YouTube As an Information Source for Femoroacetabular Impingement: A Systematic Review of Video Content Matthew G. MacLeod, M.D., Daniel J. Hoppe, M.D., M.Ed., Nicole Simunovic, M.Sc., Mohit Bhandari, M.D., F.R.C.S.C., Ph.D., Marc J. Philippon, M.D., and Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.C.
Purpose: This study was carried out to assess the quality of information available on YouTube regarding femoroacetabular impingement (FAI). Methods: YouTube was searched on September 7, 2013 using the search terms FAI, femoroacetabular impingement, and hip impingement. Analysis was restricted to the ﬁrst 3 pages of results for each search term. English language was a prerequisite for inclusion. Videos were evaluated by 2 independent reviewers (M.G.M., D.J.H.) using novel scoring checklists for diagnosis and treatment of FAI. Interobserver reliability analysis was evaluated using the intraclass correlation coefﬁcient (ICC). Videos were grouped according to quality assessment score, and the group means were analyzed for differences in video characteristics using the analysis of variance (ANOVA) model. Videos were characterized by the source of content. Results: After ﬁltering 1,288,324 potential videos, 52 videos were identiﬁed and included for analysis. The mean video quality assessment scores were 3.1 for diagnosis and 2.9 for treatment (maximum score ¼ 16). No videos were scored as excellent (quality assessment score > 12). Effective resources included 3 videos on diagnosis and one video on treatment. No statistically signiﬁcant differences were found between high- and lowscoring videos for duration, days online, views per day, likes, likes per day, likes per view, dislikes, or likes-dislikes difference for either diagnosis or treatment (P > .05 for all). The source of most of the videos was educational (67%), and most of these included physicians (66%). Conclusions: Patients searching YouTube for videos pertaining to FAI will be presented with a sizeable repository of content of overall low quality. As such, physicians need to recognize the potential inﬂuence of YouTube videos on patients’ preconceptions of their conditions and the effect on the physician-patient consultation. This review highlights the need for evidence-based, comprehensive educational videos addressing FAI diagnosis and treatment. Level of Evidence: Level V, systematic review of nonepeer-reviewed resources.
emoroacetabular impingement (FAI) is an increasingly recognized and treated condition in patients presenting with hip pain, particularly in active young adults. It is the result of a structural deformity that causes abnormal hip contact1 and can predispose From the Division of Orthopaedic Surgery, Department of Surgery (M.G.M., D.J.H., M.B., O.R.A.), and the Department of Clinical Epidemiology and Biostatistics (N.S., M.B.), McMaster University, Hamilton, Ontario, Canada; and Steadman Philippon Research Institute (M.J.P.), Vail, Colorado, U.S.A. Dr Mohit Bhandari is funded in part by a Canada Research Chair. The authors report the following potential conﬂict of interest or source of funding in relation to this article: M.B. funded in part by a Canada Research Chair and receives support from Smith & Nephew, Stryker, Zimmer, Moximed, Bioventus, DePuy, and Eli Lily; O.R.A. receives support from Smith & Nephew. Received April 9, 2014; accepted June 5, 2014. Address correspondence to Olufemi R. Ayeni, M.D., F.R.C.S.C., McMaster University Medical Center, 1200 Main St. West, Rm 4E17, Hamilton, ON L8N 3Z5, Canada. E-mail: [email protected]
Ó 2015 by the Arthroscopy Association of North America 0749-8063/14298/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.009
patients to the development of hip osteoarthritis.2 There has been a dramatic increase in the literature addressing diagnosis and management of FAI in recent times.3 Likewise, the surgical management of FAI with hip arthroscopy is becoming more prevalent in the United States. Colvin reported an 18-fold increase among young orthopaedic surgeons who performed hip arthroscopy over a 10-year time frame (1999 to 2009).4 The Internet is an easily accessible and often used source for health information, with 60% of adults reporting having gone online in the previous month to search for health information.5 However, 82% of patients have either never or only sometimes discussed with their physician the information they have retrieved on the Internet.3 YouTube is a popular nonepeer- reviewed source of short videos uploaded by individuals. It is the third most popular website in the world,6 accounting for 60% of all videos watched online.5 Every day 100 million videos are watched on YouTube.7
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 1 (January), 2015: pp 136-142
YOUTUBE AS INFORMATION SOURCE FOR FAI
With increasing frequency, patients are attending orthopaedic clinics having researched a presumptive diagnosis online or are searching information online after an initial consultation. Eighty-ﬁve percent of physicians have experienced an occasion on which a patient brought information from the Internet to a consultation.6 This has a profound impact on the patientphysician relationship, and 38% of physicians believed that the patient bringing information made the visit less efﬁcient.8 Since sources such as YouTube are sought out by patients and may play a role in their decision-making process, physicians should be cognizant of the quality of the content. In this study, the quality of information presented on YouTube for the diagnosis and treatment of FAI was systematically assessed.
