Instagram Outperforms X for Social Media Engagement Across Diversity-Focused Orthopaedic Organizations

Abstract

Introduction:

Improving diversity within orthopaedic surgery is essential for fostering a more inclusive specialty that reflects the population of patients served. Women and minorities are still markedly underrepresented within the field. Social media has become a key platform for professional networking, mentorship, and outreach, particularly for groups that have historically been underrepresented in orthopaedic surgery.

Purpose:

The purpose of this study was to analyze the content, posting strategies, and engagement on Instagram and X, formerly Twitter, of orthopaedic organizations that promote diversity in the field of orthopaedic surgery.

Methods:

Data were collected from Instagram and X for nine orthopaedic diversity organizations between January 2020 and December 2024. Likes, comments, and retweets were recorded. Posts were categorized based on intended target audience, content, format, and hashtag usage.

Results:

Across nine organizations on Instagram and eight on X, 2959 and 2848 posts were analyzed, respectively. The highest volume of posts targeted mixed or unspecified audiences (Instagram: 71%; X: 89%), while posts aimed at medical students comprised the largest specified audience (Instagram: 22%; X: 7.7%). Historical content, defined as posts highlighting key milestones or influential figures in orthopaedic surgery, received the greatest median likes on Instagram (93; range: 39 to 228) and was among the top performers on X (median: 9, range: 0 to 30). Personal/organizational spotlights also did well on X (median likes: 9; range: 0 to 211). Picture format had the highest median likes on both platforms (Instagram: 95; X: 9.5). Mixed-format posts combining text and visuals (pictures and/or videos) were most common (Instagram: 57.5%; X: 67.1%). Instagram had markedly greater total engagement than X across all years and all organizations studied (P < 0.001). Hashtags appeared in 72% of Instagram posts and 54% of X posts. Posts with hashtags were associated with greater engagement on X (P = 0.03), but not on Instagram. The most used hashtags included #NthDimensions (669 posts, 41%), #DiversityInMedicine (602 posts, 37%), and #ILookLikeASurgeon (456 posts, 28%) on Instagram, and #OrthoTwitter (595 posts, 71%), #Diversity (312 posts, 37%), and #Orthopaedics (192 posts, 23%) on X.

Conclusion:

Instagram outperformed X in engagement in promoting diversity within orthopaedic surgery across all years studied. Picture format was the most engaging, likely due to its ability to quickly capture attention and convey information. Using hashtags strategically on X can enhance user engagement and extend to visibility of diversity initiatives. Leveraging visually engaging content may further enhance engagement and broaden the reach of diversity initiatives.

Diversity is widely recognized as a critical factor in advancing equitable health care and enhancing medical team performance.^1,2 A 2019 meta-analysis by Gomez et al assessed the association between diversity, innovation, patient health outcomes, and financial performance and showed that diverse healthcare teams strengthen collaboration, improve the decision-making process, and lead to better patient outcomes.² Previous studies have explored the impact of sex and racial disparities in orthopaedic surgery and demonstrated that these disparities can potentially limit the ability to provide the highest level of care to all patients.^3,4 Despite efforts to diversify the field, orthopaedic surgery remains one of the least diverse surgical subspecialties. In 2022, Smith et al evaluated the breakdown of orthopaedic surgeons practicing in the United States and found that only 7.4% identified as female.⁵ In addition, the 2018 American Academy of Orthopaedic Surgeons (AAOS) census reported that only 1.9% of practicing orthopaedic surgeons were African American, 2.2% were Hispanic/Latino, 6.7% were Asian, and just 0.4% were Native American.⁶ Addressing this persistent lack of diversity is crucial not only for fostering a more inclusive field but also to ensure that the benefits of diverse representation extend to the patients served by orthopaedic surgeons.

Intentional efforts to promote diversity within orthopaedic surgery have increased in the past several years, driven by the work of professional organizations and advocacy groups. These efforts aim to address barriers to entry, foster mentorship, and encourage individuals from underrepresented groups to pursue a career in orthopaedic surgery. The Perry Initiative, which provides hands-on educational outreach programs and mentorship to inspire women to enter orthopaedic surgery and engineering, and Nth Dimensions, a nonprofit organization that offers mentorship, resources, and hands-on training to address workforce shortages in various specialties, are two important pipeline programs. Harbold et al⁷ evaluated the impact of the Perry Initiative on sex diversity in orthopaedic surgery residency programs. The authors found that participation in the program markedly increased the number of women pursuing a career in orthopaedic surgery. Similarly, Mason et al⁸ examined the role of Nth Dimensions in advancing diversity within the field and found that the program has been instrumental in improving access, mentorship, and representation for underrepresented minorities in orthopaedic surgery. Social media has emerged as a powerful platform for outreach and engagement, allowing these organizations to connect with broader audiences and amplify their mission. Platforms like Instagram and X, formerly Twitter, are two of the most popular social media outlets used, with Instagram having 1.4 billion monthly users in 2024 and X having 429 million users in the same year.^9,10

