The Journal of Foot & Ankle Surgery 54 (2015) 378–381
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery
journal homepage: www.jfas.org
Is the Internet a Reliable Source of Information for Patients Seeking
Total Ankle Replacement?
Andrew D. Elliott, DPM, JD 1, Annette F.P. Bartel, DPM, MPH 1, Devin Simonson, DPM 2,
Thomas S. Roukis, DPM, PhD, FACFAS 3
1
2
3
Podiatric Medicine and Surgery Resident, Postgraduate Year II, Gundersen Medical Foundation, La Crosse, WI
Podiatric Medicine and Surgery Resident, Postgraduate Year III, Gundersen Medical Foundation, La Crosse, WI
Attending Staff, Department of Orthopaedics, Podiatry, and Sports Medicine, Gundersen Health System, La Crosse, WI
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 5
The modern patient population relies on the Internet to provide knowledge about medical procedures.
However, a gap between established medical guidelines and the information provided on the Internet exists.
Because of the general poor quality of the medical information available on the Internet and the increasing
popularity of total ankle replacement (TAR) with its known potential serious complications, we undertook the
present study to evaluate the information on TAR available to the general public through the Internet and to
determine the quality of information according to authorship type and site certification status. Three common
search engines were used to identify a total of 105 websites. The TAR information quality was rated as
“excellent,” “high,” “moderate,” “low,” or “unacceptable.” The sites were evaluated for authorship or sponsorship, content, and other criteria. The data were analyzed as a complete set, as a comparison among
authorship types (academic, private, industry, or other), and by certification status. Websites with scores of
excellent or high were 35% of the sites reviewed, and 48% were ranked as poor or unacceptable. Of the
authorship types, the highest quality authorship was for the industry and other sites, which rated high or
excellent 46% of the time. Eight percent of the sites evaluated were certified; however, certification status was
not associated with improved information quality. Our study has demonstrated a low quality of TAR information available across all website types, regardless of authorship type. We suggest a partnership between
professional organizations and physicians to ensure that provider websites reflect the current indications and
contraindications of TAR to enhance patient education.
Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords:
ankle fusion
ankle implant
degenerative joint disease
joint arthroplasty
Scandinavian total ankle replacement
The modern patient population is relying more heavily on the
Internet to provide themselves with knowledge about medical
procedures before seeking a physician’s advice (1). Several studies
have attempted to replicate patients’ Internet search experience
for a variety of orthopedic conditions and procedures to determine
the reliability of information obtained from their web searches
(2–8). The results of those studies have shown a gap between
established medical guidelines and the information provided by
the websites.
End-stage ankle arthritis has traditionally been treated with
arthrodesis of the affected joint, and this is still considered the
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Thomas S. Roukis, DPM, PhD, FACFAS, Attending Staff,
Department of Orthopaedics, Podiatry, and Sports Medicine, Gundersen Health System, 2nd Floor, Founders Building, 1900 South Avenue, La Crosse, WI 54601.
E-mail address: [email protected] (T.S. Roukis).
reference standard for treatment of this pathologic entity (9).
Arthrodesis consistently reduces ankle pain but also reduces mobility
in the limb. It also increases the likelihood of painful arthritis in the
surrounding midfoot/hindfoot complex. In response to this problem,
industry and surgeons working together have developed total ankle
replacement (TAR) prosthesis systems. These prostheses have allowed
patients to retain some of the ankle joint range of motion but with a
high incidence of complications (10,11). What is clear is that careful
attention must be given to proper patient selection. If the patient is
not an appropriate candidate and the TAR fails, the sequelae can be as
serious as below-the-knee amputation of the affected extremity. Even
with these limitations, TAR has become an increasingly popular
option for treating end-stage ankle arthritis (9).
Because of the general poor quality of medical information available on the Internet and the increasing popularity of TAR with its
known potential serious complications, we undertook the present
study to evaluate and analyze the information on TAR available to the
general public through the Internet and to determine whether the
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.08.012
A.D. Elliott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 378–381
quality of information varies according to authorship type and site
approval by a certification body.
