Journal of Orthopaedic Surgery 2013;21(3):305-7
Web-based information on minimally invasive total knee arthroplasty Sanjay Meena, Aravindh Palaniswamy, Buddhadev Chowdhury
Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
ABSTRACT Purpose. To evaluate information available on the internet regarding minimally invasive total knee arthroplasty (TKA). Methods. The 3 most popular search engines (Google, Yahoo, and MSN) were used to search the keyword ‘minimally invasive knee replacement’. The top 50 websites from each search engine were evaluated for authorship and contents; duplicate websites were not double-counted. Results. Of the 150 websites, 51% were authored by a hospital/university, 26% by private medical groups, 14% were news stories, and 9% were from orthopaedic industry sources. 73% offered the opportunity to make an appointment. 18% described the surgical technique, whereas only 9% explained patient eligibility. 25% described the risks, whereas only 3% made reference to peer-reviewed publications. >82% made specific claims regarding the advantages of minimally invasive surgery. Conclusion. Most websites providing minimally invasive TKA information were insufficient in terms
of explaining surgical technique, patient eligibility, and assoicated risks. Key words: arthroplasty, replacement, knee; internet; surgical procedures, minimally invasive
INTRODUCTION The internet has become a popular source of medical information. In 2008, an estimated 61% of adults in the United States used online sources for gathering health information. The information acquired may influence how patients manage their health with or without the aid of their doctors.1 The quality of health information on the internet is subject to commercial pressures, similar to those in print media.2 Minimally invasive total knee arthroplasty (TKA) has recently been introduced. Its proponents suggest quicker recovery, less blood loss, decreased softtissue trauma, less postoperative pain, and improved cosmetic outcomes.3–7 However, potential drawbacks include longer tourniquet time, poor component placement, and early implant failure.8–12 The potential benefits must be considered in terms of any additional
Address correspondence and reprint requests to: Dr Sanjay Meena, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, 110029, India. Email: [email protected]
Journal of Orthopaedic Surgery
306 S Meena et al.
risks caused by limited surgical exposure. This study aimed to evaluate the information available on the internet regarding minimally invasive TKA. MATERIALS AND METHODS On 24 July 2012, the 3 most popular search engines (Google, Yahoo, and MSN) were used to search the keyword ‘minimally invasive knee replacement’. The top 50 websites from each search engine were evaluated for authorship and contents; duplicate websites were not double-counted. The evaluation criteria were the same as those used in a study of minimally invasive total hip arthroplasty.13 The authorship of each website was categorised as (1) hospital or university (public or private), (2) private physician/group, (3) orthopaedic manufacturer/industry, and (4) news bulletin or story. Whether there was means to contact or make an appointment with the author or institution was noted. Whether there was a description of patient eligibility for minimally invasive TKA was noted; the description was considered adequate when there were inclusion and exclusion criteria, including age, comorbidities, and body habitus. Whether there was a description of the surgical technique (using diagrams, graphics, and/or videos) and whether there was a description of the differences between the standard and minimally invasive approaches were noted. Whether there were specific claims regarding blood loss, perioperative pain, length of hospital stay, scar length, and recovery time were noted, as were specific risks associated with both traditional and minimally invasive TKA, including general risks associated with TKA (infection, deep
venous thrombosis, bleeding, and soft tissue damage) and theoretical risks associated with a minimally invasive TKA (femural fracture, nerve injury, wound infection secondary to extensive tissue retraction, and component malposition). Whether there were references to peer-reviewed publications concerning traditional and minimally invasive TKA was also noted. RESULTS Of the 150 websites, 51% were authored by a hospital or university, 27% were by a private medical group, 14% were news stories, and 9% were from orthopaedic device manufacturers (Table). 73% of the websites offered the opportunity to contact or make an appointment with a physician or hospital group. 18% described the surgical technique, whereas only 9% explained patient eligibility. In terms of specific claims, 46% claimed less blood loss, 82% claimed less surgical scar, and 78% claimed short hospital stay. 25% described the potential risks associated with the traditional or minimally invasive TKA. Only 3% provided references to peer-reviewed publications. DISCUSSION Websites owned by private physicians were more likely to be primarily intended for marketing rather than patient education. In a study evaluating the internet regarding minimally invasive total hip arthroplasty, >50% of websites offered the option to make an online appointment, whereas only 15% explained patient eligibility criteria for the