Previous studies have highlighted the role of social media in health care. Edmonson et al¹¹ found that Instagram is a highly effective platform for orthopaedic surgeons to engage with patients and colleagues. The authors demonstrated that Instagram generated markedly higher social media engagement across all categories compared with X, with team coverage, personal life, and pathway to becoming a physician being the most popular content types. Previous studies demonstrated that orthopaedic surgery residency programs with a social media presence received a greater number of applications and had increased racial and sex diversity among residents.^12,13 Specifically, Wang et al found that programs with X accounts were associated with greater diversity, whereas engagement positively correlated with applicant numbers. Although these studies demonstrate the potential of social media, there are a lack of studies examining the specific content strategies and engagement metrics of organizations promoting diversity within orthopaedic surgery. This represents a critical gap, as effective social media strategies could further amplify the reach and impact of these organizations. The purpose of this study was to analyze the content, posting strategies, and audience engagement on Instagram and X, Formerly Twitter, of orthopaedic organizations that promote diversity in the field of orthopaedic surgery.

Methods

Organizations that aim to increase diversity within orthopaedic surgery were selected for inclusion. Nine organizations were identified: Ruth Jackson Orthopaedic Society (RJOS), American Association of Latin Orthopaedic Surgeons (AALOS), J. Robert Gladden Orthopaedic Society (JRGOS), Pride Ortho, International Orthopaedic Diversity Alliance (IODA), Women in Orthopaedics Worldwide (WOW), The Perry Initiative, Nth Dimensions, and Black Women Orthopaedic Surgeons (BWOS).

Data Collection

Organizations were identified through (1) a structured review of the American Academy of Orthopaedic Surgeons (AAOS) Diversity Advisory Board listings and affiliated organization directories, (2) review of prior peer-reviewed literature on diversity-focused orthopaedic organizations, and (3) iterative reference checking of the websites and social media profiles of identified organizations. Posts were retrieved manually by directly accessing each organization's publicly available Instagram and X profiles between November 2024 and January 2025. Posts shared between January 1, 2020, and December 31, 2024, were eligible for inclusion. For each profile, all posts within the observation window were reviewed in reverse-chronological order until the earliest in-range post was reached. Reposts (Instagram “regrams” and X retweets of external accounts) were excluded to avoid duplicate counting; original cross-platform posts were retained on each platform on which they appeared. Posts that had been deleted before data collection were not recoverable and therefore could not be included. Engagement metrics (likes, comments, retweets) were recorded as displayed at the time of retrieval and entered into a study database in Microsoft Excel (Microsoft Corp., Redmond, WA). No third-party scraping software, automated API queries, or paid analytics tools were used.

A coding scheme was developed during a preliminary review of the available data. The scheme defined each target audience category, content category, and format category with operational decision rules and example posts. Posts were divided and coded by two independent reviewers, with each reviewer responsible for a portion of the total sample. Disagreements were resolved by discussion between the two reviewers. Coding was done manually; no machine-learning or automated content-classification tools were used.

The following data were collected from each post: date, intended target (high school students, college students, medical students, residents, surgeons/attendings, mixed/unspecified), post content (personal spotlight, organization spotlight/promotion, historical content, promoting event, event recap, scholarships/grants/funding, conference/symposium/summit, educational content, volunteerism, celebration, general/news announcement), post format (text, picture, video, short-form video, infographic, mixed), likes, comments, retweets, and hashtag usage. The intended target of each post was identified by analyzing the wording, tone, and direct mentions within the post, such as references to specific career stages or clearly stated eligibility criteria for programs.

Statistical Analysis

Posts on both Instagram and X were analyzed to determine which post content and format categories were most common (%) and which were associated with the greatest engagement (represented by the median likes). Given that social media engagement data are characteristically non-normally distributed and highly right-skewed, with a small number of posts achieving disproportionately high levels of interaction, median engagement values were used as the primary summary measure rather than means. The use of median likes per post reduces the influence of viral outliers and provides a more robust estimate of typical engagement across content, audience, and format categories. This approach allows for more meaningful comparisons between platforms and post characteristics by reflecting central tendency without distortion from extreme values, which is a well-recognized consideration in analyses of social media-derived metrics.

