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Determinants of patient satisfaction after surgery or corticosteroid injection

for trapeziometacarpal osteoarthritis: Results of a prospective cohort study

Article  in  Archives of Orthopaedic and Trauma Surgery · November 2014

DOI: 10.1007/s00402-014-2119-0 · Source: PubMed

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Arch Orthop Trauma Surg
DOI 10.1007/s00402-014-2119-0
HANDSURGERY
Determinants of patient satisfaction after surgery
or corticosteroid injection for trapeziometacarpal
osteoarthritis: results of a prospective cohort study
Miriam Marks • Laurent Audigé • Lisa Reissner •
Daniel B. Herren • Stephan Schindele •
Thea P. M. Vliet Vlieland
Received: 5 May 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Introduction The evaluation of patient satisfaction is
becoming increasingly important in assessing treatment
outcomes. The objective of this study was to analyze the
determinants of treatment satisfaction in patients with tra-
peziometacarpal osteoarthritis (TMC OA) after surgery or
corticosteroid injection.
Materials and methods Prospective cohort study of
patients with TMC OA who received surgery or cortico-
steroid injection was carried out. Socio-demographic and
clinical data were recorded at baseline and 1 year after the
intervention, and patients filled out the Michigan Hand
Outcomes Questionnaire (MHQ). On a 5-point Likert scale,
patients reported baseline expectations, expectation fulfill-
ment at 1 year, as well as satisfaction with the treatment
result. To identify determinants of satisfaction, we entered
these variables into one ordered logistic regression model
for surgical patients and another for patients with injection.
Results We included 146 patients, 88 of whom were
treated surgically. With respect to satisfaction at 1 year,
87 % of the surgical patients were somewhat or very sat-
isfied with the treatment result, whereas only 49 % of the
patients with injection were satisfied. Expectations being
fulfilled was the only determinant of treatment satisfaction
M. Marks (&)
L. Audigé
Department of Research and Development, Schulthess Clinic,
Lengghalde 2, 8008 Zurich, Switzerland
e-mail: Miriam.Marks@kws.ch
M. Marks
T. P. M. Vliet Vlieland
Department of Orthopaedics, Leiden University Medical Center,
Leiden, The Netherlands
L. Reissner
D. B. Herren
S. Schindele
Department of Hand Surgery, Schulthess Clinic,
Zurich, Switzerland
in the surgical group. In the injection group, a more
advanced Eaton stage of TMC OA and greater pain at
1 year were associated with reduced satisfaction.
Conclusions Surgery for TMC OA leads to high patient
satisfaction, whereas only half of the patients treated with
corticosteroid injection were satisfied with the treatment
result. An advanced stage of TMC OA and higher pain lead
to reduced treatment satisfaction in the latter group, indi-
cating that corticosteroid injection is only effective for
patients in a lower stage of disease. As fulfillment of
expectations was an important determinant of satisfaction
in the surgical group, we emphasize the need to provide
comprehensive information prior to surgery, so that the
patient’s expectations of treatment outcome are realistic.
Keywords Carpometacarpal joint
Injection

