Patient perception of medial patellofemoral ligament reconstruction on Instagram

Abstract

To date, there is limited social media evaluation of patients after medial patellofemoral ligament (MPFL) reconstruction and analysis of their perceived surgical outcome. The purpose of this study was to examine patient perceived outcomes after MPFL reconstruction via social media analysis on Instagram. A total of 486 posts containing “#MPFL” were included in the assessment. The tone of the post was examined in relation to demographic variables and the content of the post. When comparing posts containing positive vs. negative tone, those referencing rehabilitation (P < 0.0001) and activities of daily living (ADLs) (P = 0.0002) were more likely to be positive. Posts referencing surgical incision or scar (P = 0.02) or postoperative instability/dislocation (P < 0.0001) were more likely to have a negative tone. Multivariable logistic regression identified references to incision/scar (odds ratio [OR]: 0.446, P = 0.0264) and instability/dislocation (OR: 0.071, P < 0.0001) as strong negative predictors of positive tone. However, referencing rehabilitation (OR: 2.464, P = 0.0091) or ADLs (OR: 2.251, P = 0.0187) substantially increased the likelihood of a positive post tone. In conclusion, positive tone was associated with improved rehabilitation and ability to perform ADLs postoperatively. In contrast, negative tone was associated with dissatisfaction with the scar/incision, as well as postoperative patellar instability.

Although an increasing number of studies have employed hashtag-based searches to examine patient perceptions of orthopedic procedures,^1–7 to the authors’ knowledge, no studies have used this methodology to evaluate patient perceptions following medial patellofemoral ligament (MPFL) reconstruction. MPFL reconstruction is one of multiple operative treatment approaches available to treat patellar instability, characterized by either acute or recurrent dislocation of the patella, which often presents with complaints of instability and anterior knee pain.⁸ This condition accounts for 3% of all knee injuries and most commonly occurs in individuals in their second or third decade of life, with an incidence of 29 per 100,000 in the adolescent population compared with 6 per 100,000 in the general population.^8,9 This epidemiologic pattern inadvertently corresponds with the pattern of social media use among age categories. Based on research conducted by Pew Research Center, 75% of people aged 18 to 24 and 57% of people aged 25 to 29 years have engaged with the platform Instagram.⁹ Instagram serves as both a social media site and a photo sharing platform, allowing users to share pictures, videos, or text-containing graphics along with a caption describing their post.¹⁰ Based on Instagram user demographics and the demographics of patients more likely to undergo MPFL reconstruction, Instagram may provide valuable information concerning the perspectives of MPFL reconstruction patients. This study analyzed Instagram content posted by MPFL reconstruction patients to ascertain perceived patient outcomes. Due to previous evidence suggesting improved outcome scores following MPFL reconstruction, the authors hypothesized that most Instagram content regarding MPFL reconstruction would contain a positive tone.^11–13

METHODS

A third-party application, Picodash (San Francisco, CA), was utilized to search Instagram for posts that contained the term “#MPFL” within the associated post caption. Originally known as an octothorpe, a hashtag (#) is a search filter on social media that allows users to filter and search content unique to their interests. Ethical approval was not necessary, as all posts have been made publicly available by the user. Four reviewers evaluated all posts and determined tone positivity or negativity. Prior to statistical analysis, the reviewers agreed upon all posts. Disagreements between reviewers were resolved through formal discussion with the remaining authors.

The third-party application identified 2521 posts that met the original search criteria. We excluded 2035 posts due to their association with personal physician accounts, health accounts, or industry accounts intended for advertisement or because they were unrelated to medicine. Among the remaining 486 posts, we assessed the following variables: gender, tone (positive/negative), instability/dislocation postoperatively, pain, reference to surgical incision/scar, return to sport, brace, age (pediatric/adult), rehabilitation, and activities of daily living (ADL).

Data were entered into Microsoft Excel 2011 (Microsoft Corporation, Redmond, WA), and statistical analyses were conducted in SAS 9.4 software (SAS Institute, Cary, NC). Chi-square testing was used for categorical variables. To identify independent predictors for positive post tone, we conducted data analysis in two phases. First, individual covariates were assessed using chi-square testing for positive tone. Second, parameters independently predictive of positive tone (P < 0.05) on bivariate analysis were combined into a multivariable logistic regression model generating relevant odds ratios (OR) and 95% confidence intervals. Model calibration was assessed using the Hosmer-Lemeshow test (with P > 0.05 indicating adequate calibration).

RESULTS

Posts discussing rehabilitation (OR: 2.464, P = 0.0091) and ADLs (OR: 2.251, P = 0.0187) were significantly more likely to be positive, and posts referencing surgical incision/scar (OR: 0.446, P = 0.0264) or postoperative instability/dislocation (OR: 0.071, P < 0.0001) were significantly more likely to be negative. Table 1 presents descriptive statistics on patient and post characteristics. Table 2 provides the results of univariate and multivariable logistic regression analyses.

Table 1.