Methods Search Strategy YouTube was searched on September 7, 2013 for videos containing information relating to FAI using the following search terms: (1) FAI, (2) femoroacetabular impingement, and (3) hip impingement. The standard YouTube search setting of “relevance” was used. Search results were restricted to the ﬁrst 3 pages of results on the assumption that users would not look beyond the third page of results for video information. Videos were excluded if they were non-English or were not related to pathologic conditions of the hip. Duplicate videos were excluded as were those with no accompanying audio. Search methodology is shown in Figure 1. This study was exempt from institutional review by our ethics board because it involved use of public access data only. Data Review Two physicians (M.G.M., D.J.H.) independently assessed each video and recorded characteristics including duration, date uploaded, views, likes, and dislikes. From these data, we calculated the number of days online, views per day, likes per day, likes per view, and likes-dislikes difference. Because no evaluation tool exists for assessing the quality of diagnostic information for FAI, the authors created novel scoring systems for diagnosis (Table 1) and treatment (Table 2) information based on a review of the literature and expert opinion.1,913 A single point was given for each item present from the checklists except the complications section of the treatment scoring checklist, which gave a maximum of 2 points if 4 or more complications were discussed. Scoring discrepancies were settled by consensus discussion. Videos uploaded as part of a string, for instance with the title “Femoroacetabular Impingement Surgery Part 1 of 9,” were analyzed as a single video. In addition, one video was considered part of a string because it showed an external view of hip arthroscopy and a separate but
Fig 1. Search methodology for included FAI-related YouTube videos.
related video with the same audio showed an internal arthroscopic view of the same procedure. After all videos were watched, they were categorized according to source of content into 6 groups. Categories included educational, technique, news program, advertisement, testimonial, and other. Educational videos were further subcategorized into those with physician and those with non-physician sources. Data Analyses Videos were grouped according to their score as excellent (13 to 16), very useful (9 to 12), moderately useful (5 to 8), somewhat useful (1 to 4), or not useful (0). Categorical data were reported as frequencies and relative frequencies, and continuous data were reported as means. The analysis of variance (ANOVA) model was used to compare means. For the video quality assessment, the scores between reviewers (M.G.M., D.J.H.) were analyzed for intraobserver reliability using the intraclass
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Table 1. Diagnostic Information Quality Assessment Checklist
Table 2. Treatment Information Quality Assessment Checklist
Discussion of what FAI is (cam lesion, pincer lesions) Discussion of differential diagnosis of hip pain Hip pain (groin, lateral, buttock, anterior thigh, knee) “C sign” Mechanical symptoms (catching, clicking, locking, instability) Provoking factors (pain with activity, repetitive hip ﬂexion, prolonged sitting) High-risk activities (athletic activity, repetitive hip ﬂexion and rotation) Pre-existing pathologic hip conditions (DDH, SCFE, Legg-Calve-Perthes disease, coxa vara, malunited femoral neck space, femoral osteotomy, acetabular osteotomy) Limited range of motion (decreased ﬂexion, adduction, internal rotation) Log roll Resisted straight leg raise Impingement test Posterior impingement test (ﬂexion, abduction, external rotation) Radiographic ﬁndings Advanced imaging (CT, CTA, MRI, MRA) Diagnostic hip injection with local anesthetic
NOTE. 1 point for each line item. Maximum score ¼ 16. CT, computed tomography; CTA, computed tomography arthrography; DDH, developmental dysplasia of the hip; MRA, magnetic resonance imaging arthrography; MRI, magnetic resonance imaging; SCFE, slipped capital femoral epiphysis.
correlation coefﬁcient (ICC). Data were analyzed with IBM SPSS Statistics, version 20 (SPSS, Chicago, IL).
Results The search identiﬁed 1,288,324 videos (search term FAI ¼ 1,280,000 videos, femoroacetabular impingement ¼ 674 videos, and hip impingement ¼ 7,650 videos). After limiting the review to the ﬁrst 3 pages of search results, 159 videos were identiﬁed. After applying exclusion criteria, 52 videos were included for analysis (Fig 1). Reasons for exclusion included 21 videos duplicated by different search terms, 39 non-English videos, 19 videos not related to pathologic conditions of the hip, and 28 videos without any audio. Videos ranged in upload date from November 6, 2008 to July 8, 2013. The reviewers had excellent agreement for the diagnosis quality assessment score (ICC, 0.95; 95% conﬁdence interval, 0.94 to 0.97) and treatment quality assessment score (ICC, 0.88; 95% conﬁdence interval, 0.84 to 0.91). The frequency distribution of the quality assessment scores is shown in Figure 2. The source of the majority of videos was educational (67%), and the preponderance of these included a physician spokesperson (66%). Sources of video content are detailed in Figure 3.