Osteoarthritis
Satisfaction
Surgery
Introduction
After the distal interphalangeal joints, the trapeziometa-
carpal (TMC) joint is the hand joint most frequently
affected by osteoarthritis (OA) [15]. Treatment strategies
consist of either surgical or conservative management [1].
Trapezium resection with ligament reconstruction and
tendon interposition (LRTI) is the primary choice for
62–68 % of American hand surgeons who perform surgery
for TMC OA [4, 38]. In the conservative treatment of TMC
OA, 89 % of American hand surgeons prefer corticosteroid
injections [38].
Irrespective of the type of intervention, an evaluation of
patient satisfaction is becoming increasingly important in
assessing treatment outcomes. Satisfied patients are more
compliant with treatment and are more likely to return to
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 Author's personal copy
the same healthcare provider [23, 28]. However, quanti-
fying satisfaction is demanding because of the influence of
a variety of, so far, poorly defined factors on the patient‘s
perception of a satisfactory outcome [5, 23].
In hand surgery, it has been shown that the factors like
pain and function are associated with treatment satisfac-
tion. Furthermore, the appearance of the hand, its strength,
range of motion, and expectations fulfilled seem to influ-
ence the satisfaction of patients with various hand disorders
[26]. A retrospective study including patients with TMC
OA after implant arthroplasty found that pain, movement,
strength, and functional ability were moderately correlated
with satisfaction [22], but no prospective studies investi-
gating the determinants of patient satisfaction after surgical
and conservative management of TMC OA are currently
available.
The objective of this study was to analyze the deter-
minants of treatment satisfaction in patients with TMC OA
after surgery or corticosteroid injection.
Methods
This analysis is part of a monocenter, prospective cohort
study which was carried out in the department of hand
surgery of an orthopedic hospital and was approved by the
local ethics committee.
Patients and treatment
The parent study included all patients, with a radiograph-
ically confirmed diagnosis of TMC OA who underwent
either conservative or surgical treatment for that condition
in the months from September 2011 to November 2012.
Exclusion criteria were: TMC OA was not the main
problem at the time of consultation, rheumatoid arthritis,
concomitant surgery on other fingers, legal incompetence,
poor general condition precluding study participation,
previous inclusion in this study for the other hand, and
insufficient knowledge of the German language to com-
plete the questionnaires. All eligible patients were asked to
participate by their hand surgeon, and were consecutively
enrolled in the study after they had given written informed
consent.
For the present analysis, the surgical group included
only patients who received trapeziectomy with LRTI
according to Epping [11], Weilby [37], or Sigfusson and
Lundborg [31], whichever method was preferred and rou-
tinely performed by each surgeon. In some cases, the sur-
geon chose a GraftJacket as interpositional material [20].
Additional procedure such as carpal tunnel release was also
performed, if required. Conservative treatment consisted of
at least 1 corticosteroid injection.
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Arch Orthop Trauma Surg
In each case, the surgeon chose the treatment strategy in
discussion with the patient. Analgesics or hand therapy
including splinting might have been prescribed additionally
in both groups, if it was indicated.
Some patients were initially treated with injection but
later decided on surgery. Data available until such time
were used for the analysis of conservatively treated
patients. These patients were not included in the surgical
group in the present analysis to prevent confounding from
double inclusion.
Outcome measures
An independent examiner assessed patients at baseline, and
3, 6, and 12 months after the start of treatment. Socio-
demographic and disease-related data were gathered at
baseline. At each study visit, patients underwent a clinical
assessment and completed a questionnaire set consisting of
the Michigan Hand Outcomes Questionnaire (MHQ) and
the Short Form (SF) 12, version 2.0.
The MHQ, developed by Chung et al. [6], is a hand-
specific questionnaire which yields results for each hand
separately. It consists of 37 items divided into six sub-
scales: hand function, activities of daily living (ADLs),
pain, work performance, aesthetics, and satisfaction with
hand function. The psychometric properties of the MHQ
have been assessed in patients with TMC OA and show
overall good reliability, validity, and responsiveness [25].
The total score and all six subscale scores are normalized
and range from 0 to 100; higher scores indicate better
performance, except for the pain subscale, where a higher
score denotes more pain. The German version [19] was
used for this study and the data for the affected hand were
analyzed.
The SF-12 is a short version of the SF-36 for assessing
quality of life. Its twelve questions give two component
summary measures of physical health and mental health.
The scores range from 0 to 100, with higher scores repre-
senting better health, and the norm value being 50 ± 10
[36]. Although the full version (SF-36) has been investi-
gated in patients with TMC OA, the SF-12 itself has not
[2].
Expectations were recorded at baseline. Patients gave
their most important reason for seeking treatment. They
could choose from a list of 8 predefined reasons, e.g. pain
reduction, or add free text. Patients rated their expectation