The association between hashtag usage and engagement was evaluated. A word cloud was produced to visually represent the frequency of hashtags used. Compound annual growth rate (CAGR) and linear regression were used to examine trends in posting frequency and engagement over time on both Instagram and X. Engagement on Instagram and X was compared directly for all organizations, categories, and years. Univariate analysis of dichotomous variables used the Fisher exact test, and Welch t-test was used to compare continuous variables. A P value of < 0.05 was considered a statistically significant result.

Results

Across the nine organizations on Instagram, 2959 posts were identified and reviewed. Among the eight organizations on X, 2848 posts were identified and reviewed. On both Instagram and X, most posts were for a mixed or unspecified audience (Instagram: 2103 posts, 71.1%; Twitter: 2536 posts, 89%). Of the posts where the target audience group was specified, medical students had the greatest proportion of posts (Instagram: 653 posts, 22.1%, Twitter: 217, 7.7%). There were greater median likes on Instagram than X for all target audiences, post content, and post format categories (Table 1).

Table 1.

The Proportion of Posts and Median Likes in Each Post Content, Format, and Content Categories

Instagram and Twitter Engagement	Instagram (%)	X (%)	Instagram median likes	X median likes	P
Target audience
High school students	2.5	0	79	—	—
College students	0.2	0.1	88	0.5	0.002
Medical students	22.1	7.7	92	9	<0.001
Residents	3.4	2.3	26	4	<0.001
Surgeons/attendings	0.8	0.9	62.5	6.5	<0.001
Mixed/unspecified	71.1	89	96	7	<0.001
Post content
Personal/organizational spotlight	27.7	27.9	62	9	<0.001
Historical content	0.5	0.4	93	9	<0.001
Event related	32.7	31	42	6	<0.001
Scholarships/grants/funding	2.3	2.1	80	8	<0.001
Conference/symposium/summit	3.8	6.6	54.5	7	<0.001
Educational content	9.1	15.2	36.5	5	<0.001
Volunteerism	0.9	0.6	70	5	<0.001
Celebration	15.3	8.8	71	7	<0.001
General/news announcement	7.8	7.3	41.5	6	<0.001
Post format
Text	5.4	19.5	57	5	<0.001
Picture	19.1	4	95	9.5	<0.001
Video	7.9	4.9	40	6	<0.001
Infographic	10.1	4.4	50	5	<0.001
Mixed (text and picture)	57.5	67.1	41	8	<0.001

Bolded values indicate most common and highest engagement categories.

Posts promoting or highlighting events hosted by the organizations accounted for 966 (32.7%) of the Instagram posts and 884 (30%) of X posts. Historical content, which featured influential figures and key milestones in orthopaedic surgery, generated the highest engagement on Instagram (median likes: 93; range: 39 to 228) and also did well on X (median likes: 9; range: 0 to 30), where it matched the engagement seen with personal/organizational post (median likes: 9; range: 0 to 211) (Table 1).

Most posts on both Instagram (1700 posts, 57.5%) and X (1911 posts, 67.1%) displayed a mixed format, combining text with either pictures or video. Of posts with a singular format, pictures were most common on Instagram (564 posts, 19.1%), and text was most common on Twitter (556, 19.5%), although pictures received the greatest engagement on both platforms (Instagram: median likes 95, range 3 to 1554; X: median likes 9.5; range 0 to 182) (Table 1).

Hashtags were used in 2128 posts (72%) on Instagram and 1546 posts (54%) on X. On Instagram, posts with hashtags had 53 median likes (range 0 to 1554), and posts without hashtags had 47 median likes (range 3 to 793) (Welch t-test, P value = 0.161). The most commonly used hashtags were #Nthdimensions (669 posts, 41%), #DiversityInMedicine (602 posts, 37%), and #ILookLikeASurgeon (456 posts, 28%) (Table 2, Figure 1). On X, posts with hashtags had seven median likes (range 0 to 370), and posts without hashtags had six median likes (range 0 to 426) (Welch t-test, P-value = 0.026). The most commonly used hashtags on X were #OrthoTwitter (595 posts, 71%), #Diversity (312 posts, 37%), and #Orthopaedics (192 posts, 23%) (Table 2, Figure 1).

Table 2.

Engagement Based on Whether Posts Included Hashtags

Hashtag(s) Used	%	Average likes	Median likes	Range	P
Instagram
Yes	72	77	53	0-1554	0.161
No	28	72	47	3-793
X
Yes	54	12	7	0-370	0.029
No	45	11	6	0-426

Bolded values indicate most common and highest engagement categories.