Table Websites on minimally invasive total knee arthroplasty Parameter Authorship Hospital/university Physician/group Industry News Claimed benefits Less surgical scar Less blood loss Shorter hospital stay/better rehabilitation Purpose Description of technique Patient eligibility defined Reference to the peer-reviewed literature Ability to contact/make appointment Claimed risks
No. (%) of websites Google
Yahoo
MSN
Total
24 (48) 9 (18) 6 (12) 11 (22)
27 (54) 15 (30) 4 (8) 4 (8)
25 (50) 16 (32) 3 (6) 6 (12)
76 (51) 40 (27) 13 (9) 21 (14)
39 (78) 22 (44) 35 (70)
42 (84) 25 (50) 40 (80)
42 (84) 23 (46) 42 (84)
123 (82) 70 (46) 117 (78)
13 (26) 5 (10) 3 (6) 30 (60) 12 (24)
6 (12) 5 (10) 1 (2) 42 (84) 15 (30)
8 (16) 3 (6) 0 (0) 38 (76) 11 (22)
27 (18) 13 (9) 4 (3) 110 (73) 38 (25)
Vol. 21 No. 3, December 2013
Web-based information on minimally invasive total knee arthroplasty 307
procedure.13 In another study concerning the carpal tunnel syndrome, 33% of the websites sold commercial products to evaluate carpal tunnel syndrome, and only 23% were authored by a physician or an academic organisation.14 In addition, 50% use computers regularly, but only 7% of the websites (out of 5947) contained relevant information, and only one site gave access to peer-reviewed articles.15 The benefits of minimally invasive TKA are inconclusive. Despite a lack of convincing evidence regarding such benefits, the internet is used for directto-consumer marketing. Most claims on the websites were not substantiated by evidence-based medical practice. Regarding limitations of this study, some websites may have been judged unfairly if their targeted audience were not patients. Nonetheless, this study replicated the situation faced by patients who use search engines to access information about
knee arthroplasty. It is unlikely that they encounter only the dedicated websites. Both patients and website developers have responsibility. The internet is increasingly used by patients to learn about new surgical procedures. It is important that relevant information is accurate and in line with evidencebased medical practice. The general public must be made aware that the internet is largely unregulated, and that information may not be reliable, and its content should be viewed cautiously. Patients can search Google Scholar or MEDLINE/PubMed for the current peer-reviewed articles. These articles from medical journals are more reliable and accurate. However, payment to download and help from medical personnel to interpret them may be necessary. Website developers must be aware that their websites may be viewed by an unintended audience and therefore they should state the aims and limitations of the websites. It is the responsibility of physicians to provide adequate, peer-reviewed information without bias and recommend credible websites or provide selection criteria for websites.16 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Fox S. Online health search 2006. Pew Internet and American Life Project. 2006 Oct 29. http://www. pewinternet.org/pdfs/ PIP_Online_Health_2006.pdf. Accessed 24 August 2012. 2. Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ 2002;324:573–7. 3. Tenholder M, Clarke HD, Scuderi GR. Minimal-incision total knee arthroplasty: the early clinical experience. Clin Orthop Relat Res 2005;440:67–76. 4. Laskin RS. Mini-incision: occasionally desirable, rarely necessary in opposition. J Arthroplasty 2006;21(4 Suppl 1):19–21. 5. Haas SB, Cook S, Beksac B. Minimally invasive total knee replacement through a mini midvastus approach: a comparative study. Clin Orthop Relat Res 2004;428:68–73. 6. Schroer WC, Diesfeld PJ, Reedy ME, LeMarr AR. Mini-subvastus approach for total knee arthroplasty. J Arthroplasty 2008;23:19–25. 7. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res 2003;416:185–90. 8. Chen AF, Alan RK, Redziniak DE, Tria AJ Jr. Quadriceps sparing total knee replacement. The initial experience with results at two to four years. J Bone Joint Surg Br 2006;88:1448–53. 9. Han I, Seong SC, Lee S, Yoo JH, Lee MC. Simultaneous bilateral MIS-TKA results in faster functional recovery. Clin Orthop Relat Res 2008;466:1449–53. 10. Boerger TO, Aglietti P, Mondanelli N, Sensi L. Mini-subvastus versus medial parapatellar approach in total knee arthroplasty. Clin Orthop Relat Res 2005;440:82–7. 11. Dalury DF, Dennis DA. Mini-incision total knee arthroplasty can increase risk of component malalignment. Clin Orthop Relat Res 2005;440:77–81. 12. Barrack RL, Barnes CL, Burnett RS, Miller D, Clohisy JC, Maloney WJ. Minimal incision surgery as a risk factor for early failure of total knee arthroplasty. J Arthroplasty 2009;24:489–98. 13. Labovitch RS, Bozic KJ, Hansen E. An evaluation of information available on the internet regarding minimally invasive hip arthroplasty. J Arthroplasty 2006;21:1–5. 14. Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J. Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome. J Bone Joint Surg Am 2000;82:1540–3. 15. Rose S, Bruce J, Maffulli N. Accessing the Internet for patient information about orthopedics. JAMA 1998;280:1309. 16. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor—Let the reader and viewer beware. JAMA 1997;277:1244–5.