of this reason to be fulfilled after one year on a 5-point
Likert scale ranging from ‘totally fulfilled’ to ‘not at all
fulfilled’. At each follow-up, patients were asked if their
expectations regarding the specific reason had been ful-
filled and again they answered on a 5-point Likert scale.
At every follow-up visit, we also asked about satisfac-
tion with the treatment result, which patients answered on a
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Arch Orthop Trauma Surg
5-point Likert scale ranging from ‘very satisfied’ (5 points)
to ‘very dissatisfied’ (1 point).
Key pinch was assessed in a standardized sitting position
using a digital pinch gauge (ELINK, Biometrics Ltd.,
Gwent, UK). We took the average of three measurements
on the affected hand for further analysis.
The evaluation of active thumb opposition was based on
the Kapandji index, ranging from 1 to 10 [16]. Patients try
to touch their fingers with the tip of the thumb. The score is
1 when patients are able to touch only the lateral side of the
index finger and 10 when they can reach the volar crease of
the hand.
Active MCP I extension was measured with a digital
goniometer (ELINK, Biometrics Ltd., Gwent, UK).
Standard a/p radiographs of the hand were taken at
baseline, and the severity of OA was graded from stage I
(normal articular contours with joint widening due to lig-
ament laxity) to stage IV (complete TMC joint deteriora-
tion and narrowed, sclerotic scaphotrapezial joint) using
the Eaton classification [10].
Statistics
Within-group changes for the abovementioned outcome
measures over 1 year were calculated using an analysis of
variance for repeated measures (ANOVA) with Scheffé’s
post hoc adjustment for multiple comparisons. Differences
regarding satisfaction between the patients who went to
surgery following injection compared to those who did not
were tested with the Mann–Whitney U test.
We used ordered logistic regression to identify deter-
minants of patient satisfaction. All the outcome measures
previously mentioned, at baseline and 1 year were possible
candidates for the regression model, as well as the baseline
variables of gender, age, duration of thumb complaints, and
number of previous injections. These variables were first
checked for collinearity using the variance inflation factor
(VIF). A VIF of 5 indicates moderate collinearity and a
VIF of 10 indicates severe collinearity [3]. We excluded
variables with a VIF [ 5. The remaining variables were
entered into one ordered logistic regression model for
surgical patients and another for patients treated with
injection, with treatment satisfaction at 1 year being the
dependent variable. Stepwise backward elimination
removed all variables with p [ 0.05, until only variables
with p B 0.05 were left. As some data for the dependent
variable ‘‘treatment satisfaction at 1 year’’ were missing,
we imputed such data, based on the assumption that values
were missing at random (MAR). Multiple imputation is an
accepted statistical technique to reduce bias due to missing
data and is justified by statistical theory and simulation
studies [7, 17, 32]. A multiple imputation model was built
containing relevant baseline data. We created 20 imputed
datasets and pooled them using Rubin’s combination rules.
All analyses were done with Stata 12.1.
Results
We included 146 patients in our study, of whom 88 (60 %)
received surgery, while 58 (40 %) patients received an
injection (Fig. 1). Fourteen (24 %) patients in the injection
group had surgery during the follow-up period, on average
7 ± 2.1 months after conservative treatment had started.
Baseline characteristics for both groups are displayed in
Table 1. At 1 year, data were available from 116 patients,
which correspond to a follow-up rate of 79 % (Fig. 1).
In both groups, patients showed a significantly improved
hand function after treatment, measured with the MHQ. In
the surgical group, the MHQ increased from 46 points at
baseline to 79 at 1 year (p B 0.001), whereas patients in
the injection group had scores of 59 and 67 points
(p = 0.01), respectively (Table 2).
With respect to treatment satisfaction at 1 year, 69
(87 %) of the surgical patients were somewhat or very
satisfied with the treatment result, whereas only 18 (49 %)
of the patients in the injection group reported that they
were somewhat or very satisfied with the result (Fig. 2).
Complications affecting the flexor carpi radialis tendon
occurred in three patients after surgery. Two patients
needed surgical revision but were satisfied or very satisfied
with the treatment result at 1 year. The third patient was
treated with analgesics and was still dissatisfied after a
year. At the 3 months follow-up, patients who went to
surgery between 3 and 6 months after injection were not
less satisfied than those who did not request surgery (sat-
isfaction score of 3.8 ± 1.8 vs 4.0 ± 1.2; p = 0.995). In
contrast, those who went to surgery between 6 and
12 months were less satisfied at the 6 months follow-up
than patients without subsequent surgery (3.0 ± 1.6 vs
4.2 ± 1.1; p = 0.05).
The regression analyses showed that expectations being
fulfilled was the only determinant of treatment satisfaction
at 1 year in the surgical group (Table 3). In the group who
received injection, a more advanced Eaton stage and
greater pain at 1 year were associated with reduced satis-
faction (Table 4).
Discussion
The results of this cohort study on the determinants of
satisfaction in patients with TMC OA showed that 87 % of
the surgical patients were satisfied with treatment at 1 year,
whereas only half of the patients treated with corticosteroid
injection were satisfied at this time. The fulfillment of
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Arch Orthop Trauma Surg