Nonoperative treatment (activity modiﬁcation, physiotherapy, core strengthening) Surgical indications (intra-articular pathologic conditions of the hip amenable to treatment) FAI surgical contraindications (osteoarthritis, degenerative changes, asymptomatic radiographic ﬁndings) Surgical setup (supine or lateral decubitus with traction table) Hip arthroscopy Open or miniopen procedures Labral debridement or repair Femoroplasty (femoral head-neck reshaping) Acetabular reshaping Articular cartilage procedures (chondroplasty, microfracture) Period of protected weight bearing and ROM Physiotherapy No twisting or impact activity for 12 wk Unrestricted activity at approximately 6 mo Minimum of 4 (nerve injury, vascular injury, chondral damage, ﬂuid extravasation, infection, venous thromboembolism, iatrogenic fracture, osteonecrosis, heterotopic ossiﬁcation, hip instability, adhesions); 0.5 points each; maximum 2 points
NOTE. 1 point was given for each line item except complications, for which 0.5 points were given for each complication listed. Maximum score ¼ 16. FAI, femoroacetabular impingement; ROM, range of motion.
Most videos in the diagnosis analysis (53.8%) were scored as being in the somewhat useful category. The moderately useful category (21.1%) was the next most common. Ten videos were scored a zero as not useful (19.2%). No videos were scored as excellent. Three videos were very useful (5.8%). There were no statistically signiﬁcant differences between groups for any of the recorded or calculated video characteristics. Descriptive statistics, ANOVA P values, and content source summary for the diagnosis analysis are shown in Table 3. Similarly, for the treatment analysis, most videos (60.3%) were scored as somewhat useful. The moderately useful category (21.1%) was next most common. Eight videos were scored a zero as not useful (15.4%). No videos were scored as excellent. One video was very useful (1.9%). There were no statistically signiﬁcant differences between groups for any of the recorded or calculated video characteristics. Descriptive statistics, ANOVA P values, and content source summary for the treatment analysis are shown in Table 4.
Discussion Patients searching YouTube for information on FAI will be presented with considerable content volume that is of wide ranging but overall low quality. According to our assessment scoring, no videos were
YOUTUBE AS INFORMATION SOURCE FOR FAI
Fig 2. Quality assessment results as scored applying diagnostic and treatment information checklists for included FAI-related YouTube videos.
found to score within the excellent group for diagnosis or treatment. There were 3 videos and one video, respectively, that were determined to be very useful for diagnosis and treatment information. Most videos were found to be moderately useful or somewhat useful, and a minority were not useful. According to our grading criteria, examples of effective resources included 3 videos for diagnosis and one video for treatment (Table 5). This study is the ﬁrst to evaluate the quality of FAI information on YouTube. Previous studies have looked
Fig 3. Sources of content for included FAI-related YouTube videos.
at the quality of YouTube information with regard to H1N1 inﬂuenza,14 kidney stone disease,15 tonsillectomy,16 ear tube surgery,17 acute myocardial infarction,18 cardiac auscultation,19 and the Epley maneuver.20 Quality of orthopaedic information on the Internet pertaining to anterior cruciate ligament reconstruction,21,22 pediatric orthopaedics,23 distal radius fractures,24 carpal tunnel syndrome,25 cervical disk herniation,26 cervical disk replacement,27 knee arthroscopy,28 and sports medicine29 have been investigated using popular search engines. To the best of our knowledge, there have been no studies assessing quality of information pertaining to orthopaedic diagnoses on YouTube to date. Overall, the majority of diagnostic information presented provided an accurate description of cam and pincer-type impingement. Most appropriately identiﬁed groin pain as a cardinal symptom of FAI. However, there was a scarcity of videos presenting a differential diagnosis of hip pain. Only one (https://www.youtube. com/watch?v¼kyJajIZyAfc) contained information on alternative causes of hip pain, and this video was scored as very useful. The general lack of information about causes other than FAI is of particular concern because patients may be misled into thinking that virtually all pain in the hip is caused by FAI, when in fact the differential diagnosis is quite broad.30 Furthermore, only 2 videos contained a discussion regarding pre-existing pathologic hip conditions that can predispose to FAI. Taken as a whole, the treatment information presented emphasized the speciﬁc surgical interventions available for FAI and associated labral tears. However, contraindications to surgery were rarely mentioned. Also notably absent was a discussion of the complications of FAI surgery, which were mentioned in only 2