Materials and Methods
We sought to mimic the common patient experience searching for information
pertaining to TAR to assess the reliability of Internet information for the purpose of
patient self-education. We erased our Internet browsers of all search history, cookies,
and cached data to eliminate potential search biases from previous medical-related
searches performed on our browsers. Furthermore, to the best of our abilities, we
disabled all location services for the browser and each search engine used. Google
(http://www.google.com; Mountain View, CA), Yahoo! (http://www.yahoo.com; Sunnyvale, CA), and Bing (http://www.bing.com; Bellevue, WA) were used to perform our
search using the general query “total ankle replacement.” The use of this query
returned more than 13 million sites combined among these 3 search engines. The first
35 unique sites returned by each search engine were identified and evaluated for a total
of 105 sites included in our study. The number of sites we reviewed was consistent with
that of a previously published study that used a similar search strategy (7). We evaluated each site only once. All redundant sites within a single search engine were
evaluated only once. Identical sites, each with a different uniform resource locator,
were evaluated only once. Also evaluated only once were redundant sites common to
the 3 search engines. Finally, we excluded any sites that directly linked to clinical trials
published in academic journals.
The total number of appropriate indications, candidate criteria, absolute and relative contraindications, benefits, risks, and alternative treatments listed by each site
were recorded. For a site to receive credit for including a criterion it had to include at
least 1 descriptor in the criteria (Table 1). If the sites referenced any aspect of nonlisted
criteria, it was recorded as “other.” Additionally, we recorded in binary fashion if any
criteria were stated. Whether alternative treatments were discussed as options to
consider in lieu of TAR or as options for conservative medical therapy before TAR were
not differentiated.
Using an observational method of analysis, the information provided by each site
was then analyzed. It was noted whether the sites provided specific reference to peerreviewed data. We also evaluated the sites for the presence of illustrations or images
outlining the steps of the TAR procedure, a step-by-step description of the surgical
technique, and a postoperative recovery description. We recorded whether sites provided any method of appointment scheduling for TAR consultation.
After all content data collection was performed for each site, that site was assigned a
level of information quality according to several criteria: indication, contraindication,
benefit, risk, alternative, description, peer-reviewed data, and postprocedure recovery.
These criteria were chosen on the basis of the elements of the U.S. Food and Drug
Administration Department of Health and Human Services Informed Consent for Human
Subjects (21CFR50.25, as amended January 4, 2011; available at: http://www.accessdata.
fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr¼50.25; last accessed: August 11,
2014) and other factors a patient would consider when making an informed decision. A
site received an “excellent” rating if it included 7 or 8 information quality criteria; a “high”
rating if it included 6 information quality criteria; a “moderate” rating if it included 5
information quality criteria; a “poor” rating if it included 4 information quality criteria;
and an “unacceptable” rating if it included 3 or fewer information quality criteria.
In our second step in the analysis, the sites were categorized into 4 groups:
academic, private, industry, or other. Academic sites were those sponsored by either an
accredited university or a university-affiliated healthcare institution. Private sites were
either authored by a physician or physician group operating in private practice or edited
by a physician or group of physicians operating for a private company or institution.
Industry sites were those designed and sponsored by biomedical device companies.
Other sites included general online health databases, TAR-specific sites not edited or
sponsored by a private physician, private patient-authored blogs, and sites developed
and sponsored by insurance companies. After authorship classification, we compiled
data for each authorship group.
During the final step in our analysis, the sites were classified according to certification status. The specific certifying body was noted.
Results
The overall quality of information available on the Internet to the
layperson was not good. Of the 105 sites reviewed, 19% were ranked
excellent, 16% high, 14% moderate, 14% poor, and 34% unacceptable. At
least 1 indication for TAR was listed in 71% of sites, and 35% of the sites
