral tears without surgery?”). FAI can be a difficult diagnosis for patients to comprehend, given its complexity and frequency in asymptomatic patient populations, with estimates of an incidence between 10% and 20%.
      • Sankar W.N.
      • Nevitt M.
      • Parvizi J.
      • Felson D.T.
      • Agricola R.
      • Leunig M.
      Femoroacetabular impingement: Defining the condition and its role in the pathophysiology of osteoarthritis.
      In addition, hip pain often can be confused with lower back pain, sacroiliac joint pain, pelvic floor dysfunction, and buttock or gluteal pain.
      • Chamberlain R.
      Hip pain in adults: Evaluation and differential diagnosis.
      The Warwick Agreement was created in 2016 as an international consensus agreement on the diagnosis and management of FAI; however, there still exists variation in the management of this pathology, which further disorients patients.
      • Griffin D.R.
      • Dickenson E.J.
      • O'Donnell J.
      • et al.
      The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement.
      This is highlighted in the disparity between more established arthroplasty procedures and FAI. Recent studies found indications/management to be searched only 11%, 12%, and 19% of the time in patients undergoing shoulder, knee, and hip arthroplasty, respectively.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      ,
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      The most commonly asked question online in this study, “How do you treat femoroacetabular impingement and labral tears without surgery?” attempts to address a nuanced decision of when to proceed with surgical intervention. As arthroscopic techniques evolve, the indications for surgery continue to change. Nonoperative management, including rest, activity modification, anti-inflammatory medications, corticosteroid injections, and physical therapy, is appropriate as a first-line treatment for patients with mild pathology and no mechanical symptoms. Providers should be prepared to discuss conservative treatment modalities or provide patients with educational material, or they face a high risk of patients searching online for answers to these questions and perpetuating confusion.
      Another 1 of the 3 most common questions from this study is “what is the recovery process after hip arthroscopy and are there limitations after surgery?” The goals of arthroscopic labral repair are to relieve pain, maintain hip joint function, restore the suction seal of the hip, and prevent the development of early-onset osteoarthritis.
      • Kelly B.T.
      • Weiland D.E.
      • Schenker M.L.
      • Philippon M.J.
      Arthroscopic labral repair in the hip: Surgical technique and review of the literature.
      Providers have varied postoperative rehabilitation protocols; consequently, we recommend surgeons procure materials detailing their rehabilitation protocol for patients to reference when questions arise.
      • Cvetanovich G.L.
      • Lizzio V.
      • Meta F.
      • et al.
      Variability and comprehensiveness of north american online available physical therapy protocols following hip arthroscopy for femoroacetabular impingement and labral repair.
      A source of increasingly frequent medical distortion are online patient message boards and social media. Discussion between patients online is common. Yet, FAI/labral tears possess a spectrum of disease/treatment. Patients may have similar but distinct pathology, which may lead to unrealistic expectations that may derail a patient-specific treatment plan. Pain was the second most popular search category in this study (13.6%), which is unsurprising, given impingement and labral tearing. The management of postoperative pain following hip arthroscopy is not standardized, and a study found up to 16% of providers have had to readmit a patient in the 30-day postoperative period for pain control at least once in the past year. In the same investigation, the only pain protocol that reached clinical agreement was the use of oral anti-inflammatory medications postoperatively.
      • Garcia F.L.
      • Williams B.T.
      • Maheshwer B.
      • et al.
      Pain management practice patterns after hip arthroscopy: An international survey.
      Discussing expectations preoperatively is important, as adequate pain expectations have been correlated with improved postoperative outcomes.
      • Mannion A.F.
      • Impellizzeri F.M.
      • Naal F.D.
      • Leunig M.
      Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement.
      The types of websites most encountered were from medical practices (30.4%), followed by academic groups (25.8%). These 2 website types performed poorly on the JAMA benchmark criteria analysis, scoring 1.43 and 2.03, respectively (of 4.0). The JAMA criteria were developed as tool to reflect the scientific transparency of a source and include one point each for inclusion of authorship, attribution, currency, and disclosure.
      • Silberg W.M.
      • Lundberg G.D.
      • Musacchio R.A.
      Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor—Let the reader and viewer beware.
      Of individuals seeking answers to health questions online between the ages of 15 and 30 years, approximately 80% considered the information they discovered to be reliable.
      • Beck F.
      • Richard J.B.
      • Nguyen-Thanh V.
      • Montagni I.
      • Parizot I.
      • Renahy E.
      Use of the internet as a health information resource among French young adults: Results from a nationally representative survey.
      If incomplete or incorrect information is deemed credible by patients, an awkward conversation may occur during which the surgeon must delicately correct the patient.
      • Hungerford D.S.
      Internet access produces misinformed patients: Managing the confusion.
      This conversation can put strain or mistrust in the provider–patient relationship, yet it must be had to clarify misconceptions and allow patients to make informed medical decisions. A commonly encountered hurdle in relaying complex medical knowledge to patients online is in either low-quality of available materials, or high-quality materials with complicated terminology.
      • Cassidy J.T.
      • Baker J.F.
      Orthopaedic patient information on the world wide web: An essential review.
      ,
      • Schwarz I.
      • Houck D.A.
      • Belk J.W.
      • Hop J.
      • Bravman J.T.
      • McCarty E.
      The quality and content of internet-based information on orthopaedic sports medicine requires improvement: A systematic review.
      The results of this study show that >65% of websites found by patients searching online about FAI are hosted by groups composed partly of physicians. Patients continue to use online resources at an increasing rate and are placing more trust in these resources than before; therefore, providers must ensure the content they and their practices provide online are high quality and written for a medically lay audience.
      The average JAMA score in this study was of average quality (2.15), which is similar to what has been reported in the adult reconstruction literature.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      The sites with the lowest JAMA scores were single-surgeon practices (1.35), medical practices (1.43), and academic (2.03). This shines a light on the lack of academic reporting provided by physicians on their own sites. Social media sources scored higher on the JAMA criteria (2.83), despite the common perception of social media as a source of inaccurate information and its infrequent use (2.1% of all websites in this study). Commercial, for-profit sources, which accounted for 20.6% of the websites retrieved, scored 3.20 while government sources scored the highest (3.42). It may be that nonmedical websites are motivated to provide their sources of information to validate their claims and data, whereas physicians and other medical pages do not feel the need to support their claims. Knowing the academic quality of a source allows surgeons to direct patients to accurate, easily digestible information. Still, studies continue to show that online health information is generally of low quality, and patients should defer to their provider for important medical questions.
      • Cassidy J.T.
      • Baker J.F.
      Orthopaedic patient information on the world wide web: An essential review.
      ,
      • Daraz L.
      • Morrow A.S.
      • Ponce O.J.
      • et al.
      Can patients trust online health information? A meta-narrative systematic review addressing the quality of health information on the internet.
      ,
      • Starman J.S.
      • Gettys F.K.
      • Capo J.A.
      • Fleischli J.E.
      • Norton H.J.
      • Karunakar M.A.
      Quality and content of Internet-based information for ten common orthopaedic sports medicine diagnoses.
      Future studies in this sphere should evaluate website content in further depth and examine best practices to improve the academic quality of online resources available to this patient population.