Figure 1.

Word clouds demonstrating the most common hashtags used on Instagram (left) and X (right).

Instagram had markedly greater engagement across all organizations (Welch t-test, P < 0.001) (Table 3). Instagram had markedly greater total engagement than X across all years studied (Welch t-test, P < 0.001). Instagram displayed a 5.08% annual growth rate (95% CI, 3.04 to 5.96), which was confirmed by linear regression (P value = 0.0023), whereas changes in engagement on X did not reach statistical significance on linear regression (Table 4).

Table 3.

Engagement of Each Organization on Instagram and X

Organization	Instagram			X
	Posts	Median Likes	Average Likes	Posts	Median Likes	Average Likes
RJOS	316	94	96	268	9	14
AALOS	114	44	52	96	3	7
JRGOS	351	37	59	358	5	10
Pride Ortho	221	49	65	256	11	19
IODA	616	24	31	1084	6	9
WOW	59	82	111	223	7	10
BWOS	261	25	42	140	4	12
Nth dimensions	848	87	114	423	9	13
Perry initiative	173	99	107	—	—	—

AALOS = African American Orthopaedic Society, BWOS = Black Women Orthopaedic Surgeons, IODA = International Orthopaedic Diversity Alliance, JRGOS = J. Robert Gladden Orthopaedic Society, RJOS = Ruth Jackson Orthopaedic Society, WOW = Women in Orthopaedics Worldwide.

Bolded values indicate most common and highest engagement categories.

Table 4.

Total Engagement Across all Organizations for Each Year Compared Between Instagram and X

Year	# of posts	Median likes	Range	Average likes	CAGR for likes
Instagram
2020	371	45	3-277	64	5.08% 95% CI, 3.04–5.96 P-value: 0.0023
2021	554	54	3-1554	71
2022	688	48	5-793	74
2023	635	57	0-992	80
2024	707	54	3-758	82
X
2020	405	4	0-211	9	−4.90% 95% CI, −3.8–2.5 P-value: 0.58
2021	732	8	0-426	13
2022	777	9	0-159	14
2023	500	7	0-370	11
2024	431	5	0-85	7

Bolded values indicate most common and highest engagement categories.

Discussion

The purpose of this study was to analyze the content, posting strategies and engagement on Instagram and X, formerly Twitter, of orthopaedic organizations that promote diversity in the field of orthopaedic surgery. We found that based on the median number of likes, Instagram markedly outperformed X in terms of engagement in promoting diversity within orthopaedic surgery across all post format and content categories and for all years and organizations studied. Among posts with a specified target audience, medical students were the most common group on Instagram (22.1%), whereas X had a smaller proportion (7.7%). Engagement was notably higher on Instagram across all audience, content, and format categories, with posts involving pictures receiving the most engagement on both platforms. Event-related content represented 32.7% of Instagram posts and 30% of X posts, whereas historical content garnered the highest engagement, particularly on Instagram. A mixed format combining text with images or video was most common across both platforms, and although posts with hashtags generally had slightly higher engagement than those without on both platforms, this only reached significance for X. Overall, Instagram demonstrated markedly higher engagement than X across all organizations, with a 5.08% annual growth rate, whereas engagement on X showed nonsignificant changes over time.

Abbas et al¹⁴ examined the Instagram practices of current orthopaedic surgeons that produced the highest engagement. The authors found that posts that elicited emotional responses and actively engaged the audience through questions generated markedly higher interactions compared with other types of content. This aligns with our findings on X, where personal spotlight posts had the highest engagement across all organizations, along with historical content. This suggests that social media users are drawn to content that fosters a sense of connection, relatability, and interaction rather than purely informational or promotional posts. By highlighting personal journeys, achievements, and challenges, organizations can create a more engaging online presence.

In 2023, Thawanyarat et al¹⁵ examined content posted by plastic surgeons on Instagram. The authors found that engagement levels were the highest for personal and educational content. Although we similarly found personal spotlights to be one of the most popular categories on X, on Instagram, historical content was the most popular post category, followed by scholarships/grants/funding. This suggests that audiences within the orthopaedic community are particularly drawn to content that honors historical figures within orthopaedic surgery and provides tangible opportunities for career advancement. Historical content may be highly engaging because it fosters a sense of identity, recognition, and appreciation for pioneers in the field, reinforcing the importance of representation and diversity efforts in orthopaedic surgery.