listed an absolute or relative contraindication. The trend was to point
the person toward TAR, with benefits expressed by 66% of sites but
risks outlined in only 39%. The most common benefits cited were pain
reduction and improved mobility about the ankle joint, both cited at
379
Table 1
Descriptors of considered criteria
Indications
Primary arthritis
Post-traumatic arthritis
Secondary arthritis
Failed arthrodesis
Other
Candidate criteria
Middle to old age
Independently mobile
No significant comorbidities
Normal or low body mass index
Adequate bone stock
Well-aligned and stable hindfoot
Good soft tissues condition
No neurovascular impairment of the lower extremities
Bilateral end-stage ankle osteoarthritis
Previous hindfoot and/or midfoot arthrodesis
Other
Absolute contraindications
Neuroarthropathy (Charcot foot)
Noncorrectable hindfoot alignment
Massive joint laxity
Highly compromised periarticular soft tissue
Severe sensory or motor dysfunction of the foot or ankle
Active soft tissue or bone infection
High levels of functional demands
Other
Relative contraindications
Severe osteoporosis
History of osteomyelitis
Diffuse osteonecrosis
Significant bone defect on tibial or talar site
Previous long-term immunosuppressive use
Heavy physical work
Medium level of sport participation
High body mass index
Diabetes mellitus
Tobacco abuse
Varus or valgus ankle >10
Avascular necrosis of the talus
Other
Benefits
Pain reduction
Improved mobility
Reduce strain on surrounding joints
Perform activities of daily living
Regain athletic activities
Option to revise to a ankle arthrodesis
Risks
Metallic component aseptic loosening
Infection
Pseudoarthrosis of distal syndesmosis arthrodesis (only relevant for AgilityÒ and
AgilityÒ LP Total Ankle Replacement systems, DePuy, Warsaw, IN)
Malunion
Gait abnormality
Long recovery period
Additional surgery
Arthritis in surrounding joints
Intraoperative fractures
Postoperative fracture
Delayed incision healing
Metallic component subsidence
Other
Alternative treatment
Ankle arthrodesis
Nonsteroidal anti-inflammatory drugs or analgesics
Corticosteroid injections
Hyaluronic acid injections
Below-the-knee amputation
Ankle foot orthosis
Weight loss
Activity restriction
380
A.D. Elliott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 378–381
Table 2
Benefits and descriptors of TAR reported according to authorship
Authorship
Diagrams
Step by
Step
Postoperative
Recovery
Patient
Scheduling
Available
Pain
Reduction
Improved
Mobility
Reduces Strain
on Adjacent
Joints
Perform
ADL
Regain
Athletic
Activities
Option to
Revise to
Arthrodesis
Other
Any
Benefit
Mean
Total
Benefits
Academic (n ¼ 10)
Private (n ¼ 43)
Industry (n ¼ 13)
Other (n ¼ 39)
Total (n ¼ 105)
0
5
4
5
14
0
7
6
6
19
5
14
5
14
38
7
37
1
2
47
6
25
4
25
60
7
25
6
22
60
1
9
1
4
15
1
8
1
4
14
0
2
0
4
6
0
0
0
2
2
0
0
0
1
1
7
28
6
28
69
2
2
1
2
1.5
(0)
(12)
(31)
(13)
(13)
(0)
(16)
(46)
(15)
(18)
(50)
(33)
(38)
(36)
(36)
(70)
(86)
(8)
(5)
(45)
(60)
(58)
(31)
(64)
(57)
(70)
(58)
(46)
(56)
(57)
(10)
(21)
(8)
(10)
(14)
(10)
(19)
(8)
(10)
(13)
(0)
(5)
(0)
(10)
(6)
(0)
(0)
(0)
(5)
(2)
(0)
(0)
(0)
(3)
(1)
(70)
(65)
(46)
(72)
(66)
Abbreviations: ADL, activities of daily living; TAR, total ankle replacement.
Data presented as n (%).
57% of the sites (Table 2). Infection was the most often sited complication at 27% of the sites (Table 3). Although the sites tended to list the
benefits and downplay the complications, alternative treatments
were listed in just 39% of the sites. The sites tended not to have
descriptions of the procedure, with only 18% giving step-by-step
instructions and 13% including illustrations of TAR. A postoperative
recovery description was listed in 36% of the sites. The sites involved
peer-reviewed data 29% of the time.
In categorizing the sites by authorship type, we found 10% academic, 12% industry, 41% private, and 37% other. Private sites reported
fewer complications with the procedure than did the academic,
industry, or other sites (Table 3). The academic and private sites were
far more likely than sites classified as other or industry to offer contact
information for patient appointment scheduling (Table 2). Industry
and other sites were the most likely to be listed as high or excellent
(Table 4). Interestingly, industry and private sites were the most likely
to be listed as poor or unacceptable (Table 4).
Certified sites were rare. Only 8% of the sites were certified, and the
only certifying body was the Health on Net Foundation (HONCode;
available at: https://www.hon.ch/HONcode/; last accessed August 11,
2014). No difference was seen between the certified sites and
noncertified sites and the percentage of good quality sites, with 38% of
certified sites rated either excellent or high and 35% of the noncertified sites rated the same. However, the certified sites were much less
likely to be rated as poor or unacceptable (Table 4).