      Limitations

      Limitations inherent to a study of this methodology include the use of the JAMA benchmark criteria as an assessment of online information quality. The criteria are a proxy of transparency and publishing practices and not of content accuracy and therefore an indirect measure of webpage quality, although they have been used in previous studies of similar methodology.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      An assumption in this study is that the “people also ask” algorithm is generated based on searches conducted by real patients with FAI or labral tears. It is impossible to confirm who has conducted the searches by which the algorithm is generated. This does provide the study with the added benefit of subject anonymity as opposed to in-person surveys conducted to assess patient questions. A final limitation of this study is the use of Rothwell’s classification to determine question type. The classification was primarily designed to understand questions asked in small groups, yet previously deemed appropriate for use in classifying online questions.
      • Shen T.S.
      • Driscoll D.A.
      • Islam W.
      • Bovonratwet P.
      • Haas S.B.
      • Su E.P.
      Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
      ,
      • Sudah S.
      • Pagani N.
      • Nasra M.
      • et al.
      What patients want to know about shoulder arthroplasty: A Google search analysis.
      ,
      • Kanthawala S.
      • Vermeesch A.
      • Given B.
      • Huh J.
      Answers to health questions: Internet search results versus online health community responses.

      Conclusions

      Commonly asked questions on Google regarding FAI and labral tears pertain to the indications and management of pathology as well as pain control and restrictions in activity. The majority of information is provided by medical practice, academic, and commercial sources, which have highly variable academic transparency.