Thawanyarat et al¹⁵ also found no notable difference in audience engagement between video and photograph formats. We found that across both Instagram and X, picture-based posts had more engagement than video-based content. This highlights a unique preference within the orthopaedic diversity space for visually impactful and quickly digestible content. Images may allow for immediate recognition of key individuals, historical moments, or scholarship announcements, making them more effective in capturing audience attention compared with video content, which requires more time investment from users. These findings suggest that organizations aiming to maximize social media engagement within orthopaedic surgery should prioritize visually striking images to enhance reach and impact.

A study by Lowe et al¹⁶ evaluated the main areas of sex disparity affecting current female surgeons by examining trending hashtags shared on X. The authors found that hashtags, such as #ILookLikeASurgeon and #WomenInSurgery, played an important role in amplifying discussions on sex disparities in surgery, substantially increasing engagement and expanding the visibility of these conversations to new audiences. The authors demonstrated that hashtags can be a powerful tool for raising awareness and inspiring change within the surgical community. This aligns with our findings on X, where hashtag usage had a statistically significant impact on engagement (P = 0.029), suggesting that engagement on this platform may rely more heavily on trending topics and discoverability through keyword optimization.

By contrast, our study found that hashtag usage on Instagram, although common, did not markedly affect engagement (P = 0.161). This suggests that hashtags alone may not be sufficient to increase visibility on Instagram, where engagement is likely driven more by visual appeal and content type rather than keyword-based discoverability. Given these findings, organizations seeking to enhance engagement on X should strategically incorporate hashtags related to orthopaedic surgery, diversity, and mentorship to maximize reach and interaction, as highlighted in Figure 1, whereas on Instagram, alternative strategies such as interactive content and eye-catching images may be more effective.

Limitations

There are several limitations to this study. First, Pride Ortho and BWOS created their Instagram and X accounts after 2020, so their contribution to the overall analysis more greatly affected later years. In addition, The Perry Initiative did not have an X account, which limited their contribution to engagement metrics on that platform. Because this organization primarily targets high school and medical students, its absence on X may have affected the overall engagement analysis for that audience category.

Second, median likes were used as a metric of social media engagement, but other variables can contribute to social media engagement that could not be accounted for based on the available data. Although engagement is an indicator of reach and audience interaction, it remains a surrogate measure for the ultimate objectives of diversity-focused orthopaedic organizations: increased awareness, meaningful mentorship, and downstream participation in orthopaedic training and careers. High engagement does not inherently equate to behavioral change, application submission, or sustained involvement in the orthopaedic pipeline. Consequently, these findings should be interpreted as reflecting platform effectiveness for outreach and audience interaction, not direct impact on workforce diversification.

An additional limitation relates to the classification of intended target audience. A substantial proportion of posts on both platforms, particularly on Instagram (71.1%), were categorized as directed toward a mixed or unspecified audience. Although this reflects the inherently broad and inclusive messaging strategy employed by many diversity-focused organizations, it limits the ability to draw definitive conclusions regarding targeted outreach effectiveness. Specifically, high engagement among posts with ambiguous audience designation cannot be reliably attributed to engagement by specific preorthopaedic pipeline groups, such as high school students, college students, or medical students. As a result, the observed engagement metrics may reflect interest from a heterogeneous audience that includes trainees, practicing surgeons, allies, or general followers, rather than the intended pipeline populations. This ambiguity represents a major constraint on interpretation and underscores that engagement observed in this study should be viewed as evidence of broad visibility rather than demonstrable efficacy in reaching or influencing specific pipeline stages.

In addition, because posts were divided between two reviewers rather than dual-coded in full, interrater reliability could not be formally assessed, which represents a potential source of variability in the content classification.

Future research is needed to bridge this gap between digital engagement and tangible outcomes. Prospective studies linking social media analytics to organizational data, such as applications to mentorship programs, attendance at sponsored events, or participation in funded opportunities, would provide critical insight into the translational impact of online engagement. Survey-based studies of followers or residency applicants could further elucidate how social media exposure influences career awareness, perceived accessibility of orthopaedic surgery, and decisions to seek mentorship or apply to training programs.

By framing engagement as an intermediate outcome rather than an end point, future work can more rigorously evaluate how social media strategies contribute to meaningful progress in diversity, equity, and inclusion within orthopaedic surgery. Establishing these links will be essential for optimizing digital outreach efforts and ensuring that high-performing content translates into measurable, real-world impact.

Conclusion

Instagram outperformed X in engagement in promoting diversity within orthopaedic surgery across all years studied. Picture format was the most engaging, likely due to its ability to quickly capture attention and convey information. Using hashtags strategically on X can enhance user engagement and extend to visibility of diversity initiatives. Leveraging visually engaging content may further enhance engagement and broaden the reach of diversity initiatives.