Patient characteristics and variables identified from patients posting #MPFL

Variable	Tone of Instagram post		P value
	Positive (n = 432)	Negative (n = 54)
Gender			0.1465
Male	20 (5)	5 (9)
Female	412 (95)	49 (91)
Age group			0.7527
Pediatric	22 (5)	2 (4)
Adult	410 (95)	52 (96)
Brace	87 (20)	10 (19)	0.7728
Rehabilitation	288 (67)	19 (35)	<0.001
Activities of daily living	250 (58)	17 (31)	0.0002
Incision/scar	85 (20)	18 (33)	0.0206
Pain	177 (41)	20 (37)	0.5697
Instability/dislocation	14 (3)	22 (41)	<0.001
Athlete/sport-related	36 (8)	6 (11)	0.4969

Table 2.

Results of univariate and multivariable logistic regression for #MPFL variables assessed on Instagram

	Univariate logistic regression			Multivariable logistic regression
	Odds ratio	95% CI	P value	Odds ratio	95% CI	P value
Gender	2.102	0.755–5.851	0.1549
Age group	1.268	0.288–5.581	0.7534
Incision/scar	0.49	0.265–0.910	0.0226	0.446	0.219–0.910	0.0264
Pain	1.185	0.660–2.126	0.5701
Instability/dislocation	0.049	0.023–0.104	<0.001	0.071	0.032–0.158	<0.001
Brace	1.113	0.539–2.299	0.7729
Athlete/sport related	0.729	0.292–1.818	0.4979
Activities of daily living	2.99	1.632–5.476	0.0004	2.251	1.145–4.428	0.0187
Rehabilitation	3.684	2.036–6.668	<0.001	2.464	1.251–4.850	0.0091

CI indicates confidence interval.

DISCUSSION

As medicine becomes more patient-centric, it is imperative that clinicians identify factors that are of vital importance to their patients. Within a more value-based health care system, any modifiable variable to improve outcomes after surgery should be implemented. Social media has emerged as a popular method to distribute information and presents a unique opportunity for surgeons to identify areas of improvement for their patients. Our analysis of social media posts after MPFL reconstruction revealed statistical significance between positive tone and improved rehabilitation, as well as ability to perform ADLs postoperatively. In contrast, patients who continued to have postoperative patellar instability or a recurrent patellar dislocation perceived their surgery in a negative tone. Interestingly, patients also had a negative tone related to their surgical incision/scar. Senior authors of this article have anecdotally seen similar dissatisfaction with surgical scars after surgery. Although it is technically more challenging, they have altered their surgical approach to a transverse rather than longitudinal incision, as this has improved postsurgical incision scarring and appears to be more cosmetically pleasing.

This investigation has its limitations, as do all studies that involve analysis of social media posts. Given the subjective nature of social media posts, there is inherent selective bias within the post analysis. To mitigate the degree of bias, posts in which it was difficult to discern the tone were evaluated by multiple authors and agreed upon as a team. This was felt to be the most reasonable approach to resolving this issue and minimizing confusion among social media posts. The authors also recognize that “tone” is a spectrum, with varying degrees of positivity/negativity. However, in order to perform consistent statistical analysis, a binary approach was taken, as we attempted to define the overall tone of the post as positive or negative. Additionally, the authors did not identify the number of unique accounts posting. Therefore, it is possible that an individual account could make multiple posts, positive or negative, which could influence the observed trends in the presented study.

The surgical commentary assessed by the present study occurs in most surgical procedures and may not be unique to MPFL reconstruction surgery, but it was beyond the scope of this investigation to evaluate MPFL in comparison with other surgical procedures. This same methodology has seen successful in other realms of orthopedics and has proven to be a valuable source of improved information about patients after surgery.^1–7 Additionally, the next generation of orthopedic surgeons and residency programs have begun to utilize social media platforms, such as Instagram, to represent themselves during residency recruitment.^14,15 As trainees progress from training to clinical practice, it is likely they will begin to utilize social media as a form of physician-patient connection. This emphasizes the importance of understanding what patient content is present on social media platforms in order to establish a “virtual rapport” with patients utilizing social media applications.

This social media analysis showed a largely positive tone when describing MPFL reconstruction surgery in patients. More specifically, patients with improved postoperative rehabilitation and ability to perform ADLs seemed more pleased with their operation. In contrast, patients who had recurrent patellar instability or a cosmetically displeasing scar perceived their surgery in a negative tone. These data would indicate that patients believe their surgery is a success when these variables are optimized. Physicians should utilize this information to be aggressive with rehabilitation, emphasize ADLs early in the postoperative phase, spend time with cosmetic closure, and continue to utilize sound indications leading to positive perceived outcomes of MPFL reconstruction surgery.

In conclusion, analysis of social media posts on Instagram after MPFL reconstruction demonstrated an overall positive tone toward the operative intervention. Positive tone was associated with improved rehabilitation and ability to perform ADLs postoperatively. In contrast, dissatisfaction with the scar/incision, as well as postoperative patellar instability, was associated with a negative tone in posts. Understanding variables that are important to patients with patellar instability may assist surgeons in discussions with their patients, provide guidance with postoperative expectations, and improve patients’ perceived outcome after MPFL reconstruction.