      Supplementary Data

      References

        • Silver M.P.
        Patient perspectives on online health information and communication with doctors: A qualitative study of patients 50 years old and over.
        J Med Internet Res. 2015; 17: e19
        • Fasulo S.M.
        • Testa E.J.
        • Lawler S.M.
        • Fitzgerald M.
        • Lowe J.T.
        • Jawa A.
        A preoperative educational video improves patient satisfaction and perceived knowledge, but not patient understanding for total shoulder arthroplasty: A randomized, surgeon-blinded study.
        J Shoulder Elbow Arthroplasty. 2018; 22471549218792966
        • Fraval A.
        • Ming Chong Y.
        • Holcdorf D.
        • Plunkett V.
        • Tran P.
        Internet use by orthopaedic outpatients—current trends and practices.
        Australas Med J. 2012; 5: 633-638
        • Koenig S.
        • Nadarajah V.
        • Smuda M.P.
        • Meredith S.
        • Packer J.D.
        • Henn 3rd, R.F.
        Patients' use and perception of internet-based orthopaedic sports medicine resources.
        Orthop J Sports Med. 2018; 62325967118796469
        • Janik P.E.
        • Charytonowicz M.
        • Szczyt M.
        • Miszczyk J.
        Internet and social media as a source of information about plastic surgery: Comparison between public and private sector, a 2-center study.
        Plast Reconstr Surg Glob Open. 2019; 7: e2127
        • Parmeshwar N.
        • Reid C.M.
        • Park A.J.
        • Brandel M.G.
        • Dobke M.K.
        • Gosman A.A.
        Evaluation of information sources in plastic surgery decision-making.
        Cureus. 2018; 10e2773
        • Samuel N.
        • Alotaibi N.M.
        • Lozano A.M.
        YouTube as a source of information on neurosurgery.
        World Neurosurg. 2017; 105: 394-398
        • Alotaibi N.M.
        • Samuel N.
        • Wang J.
        • et al.
        The use of social media communications in brain aneurysms and subarachnoid hemorrhage: A mixed-method analysis.
        World Neurosurg. 2017; 98: 456-462
        • Houck D.A.
        • Kraeutler M.J.
        • Belk J.W.
        • McCarty E.C.
        • Bravman J.T.
        Evaluation of information available on the internet regarding reverse total shoulder arthroplasty.
        Shoulder Elbow. 2019; 11 (suppl 2): 29-34
        • Shen T.S.
        • Driscoll D.A.
        • Islam W.
        • Bovonratwet P.
        • Haas S.B.
        • Su E.P.
        Modern internet search analytics and total joint arthroplasty: What are patients asking and reading online?.
        J Arthroplasty. 2021; 36: 1224-1231
        • Sudah S.
        • Pagani N.
        • Nasra M.
        • et al.
        What patients want to know about shoulder arthroplasty: A Google search analysis.
        Semin Arthroplasty. 2021; 32: 162-168
        • Matthews J.R.
        • Harrison C.M.
        • Hughes T.M.
        • Dezfuli B.
        • Sheppard J.
        Web page content and quality assessed for shoulder replacement.
        Am J Orthop (Belle Mead NJ). 2016; 45: E20-E26
        • Monroe E.J.
        • Selley R.S.
        • Gombera M.M.
        • et al.
        The quality and accuracy of online resources for total and reverse shoulder replacement.
        J Surg Orthop Adv. 2019; 28: 290-294
        • Bedi A.
        • Kelly B.T.
        Femoroacetabular impingement.
        J Bone Joint Surg Am. 2013; 95: 82-92
        • Kessels R.P.
        Patients' memory for medical information.
        J R Soc Med. 2003; 96: 219-222
        • Rothwell J.
        Mixed company: Communicating in small groups and teams.
        10th ed. Oxford University Press (OUP), Oxford2006
        • Suzuki S.
        • Awaya G.
        • Okada Y.
        • Maekawa M.
        • Ikeda T.
        • Tada H.
        Arthroscopic diagnosis of ruptured acetabular labrum.
        Acta Orthop Scand. 1986; 57: 513-515
        • Cvetanovich G.L.
        • Lizzio V.
        • Meta F.
        • et al.