Fig. 1 Patient recruitment diagram

Table 1 Baseline characteristics of 146 patients stratified by In this non-randomized study, we saw that patients
treatment treated with a corticosteroid injection had a better func-
Characteristics Surgery Conservative tional status at baseline and shorter duration of complaints
(n = 88) (n = 58) than patients scheduled for surgery. Despite the better pre-
conditions of the conservatively treated patients, these
Female, no. (%) 78 (89) 46 (79)
patients were less satisfied with the treatment result than
Age (years) 63.2 ± 9.1 64.4 ± 9.8
patients who were operated. Furthermore, although being
Patients taking drugs for thumb pain, 40 (45) 12 (21)
no (%)
statistically significant, the change in the MHQ score
between baseline and 1 year in the injection group was
Number of drugs per week for thumb 7.9 ± 5.9 8.5 ± 7.8
pain only 8 points. As this change is below the value of 17
Duration of complaints (months) 45 ± 55 24 ± 21 points for the minimum important change (MIC) [25], we
Eaton stage of osteoarthritis 2.9 ± 0.7 2.7 ± 0.5 can assume that this result is not clinically meaningful for
Intervention, no. the patients. This suggestion is in accordance to other
Trapeziectomy and LRTI 80 studies who found that corticosteroid injections can indeed
Trapeziectomy and LRTI and CTS 6 significantly reduce pain but only in the short term, with a
release single injection being effective for about 4 weeks up to
Trapeziectomy and LR and 2 6 months [14, 18, 21, 33].
interposition with GraftJacket The decision for the treatment strategy was made indi-
Corticosteroid injection 58 vidually for each of our patients. Our hand surgeons usu-
If not otherwise indicated, the mean ± standard deviation is given ally prefer to treat patients with only mild complaints
LRTI ligament reconstruction and tendon interposition, CTS carpal
conservatively, but suggest surgery to patients with severe
tunnel syndrome pain and restrictions in their daily life. This approach is
similar to that in other studies recommending surgery in
cases where pain limits the activities of daily living or
expectations was an important determinant of treatment when conservative treatment fails [1, 8, 39].
satisfaction in the surgical group, while a more advanced Our results show, that expectations being fulfilled is a
Eaton stage and greater pain at 1 year were associated with strong determinant of treatment satisfaction in the surgical
reduced satisfaction in the injection group. group. An association between expectations fulfilled and

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Arch Orthop Trauma Surg

Table 2 Results of the outcome Outcome measure Surgery p value Conservative p value
measures at baseline and 1 year
Baseline 1 year Baseline 1 year

MHQ total score (0–100, 100 = best) 46 ± 15 79 ± 16 £0.001 59 ± 13 67 ± 16 0.010

SF-12 Physical Health (0–100, 37 ± 7.9 46 ± 10 £0.001 40 ± 8.3 40 ± 9.2 0.520
100 = best, 50 = norm)
SF-12 Mental Health (0–100, 50 ± 13 53 ± 11 0.091 50 ± 12 50 ± 10 0.985
100 = best, 50 = norm)
MHQ Michigan Hand Outcomes Kapandji Index (0–10, 10 = best) 8.4 ± 1.8 9.0 ± 1.1 0.005 9.1 ± 1.1 8.9 ± 1.5 0.930
Questionnaire, SF-12 Short Key pinch (kg) 3.0 ± 1.9 3.6 ± 1.8 0.012 4.4 ± 2.2 3.9 ± 2.2 0.445
Form 12 questionnaire, MCP Active MCP extension (°) 7.8 ± 11 12 ± 8.9 £0.001 11 ± 10 11 ± 9.5 0.758
metacarpophalangeal joint I

Fig. 2 Treatment satisfaction of surgical and conservatively treated patients at different times of follow-up

Table 3 Results of the ordered logistic regression on treatment sat- Table 4 Results of the ordered logistic regression on treatment sat-
isfaction at 1 year for surgical patients isfaction at 1 year for patients treated with corticosteroid injection
Coefficient Standard p value 95 % Coefficient Standard p value 95 %
error confidence error confidence
interval interval