Discussion
The general patient population has increasingly used the Internet to
research their medical conditions and treatment options (1). Patients
Table 3
Potential complications of TAR reported stratified by authorship
Complications
Academic,
n ¼ 10
Private,
n ¼ 43
Industry,
n ¼ 13
Other,
n ¼ 39
Total,
N ¼ 105
Metallic component aseptic
loosening
Infection
Pseudoarthrosis of distal
syndesmosis arthrodesis
Malunion
Gait abnormality
Long recovery period
Additional surgery
Arthritis in surrounding joints
Intraoperative factures
Delayed wound healing
Postoperative fracture
Metallic component subsidence
Other
Any complication
Mean total
1 (10)
4 (9)
1 (8)
13 (33)
19 (18)
1 (10)
0 (0)
5 (12)
0 (0)
6 (46)
1 (8)
16 (41)
1 (3)
28 (27)
2 (2)
0
0
2
3
1
0
2
1
0
0
4
2
2
1
1
7
0
3
3
1
1
0
8
1
1
0
0
2
1
0
2
0
0
0
6
3
4
4
10
14
6
10
12
2
5
0
23
3
7
5
13
26
8
13
19
4
6
0
41
2
(0)
(0)
(20)
(30)
(10)
(0)
(20)
(10)
(0)
(0)
(40)
Abbreviation: TAR, total ankle replacement.
Data presented as n (%).
(5)
(2)
(2)
(16)
(0)
(7)
(7)
(2)
(2)
(0)
(19)
(8)
(0)
(0)
(15)
(8)
(0)
(15)
(0)
(0)
(0)
(46)
(10)
(10)
(26)
(36)
(15)
(26)
(31)
(5)
(13)
(0)
(59)
(7)
(5)
(12)
(25)
(8)
(12)
(18)
(4)
(6)
(0)
(39)
frequently come to their physician having chosen a treatment for
themselves according solely to information gained from the Internet.
Numerous studies have demonstrated the poor overall quality of
medical information available to the public on the Internet (2–8).
Framed in the success of total knee and hip replacements, it is only
natural for people to look to TAR for treatment of their end-stage
ankle arthritis. However, TAR has not enjoyed the outcome success
of total hip or total knee replacements. During its infancy in the 1970s
and 1980s, the outcomes were so poor, the procedure was almost
abandoned. With improvements in implant technology, familiarity
with the surgical technique, and better patient selection, the outcomes of the surgery have improved dramatically (9). TAR has
enjoyed so much success that the procedure has begun to rival ankle
arthrodesis as a viable alternative for the treatment of end-stage ankle
arthritis (12). Although TAR does offer a good treatment option for
end-stage ankle arthritis among a select patient population, it still has
many of the difficulties, albeit to a lesser degree, seen in its earlier
versions. Because of the complex nature of the procedure, the potential for catastrophic outcomes, and the need for discriminating
patient selection, we undertook the present study to determine
whether this information was being accurately conveyed to the general public.
The results of our study showed a consistently low to moderate
quality of information on TAR available across all websites and all
authorship types. Our classification system was based on similar
studies that used the basic elements of informed consent as a
guideline (7). We also used position papers from relevant professional
organizations to formulate generally accepted risks, benefits, indications, contraindications, and alternative treatments categories
and factors considered in appropriate patient selection (13,14). Just as
in previous studies, it was not necessary for a website to list all, or
even most of, the generally accepted elements in each category (2–8).
For each site to receive credit in a category, they merely had to list 1
element. Even with this low bar to clear, 49% of the websites provided
information that was deemed poor or unacceptable. By far, the 2 most
common benefits listed were pain reduction and improved mobility
about the ankle joint. Patient selection is a vital part of TAR success.
Only 41% of sites listed even 1 factor for criteria in patient selection.
The most common factor was older age and independent mobility,
and the average number of factors listed was 3. The lack of specific
listed factors would engender a false sense of inclusiveness about this
procedure. The percentage of sites listing at least 1 possible complication was 39%, with infection and additional surgery the most
commonly cited complications. The overall impression given by these
websites was that of a broadly applicable procedure with minimal
short- and long-term risk.