        Variability and comprehensiveness of north american online available physical therapy protocols following hip arthroscopy for femoroacetabular impingement and labral repair.
        Arthroscopy. 2017; 33: 1998-2005
        • Jones D.M.
        • Kemp J.L.
        • Crossley K.M.
        • Hart H.F.
        • Ackerman I.N.
        Mismatch between expectations and physical activity outcomes at six months following hip-arthroscopy: A qualitative study.
        Phys Ther Sport. 2020; 45: 14-22
        • Chahla J.
        • Beck E.C.
        • Nwachukwu B.U.
        • Alter T.
        • Harris J.D.
        • Nho S.J.
        Is there an association between preoperative expectations and patient-reported outcome after hip arthroscopy for femoroacetabular impingement syndrome?.
        Arthroscopy. 2019; 35 (e1): 3250-3258
        • Sankar W.N.
        • Nevitt M.
        • Parvizi J.
        • Felson D.T.
        • Agricola R.
        • Leunig M.
        Femoroacetabular impingement: Defining the condition and its role in the pathophysiology of osteoarthritis.
        J Am Acad Orthop Surg. 2013; 21 (21 suppl 1): S7-S15
        • Chamberlain R.
        Hip pain in adults: Evaluation and differential diagnosis.
        Am Fam Physician. 2021; 103: 81-89
        • Griffin D.R.
        • Dickenson E.J.
        • O'Donnell J.
        • et al.
        The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement.
        Br J Sports Med. 2016; 50: 1169-1176
        • Kelly B.T.
        • Weiland D.E.
        • Schenker M.L.
        • Philippon M.J.
        Arthroscopic labral repair in the hip: Surgical technique and review of the literature.
        Arthroscopy. 2005; 21: 1496-1504
        • Garcia F.L.
        • Williams B.T.
        • Maheshwer B.
        • et al.
        Pain management practice patterns after hip arthroscopy: An international survey.
        J Hip Preserv Surg. 2020; 7: 537-546
        • Mannion A.F.
        • Impellizzeri F.M.
        • Naal F.D.
        • Leunig M.
        Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement.
        Osteoarthritis Cartilage. 2013; 21: 44-50
        • Silberg W.M.
        • Lundberg G.D.
        • Musacchio R.A.
        Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor—Let the reader and viewer beware.
        JAMA. 1997; 277: 1244-1245
        • Beck F.
        • Richard J.B.
        • Nguyen-Thanh V.
        • Montagni I.
        • Parizot I.
        • Renahy E.
        Use of the internet as a health information resource among French young adults: Results from a nationally representative survey.
        J Med Internet Res. 2014; 16: e128
        • Hungerford D.S.
        Internet access produces misinformed patients: Managing the confusion.
        Orthopedics. 2009; 32
        • Cassidy J.T.
        • Baker J.F.
        Orthopaedic patient information on the world wide web: An essential review.
        J Bone Joint Surg Am. 2016; 98: 325-338
        • Schwarz I.
        • Houck D.A.
        • Belk J.W.
        • Hop J.
        • Bravman J.T.
        • McCarty E.
        The quality and content of internet-based information on orthopaedic sports medicine requires improvement: A systematic review.
        Arthrosc Sports Med Rehabil. 2021; 3: e1547-e1555
        • Daraz L.
        • Morrow A.S.
        • Ponce O.J.
        • et al.
        Can patients trust online health information? A meta-narrative systematic review addressing the quality of health information on the internet.
        J Gen Intern Med. 2019; 34: 1884-1891
        • Starman J.S.
        • Gettys F.K.
        • Capo J.A.
        • Fleischli J.E.
        • Norton H.J.
        • Karunakar M.A.
        Quality and content of Internet-based information for ten common orthopaedic sports medicine diagnoses.
        J Bone Joint Surg Am. 2010; 92: 1612-1618
        • Kanthawala S.
        • Vermeesch A.
        • Given B.
        • Huh J.
        Answers to health questions: Internet search results versus online health community responses.
        J Med Internet Res. 2016; 18: e95