Expectations 3.17 0.62 B0.001 1.95–4.38 Eaton stage of -2.00 0.68 0.003 -3.34 to
fulfilled at osteoarthritis -0.66
1 year MHQ pain score -0.08 0.02 B0.001 -0.12 to
at 1 year -0.04
MHQ Michigan Hand Outcomes Questionnaire
patient satisfaction has also been reported for patients after
MCP arthroplasty [30]. In patients after carpal tunnel
release, it has been shown that expectations being met and Shoulder and Hand questionnaire (DASH) scores. The
a generally optimistic view of health accounted for 31 % of association between expectations and satisfaction revealed
the variability in postoperative Disabilities of Arm, in our study substantiates the relevance of the decision-

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making process (i.e. shared decision making) prior to a
surgery. It is important that the physician is aware of the
patient’s expectations to ensure that the patient makes
realistic assumptions about the possible treatment outcome
[27, 35].
In patients treated with injection, a more severe stage of
TMC OA and higher residual pain determined lower
patient satisfaction, indicating that corticosteroid injection
is only effective for patients with a lower stage of disease.
These findings are substantiated by other studies, where
patients with stage I or II TMC OA obtain greater and more
sustained benefit from conservative treatment than patients
with more severe TMC OA [9, 18]. Furthermore,
researchers recommend surgery in cases where pain limits
the activities of daily living or when conservative treatment
fails [1, 8, 39].
In a systematic review of determinants of patient satis-
faction after any orthopedic intervention to the hand, it was
found that other parameters, such as esthetics, range of
motion, or strength may influence satisfaction [26]. How-
ever, we did not find any of these variables to be a deter-
minant of satisfaction in our groups. We suggest that the
appearance of the hand may not be as important to patients
with TMC OA as it is, for example, to patients with
rheumatoid arthritis [12, 24]. Regarding the so-called
objective outcomes, there is conflicting evidence in the
literature, to what extent they indeed influence patient
satisfaction [26].
When assessing patient satisfaction it must be remem-
bered that several dimensions contribute to the individual
perception of satisfaction. Satisfaction with the treatment
outcome is only one aspect. Other aspects include facilities,
service features, continuity of care, humaneness, compe-
tence, and the treatment process itself [13, 23]. Further-
more, patient satisfaction is influenced by specific personal
characteristics comprising expectations, demographics, and
personal preferences [29].
The present study has some limitations: our patients
received different conservative or surgical interventions,
because the treatment strategy was chosen individually in
each case. This precludes any conclusions for or against a
specific intervention. As some data were missing, we were
forced to impute them. In cases where data are missing, a
‘‘replacement’’ of such values is recommended instead of
analyzing only complete cases. With multiple imputation,
bias due to missing data can be reduced, but data are still
estimations [7, 17, 32]. An example of the use of multiple
imputation in patients with hand OA can be found in a
cross-sectional study with incomplete survey data [34].
Further research is needed to address the issue of assessing
patient satisfaction and expectations. As these outcomes
have previously been measured using various approaches
such as Likert scales, visual analog scales, or self-
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Arch Orthop Trauma Surg
developed questionnaires, statistical comparisons between
studies are not possible [26]. One focus should be the
development of a standardized assessment tool for routine
use in clinical practice to evaluate patients’ expectations
prior to treatment, fulfillment of expectations, and satis-
faction at the end of treatment.
Based on our results, we can conclude that surgery for
TMC OA leads to high patient satisfaction, whereas only half
of the patients treated with a corticoid injection were satisfied
with the treatment result. An advanced stage of TMC OA and
higher pain lead to reduced treatment satisfaction in the latter
group indicating that corticosteroid injection is only effec-
tive for patients with a lower stage of disease. After surgery,
expectations being fulfilled is a strong determinant of treat-
ment satisfaction. This highlights the need to evaluate
expectations and provide patients with comprehensive
information prior to any intervention, to ensure that their
expectations of the treatment outcome are realistic.
Acknowledgments We would like to thank Dr. Meryl Clarke for
her support in preparing the manuscript, Prof. Dr. Rob Nelissen and
Dr. Jörg Goldhahn for their contributions during study planning, Dr.
Sebastian Kluge and Dr. Silvia Kündig for their contributions to
patient recruitment, and Stefanie Hensler and Franziska Kohler for
their assistance in data collection.
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