Our analysis of information according to site authorship confirmed
a previous study’s observation on vertebroplasty and patient selfeducation (7). Although conventional wisdom might suggest that
academic sites would provide a more complete view of TAR, only 30%
of these sites were ranked as high or excellent. Compounding this
fault, they only listed peer-reviewed references 10% of the time. In
A.D. Elliott et al. / The Journal of Foot & Ankle Surgery 54 (2015) 378–381
Table 4
Site information quality distribution stratified by authorship and certification
Authorship
Excellent
High
Moderate
Poor
Unacceptable
Academic (n ¼ 10)
Private (n ¼ 43)
Industry (n ¼ 13)
Other (n ¼ 39)
Total (n ¼ 105)
Certified (n ¼ 8)
Noncertified (n ¼ 97)
1
3
4
12
20
1
19
2
7
2
6
17
2
15
5
5
0
5
15
3
12
0
8
0
7
15
2
13
2
18
7
9
36
0
36
(10)
(7)
(31)
(31)
(19)
(13)
(20)
(20)
(16)
(15)
(15)
(16)
(25)
(15)
(50)
(12)
(0)
(13)
(14)
(38)
(12)
(0)
(19)
(0)
(18)
(14)
(25)
(13)
(20)
(42)
(54)
(23)
(34)
(0)
(37)
Data presented as n (%).
contrast, private and industry sites were considered high or excellent
46% and 24% of the time, respectively. The private and industry sites
also cited peer-reviewed data 43% and 18% of the time, respectively.
This might have resulted from private and industry sites attempting to
add academic weight to their sites and academic institutions
believing that their claims inherently carry that weight. Academic
sites also scored lower in providing both indications and contraindications for TAR. These findings would suggest that a patient is more
likely to receive balanced and quality information from a private- or
industry-based site than from an academic one. However, as listed in
Table 4, our search revealed that both private and industry sites were
ranked unacceptable (42% and 54% of the time, respectively) more
often than were academic (20%) or other (23%) sites. Therefore, it
remains a matter for conjecture which authorship site type ultimately
can be considered to provide the most balanced and quality
information.
A small percentage of the sites visited were listed as certified by
HONCode, a group whose purpose is to promote accurate information
on the Internet. HONCode certifies websites according to the accuracy
of the material presented; however, they do not take into account the
actual amount of information presented (7). This limits the value of
the certification by not certifying the completeness of the information. Despite this limitation, it would be expected that certified sites
provide a higher quality of data. Although none of the certified sites
were ranked as unacceptable, no difference was found between the
HONCode-certified and noncertified sites ranked moderate or greater
(38% vs 36%).
Our study had several limitations. The threshold for a site to receive
credit for an information quality criterion was low. This might have
biased the results by giving a more favorable impression on the quality
of information available than actually exists. The select number of sites
searched from each search engine might have eliminated websites
with exceedingly good information. However, studies of Internet
searches have shown that the vast majority of searchers will select a
site within the first 35 results (15). We also limited our search by using
a single, generic search phrase. The phrase was selected, because it
was one we believed patients would be most likely to use and would
result in websites that directly discuss TAR. We also assumed that
more specific phrases or ones that varied slightly in their wording
would lead to similar search results. Another weakness was that a
single researcher did not review all the websites. This could have led to
differing interpretations of website information. However, whenever a
dispute occurred regarding the meaning of a phrase within a website,
the primary author (A.D.E.) served as the final arbiter.
The Internet is a tempting place for patients to educate themselves
on their condition and possible treatment options. Just as our study
and other studies have shown, the information available on the
Internet is often not complete or accurate. The Internet does not
replace the role of the physician in patient education and procedure
selection. Most sites available on the Internet regarding TAR were
found to be of less than even moderate quality. Sites that a person
would tend to trust more, academic sites, showed no significant
advantage in the quality of information they conveyed compared with
381
the other site types. Most of the sites suffered from focusing more on
the benefits and indications for surgery than on the possible complications and contraindications. Even the HONCode-certified sites
offered no better source of information than the noncertified sites.
This leads to the common occurrence of the physician having to
re-educate or convince a patient not to undergo a procedure the
patient was sure was needed. Although regulation of Internet content
is an almost impossible task, steps can be taken to help ensure that
the information provided is complete and well rounded.
An interesting and unintended result from our search was to review our institution’s website (available at: http://www.gundersen
health.org/podiatry/total-ankle-replacement; last accessed August
11, 2014). Patient education is emphasized at the Gundersen Health
System, and this was reflected in its scores. It ranked among the
highest quality websites, receiving a grade of excellent. The site reported 5 of 5 indications, but, more importantly, they stated 11 of the
13 complications of TAR. The frankness was a rarity among the
websites. We would suggest that companies and institutions
attempting to create a website to educate their patients on TAR should
consider, not only professional organizations’ guidelines (13,14), but
also Gundersen Health System and other organizations with a similar
emphasis on patient education for examples on how to create a truly
balanced and informative website for patients interested in TAR. We
would also suggest an eventual partnership among professional
organizations and physicians to ensure that their websites fully reflect
the current understanding of TAR.
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