Web-based information on minimally invasive total knee arthroplasty Sanjay Meena, Aravindh Palaniswamy, Buddhadev Chowdhury
Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
ABSTRACT Purpose. To evaluate information available on the internet regarding minimally invasive total knee arthroplasty (TKA). Methods. The 3 most popular search engines (Google, Yahoo, and MSN) were used to search the keyword ‘minimally invasive knee replacement’. The top 50 websites from each search engine were evaluated for authorship and contents; duplicate websites were not double-counted. Results. Of the 150 websites, 51% were authored by a hospital/university, 26% by private medical groups, 14% were news stories, and 9% were from orthopaedic industry sources. 73% offered the opportunity to make an appointment. 18% described the surgical technique, whereas only 9% explained patient eligibility. 25% described the risks, whereas only 3% made reference to peer-reviewed publications. >82% made specific claims regarding the advantages of minimally invasive surgery. Conclusion. Most websites providing minimally invasive TKA information were insufficient in terms
of explaining surgical technique, patient eligibility, and assoicated risks. Key words: arthroplasty, replacement, knee; internet; surgical procedures, minimally invasive
INTRODUCTION The internet has become a popular source of medical information. In 2008, an estimated 61% of adults in the United States used online sources for gathering health information. The information acquired may influence how patients manage their health with or without the aid of their doctors.1 The quality of health information on the internet is subject to commercial pressures, similar to those in print media.2 Minimally invasive total knee arthroplasty (TKA) has recently been introduced. Its proponents suggest quicker recovery, less blood loss, decreased softtissue trauma, less postoperative pain, and improved cosmetic outcomes.3–7 However, potential drawbacks include longer tourniquet time, poor component placement, and early implant failure.8–12 The potential benefits must be considered in terms of any additional
Address correspondence and reprint requests to: Dr Sanjay Meena, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, 110029, India. Email: [email protected]
Journal of Orthopaedic Surgery
306 S Meena et al.
risks caused by limited surgical exposure. This study aimed to evaluate the information available on the internet regarding minimally invasive TKA. MATERIALS AND METHODS On 24 July 2012, the 3 most popular search engines (Google, Yahoo, and MSN) were used to search the keyword ‘minimally invasive knee replacement’. The top 50 websites from each search engine were evaluated for authorship and contents; duplicate websites were not double-counted. The evaluation criteria were the same as those used in a study of minimally invasive total hip arthroplasty.13 The authorship of each website was categorised as (1) hospital or university (public or private), (2) private physician/group, (3) orthopaedic manufacturer/industry, and (4) news bulletin or story. Whether there was means to contact or make an appointment with the author or institution was noted. Whether there was a description of patient eligibility for minimally invasive TKA was noted; the description was considered adequate when there were inclusion and exclusion criteria, including age, comorbidities, and body habitus. Whether there was a description of the surgical technique (using diagrams, graphics, and/or videos) and whether there was a description of the differences between the standard and minimally invasive approaches were noted. Whether there were specific claims regarding blood loss, perioperative pain, length of hospital stay, scar length, and recovery time were noted, as were specific risks associated with both traditional and minimally invasive TKA, including general risks associated with TKA (infection, deep
venous thrombosis, bleeding, and soft tissue damage) and theoretical risks associated with a minimally invasive TKA (femural fracture, nerve injury, wound infection secondary to extensive tissue retraction, and component malposition). Whether there were references to peer-reviewed publications concerning traditional and minimally invasive TKA was also noted. RESULTS Of the 150 websites, 51% were authored by a hospital or university, 27% were by a private medical group, 14% were news stories, and 9% were from orthopaedic device manufacturers (Table). 73% of the websites offered the opportunity to contact or make an appointment with a physician or hospital group. 18% described the surgical technique, whereas only 9% explained patient eligibility. In terms of specific claims, 46% claimed less blood loss, 82% claimed less surgical scar, and 78% claimed short hospital stay. 25% described the potential risks associated with the traditional or minimally invasive TKA. Only 3% provided references to peer-reviewed publications. DISCUSSION Websites owned by private physicians were more likely to be primarily intended for marketing rather than patient education. In a study evaluating the internet regarding minimally invasive total hip arthroplasty, >50% of websites offered the option to make an online appointment, whereas only 15% explained patient eligibility criteria for the
