TAR is a biomechanical complex and technically challenging procedure which, despite advances, requires strict post-operative program compliance and carries a high risk of complications [28-30]. Thus, if patients are to be able to fully consent to this undertaking, they must have access to reliable information at a level which is easily comprehendible .
As observed in previous studies regarding health consumers and the internet, this study has demonstrated that the majority of health education websites regarding TAR exceed the comprehension level of the intended audience [44-50,54]. By failing to adhere to the suggested levels of readability, these websites which are meant to assist patients in understanding their procedure will instead create confusion and anxiety, potentiating the risk of patients developing cyberchondria . This will affect levels of adherence with post-operative care, leading to missed appointments, increased complications, increased hospital re-admission rates and reduced satisfaction with overall treatment outcomes [33-38]. A lack of credible information may affect the patient’s ability to give informed consent in regards to a procedure . As mentioned in the introduction to this article, TAR has an extremely specific post-operative course which includes a significant amount of time non-weight bearing; failure to comply with this due to a lack of understanding and adherence could result in potentially disastrous complications [28-30,37].
It is thus disquieting that the TAR sites evaluated in the study exhibited an average RGL of 8.31, well above those recommended previously [40-41,56-57]. 84% of the materials which underwent analysis scored above the recommended sixth-grade reading level with roughly 25% of the materials evaluated were scored at readability levels advised for university textbooks. This observation has note only been noted during this specific study but appears as a consistent trend across the literature, supporting a developing worrisome trend that patients will not be able to fully perceive the information regarding TAR [33-39,49].
However, a surprising yet positive aspect which must be noted during this analysis is that although the mean RGL for the TAR websites is above the recommended standard, it is better than the quoted RGL scores for hip and knee arthroplasty in the literature. One paper by Shnaekel et al analysed nine sets of patient education material for hip and knee arthroplasty and found them to have a cumulative RGL of 10.5 . Similarly, Polishchuk et al published a study in 2012 which estimated Reading Grade Level using a different readability test, the Flesch-Kincaid. Using this test, their study shows an estimated RGL for arthroplasty materials of 11.1 . These figures suggest that while TAR website Reading Grade Levels may not be compliant with the recommended standards, there is an awareness of the need to simplify the information among Foot and Ankle specialists.
This difference could be speculated to be associated with the fact that most orthopaedic surgeons are aware that the majority of patients will know someone within their social or family circles who will have had a hip or knee arthroplasty procedure that they will be able to seek counsel from. However, TAR is a rarer procedure and thus, places more onus on the physician to provide quality information to the patient. This sense of responsibility may be translated into better quality of information being presented on websites, in a bid to communicate more effectively with potential health consumers.
A second concerning trend noted during the analysis is the low FRES scores for the commercial, academic and physician sections shown in Figure 2. The scores for the academic websites, which are affiliated with major teaching hospitals, and for physician sites, which are private foot and ankle specialists, are 55.85 and 53.66 respectively. These FRES score, as noted in Table 2, means that these websites are at a level that requires nearly university level education to be read and understood on the first pass; this is not feasible for many patients and may leave them confused and overwhelmed. The commercial websites have a mean FRES score of 37.97, which means they require higher education to be able to understand these websites. While it must be acknowledged that commercial sites will contain more technical terms than are perhaps found in the other categories, their FRES score is approximately on par with the readability of the score given to Harvard Law Review [44-47,52]. This would be beyond the scope of comprehension for the majority of patients.
There is much scope to further improve the readability of the TAR websites and to make them compliant with the suggested RGL standards. The Agency for Healthcare Research and Quality (AHRQ) has previously advised an approach of assuming all patients and caregivers have difficulty understanding health information and should be communicated with in a manner that anyone can understand . Suggested application of this method for health-related education materials includes the use of diagrams and simple words in a simple conversational style while avoiding jargon [60-65]. Videos could be used to provide an additional further understanding of the procedure and its rehabilitation course.
Orthopaedic surgeons who have a specialised interest in foot and ankle surgery should undertake the responsibility of creating easily comprehensible, high quality education materials based on these guidelines. TAR requires a unique perspective in that the material should not only provide information regarding the surgery itself but should also provide in-depth data about the post-operative care and rehabilitation. Once created, physicians and hospitals should then evaluate these materials using the widely available readability software. Ideally, they should look for a readability software that identifies complex words and offers substitutions; the authors suggest this as most experienced physicians are used to academic script and may be blinded to what constitutes a simple or complex word. An example of this would be substituting the more complex “components” for the simpler, more readily understood words “parts” .
The final suggestion the authors submit for improving readability and accessibility is to have websites offer translation options where possible. Society has become extensively multicultural in the last two decades and it is no longer acceptable to assume that English is the first language of every household or health consumer .
This study is the first to consider the readability of the information on the internet in regards to TAR. However, it must be acknowledged that there are shortcomings within the study . Materials on the internet are in constant flux yet we limited are search strings to a single day. Thus, we acknowledge that there may be better websites which were missed as a result. Furthermore, the first three pages of each search engine was evaluated for each search term; while this was in keeping with the guidelines followed in previous studies, it may mean that more accessible and readable websites on later pages have been excluded [39,49].
A final limitation is the software used. The readability formulae determine the difficulty of the passage is based on the letters per word, the syllables per word or the number of words per sentence. This means that everyday words such as ‘replacement’ may generate a higher RGL than words with fewer syllables and letters such as ‘physis’ which is a medical term and would be poorly understood by the general public .