M. G. MACLEOD ET AL.
Table 3. Descriptive Statistics, ANOVA P Values, and Source Summary for Video Diagnostic Information Variable Number of videos Mean duration, min:s Mean no. of days online Mean no. of views Mean no. views per day Mean no. of likes Mean no. likes per day Mean no. likes per view Mean no. of dislikes Mean difference likes-dislikes Source Educational (physician) Educational (non-physician) Technique News program Advertisement Personal testimonial Other
Excellent 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A
Very Useful 3 8:39 538 5,168 7.6 15.3 0.0349 0.0063 0.7 14.7
Moderately Useful 11 5:17 572 2,445 6.0 6.0 0.0171 0.0046 0.1 5.9
N/A N/A N/A N/A N/A N/A N/A
2 1 0 0 0 0 0
7 2 1 0 0 1 0
Somewhat Useful 28 3:28 690 4,202 5.5 6.5 0.0097 0.0021 0.3 6.2 13 6 3 3 3 0 0
Not Useful 10 3:42 699 4,657 6.0 6.6 0.0099 0.0019 0.3 6.3
ANOVA P Values .123 .768 .661 .955 .710 .300 .670 .337 .737
1 3 3 0 0 1 1
ANOVA, analysis of variance; N/A, not available.
videos. One of these videos was the sole video to score in the very useful category. Postoperative rehabilitation was mentioned in a minority of videos. However, these tended to emphasize rates of return to sport and the need for postoperative physiotherapy. Frequently omitted were details of the rehabilitation protocol that would be important to the patient, including restrictions on weight-bearing status, range of motion, and time lines for progression of activity. There were no statistically signiﬁcant differences in recorded or calculated video characteristics between quality assessment groupings for either diagnosis or treatment, including duration, days online, views, views per day, likes, likes per day, likes per view,
dislikes, or likes-dislikes difference. Consequently, these characteristics cannot be used to help identify the most useful resources. Limitations There are a few limitations inherent in our study. No validated tools exist for evaluating the quality of video health information. As such, we created quality assessment checklists based on a review of relevant FAI literature and expert discussion. We did note excellent agreement between independent video reviewers for both diagnosis and treatment scoring. Second, our search was performed using 3 search terms at a single time point. YouTube is a dynamic repository of video
Table 4. Descriptive Statistics, ANOVA P Values, and Source Summary for Video Treatment Information Variable Number of videos Mean duration, min:s Mean no. of days online Mean no. of views Mean no. of views per day Mean no. of likes Mean no. likes per day Mean no. likes per view Mean no. of dislikes Mean difference likes-dislikes Source Educational (physician) Educational (non-physician) Technique News program Advertisement Personal testimonial Other
Excellent 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A
Very Useful 1 4:03 1,039 1,433 1.4 2.0 0.0019 0.0014 1.0 1.0
Moderately Useful 11 17:27 573 5,037 9.9 10.6 0.0272 0.0048 0.4 10.3
N/A N/A N/A N/A N/A N/A N/A
1 0 0 0 0 0 0
7 0 4 0 0 0 0
ANOVA, analysis of variance; N/A, not available.
Somewhat Useful 32 21:00 661 3,530 4.4 5.8 0.0089 0.0027 0.2 5.7 11 8 4 3 3 2 0
Not Useful 8 12:00 747 6,252 8.1 6.9 0.0097 0.0008 0.4 6.5 4 4 0 0 0 0 1
ANOVA P Values .110 .649 .633 .438 .741 .139 .099 .578 .742
YOUTUBE AS INFORMATION SOURCE FOR FAI
Table 5. Most Useful Videos As Identiﬁed by Applying Scoring Checklists Title Femoral Acetabular Impingement (FAI) dHip Arthroscopic Surgery Femoroacetabular Impingement Femoral Acetabular Impingementd Arthroscopic Labrum Repair Hip Impingement Surgical Treatment
information, and as such search results may vary over time. YouTube’s search algorithm is proprietary, and search results may vary based on variables such as geographic location. Additionally, our analysis was limited to content directly searched on the YouTube site and may not account for videos accessed from links on other sites patients may use to access information regarding FAI diagnosis. Finally, non-Englishelanguage videos were excluded from analysis, further reducing the generalizability of our results. Future Directions We examined the quality of FAI information on YouTube, but patients may be accessing information on this topic from other websites. Other studies in the literature have investigated quality of orthopaedic information on the Internet using popular search engines to identify websites for evaluation.21-29 This type of investigation, with regard to FAI, would represent a logical next step. Also, given the limitation in the video information found in this study, physicians may want to commit to creating and promoting comprehensive videos that cover this topic on YouTube.
Conclusions Patients searching YouTube for videos pertaining to FAI will be presented with a sizeable repository of content of overall low quality. As such, physicians need to recognize the potential inﬂuence of YouTube videos on patients’ preconceptions of their conditions and the effect on the physician-patient consultation. This review highlights the need for evidence-based comprehensive educational videos addressing FAI diagnosis and treatment.
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