Table Websites on minimally invasive total knee arthroplasty Parameter Authorship Hospital/university Physician/group Industry News Claimed benefits Less surgical scar Less blood loss Shorter hospital stay/better rehabilitation Purpose Description of technique Patient eligibility defined Reference to the peer-reviewed literature Ability to contact/make appointment Claimed risks
No. (%) of websites Google
Yahoo
MSN
Total
24 (48) 9 (18) 6 (12) 11 (22)
27 (54) 15 (30) 4 (8) 4 (8)
25 (50) 16 (32) 3 (6) 6 (12)
76 (51) 40 (27) 13 (9) 21 (14)
39 (78) 22 (44) 35 (70)
42 (84) 25 (50) 40 (80)
42 (84) 23 (46) 42 (84)
123 (82) 70 (46) 117 (78)
13 (26) 5 (10) 3 (6) 30 (60) 12 (24)
6 (12) 5 (10) 1 (2) 42 (84) 15 (30)
8 (16) 3 (6) 0 (0) 38 (76) 11 (22)
27 (18) 13 (9) 4 (3) 110 (73) 38 (25)
Vol. 21 No. 3, December 2013
Web-based information on minimally invasive total knee arthroplasty 307
procedure.13 In another study concerning the carpal tunnel syndrome, 33% of the websites sold commercial products to evaluate carpal tunnel syndrome, and only 23% were authored by a physician or an academic organisation.14 In addition, 50% use computers regularly, but only 7% of the websites (out of 5947) contained relevant information, and only one site gave access to peer-reviewed articles.15 The benefits of minimally invasive TKA are inconclusive. Despite a lack of convincing evidence regarding such benefits, the internet is used for directto-consumer marketing. Most claims on the websites were not substantiated by evidence-based medical practice. Regarding limitations of this study, some websites may have been judged unfairly if their targeted audience were not patients. Nonetheless, this study replicated the situation faced by patients who use search engines to access information about
knee arthroplasty. It is unlikely that they encounter only the dedicated websites. Both patients and website developers have responsibility. The internet is increasingly used by patients to learn about new surgical procedures. It is important that relevant information is accurate and in line with evidencebased medical practice. The general public must be made aware that the internet is largely unregulated, and that information may not be reliable, and its content should be viewed cautiously. Patients can search Google Scholar or MEDLINE/PubMed for the current peer-reviewed articles. These articles from medical journals are more reliable and accurate. However, payment to download and help from medical personnel to interpret them may be necessary. Website developers must be aware that their websites may be viewed by an unintended audience and therefore they should state the aims and limitations of the websites. It is the responsibility of physicians to provide adequate, peer-reviewed information without bias and recommend credible websites or provide selection criteria for websites.16 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Fox S. Online health search 2006. Pew Internet and American Life Project. 2006 Oct 29. http://www. pewinternet.org/pdfs/ PIP_Online_Health_2006.pdf. Accessed 24 August 2012. 2. Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ 2002;324:573–7. 3. Tenholder M, Clarke HD, Scuderi GR. Minimal-incision total knee arthroplasty: the early clinical experience. Clin Orthop Relat Res 2005;440:67–76. 4. Laskin RS. Mini-incision: occasionally desirable, rarely necessary in opposition. J Arthroplasty 2006;21(4 Suppl 1):19–21. 5. Haas SB, Cook S, Beksac B. Minimally invasive total knee replacement through a mini midvastus approach: a comparative study. Clin Orthop Relat Res 2004;428:68–73. 6. Schroer WC, Diesfeld PJ, Reedy ME, LeMarr AR. Mini-subvastus approach for total knee arthroplasty. J Arthroplasty 2008;23:19–25. 7. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res 2003;416:185–90. 8. Chen AF, Alan RK, Redziniak DE, Tria AJ Jr. Quadriceps sparing total knee replacement. The initial experience with results at two to four years. J Bone Joint Surg Br 2006;88:1448–53. 9. Han I, Seong SC, Lee S, Yoo JH, Lee MC. Simultaneous bilateral MIS-TKA results in faster functional recovery. Clin Orthop Relat Res 2008;466:1449–53. 10. Boerger TO, Aglietti P, Mondanelli N, Sensi L. Mini-subvastus versus medial parapatellar approach in total knee arthroplasty. Clin Orthop Relat Res 2005;440:82–7. 11. Dalury DF, Dennis DA. Mini-incision total knee arthroplasty can increase risk of component malalignment. Clin Orthop Relat Res 2005;440:77–81. 12. Barrack RL, Barnes CL, Burnett RS, Miller D, Clohisy JC, Maloney WJ. Minimal incision surgery as a risk factor for early failure of total knee arthroplasty. J Arthroplasty 2009;24:489–98. 13. Labovitch RS, Bozic KJ, Hansen E. An evaluation of information available on the internet regarding minimally invasive hip arthroplasty. J Arthroplasty 2006;21:1–5. 14. Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J. Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome. J Bone Joint Surg Am 2000;82:1540–3. 15. Rose S, Bruce J, Maffulli N. Accessing the Internet for patient information about orthopedics. JAMA 1998;280:1309. 16. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor—Let the reader and viewer beware. JAMA 1997;277:1244–5.
