The Attitudes of Patients Toward Orthopaedic Post-surgical Scars

Background Post-surgical scars (PSS) are an expected consequence of surgery. Several factors have previously been associated with PSS satisfaction including patient age and time elapsed post-operative. Little data are available regarding patient attitudes toward orthopaedic PSS. Knowledge of patient attitudes and the various associated factors may allow physicians to administer peri-operative care to mitigate the potential negative effects of PSS. Our study aims to investigate the attitudes of patients toward their PSS using quantitative scar assessment scales and to identify factors associated with PSS satisfaction. Methods We conducted a retrospective study with a follow-up. We included all patients with orthopaedic PSS on their upper or lower limbs between two and 18 weeks postoperative attending Cork University Hospital, Ireland, between February and August 2022. Patients completed an initial baseline questionnaire and then a follow-up questionnaire six months post-operative. The Patient and Observer Scar Assessment Scale (POSAS) evaluated PSS satisfaction. The European Quality of Life 5 Domain (EQ-5D), alongside several Likert scales, evaluated the patient's quality of life (QoL). Results In total, 91 patients were included. The mean POSAS score was 28.41 (95% CI, 25.85-30.97). Younger patient age (p=0.045) and decreased time passed post-operatively (p=0.002) were associated with poorer PSS satisfaction. Patients reporting their PSS appearing worse than expected were more likely to agree that their QoL had been adversely affected by it (p=0.001). Conclusion Most patients were satisfied with their orthopaedic PSS. This study identified several factors associated with poor PSS satisfaction. Our finding, which associated patient scar expectations and QoL, is novel and has not been previously examined. Accordingly, peri-operative interventions, including scar expectation management, may be implemented to mitigate scar-related QoL impact.


Introduction
Post-surgical scars (PSS) are an inevitable consequence of surgery.Previous studies have indicated that patients are broadly satisfied with their PSS [1][2][3] although some may experience a poorer quality of life (QoL) [4].
The Patient and Observer Scar Assessment Scale (POSAS) [5] is a validated, quantitative scoring tool that evaluates aspects of a PSS, including pain and colour.Similarly, questionnaires such as the European Quality of Life 5 Dimension (EQ-5D) [6], as well as Likert scales [7], can quantitatively evaluate a patient's QoL.
Numerous factors are believed to influence patients' attitudes towards their PSS, including time elapsed post-operation, patient age, race, and scar location [8,9].
Understanding the factors influencing patient PSS satisfaction facilitates targeted peri-operative interventions that may improve PSS cosmesis, patient satisfaction, and QoL.These include peri-operative discussions managing patient PSS expectations [10] and post-operative treatments [11].Unfortunately, there is little data available regarding patient attitudes towards orthopaedic PSS.
Our study aims to investigate the attitudes of patients towards their PSS using quantitative scar assessment scales and to identify factors associated with PSS satisfaction.

Inclusion and exclusion criteria
We conducted a retrospective study with a follow-up.We included all patients with orthopaedic PSS on their upper or lower limbs who attended Cork University Hospital (CUH), Ireland, between February and August 2022 and were between two and 18 weeks post-operative.
We excluded patients with diagnosed dementia, patients who underwent orthopaedic surgery at another facility, and patients with PSS in other body locations.

Data collection
Ethical approval was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals (Approval number: ECM 6 (h)).Following approval, the author attended CUH and accessed patient notes to identify patients who met the inclusion criteria and were due to attend that day.
The patient completed the following questionnaires: A general information questionnaire (which included consent to participate) (Figure 1), the patient section of the Patient and Observer Scar Assessment Scale (POSAS) (Figure 2), the European Quality of Life 5 Dimension Scale (EQ-5D) (Figure 3), and several Likert scales (Figure 4).

FIGURE 4: Likert Scale Questionnaire
The questionnaires were administered to patients on two occasions: between two and 18 weeks postoperative (in-person at the CUH orthopaedic fracture clinic, baseline questionnaire) and at six months postoperative (via telephone).

Retrospective chart review
After completion of the initial questionnaire, the following data were collected from participant postoperative notes: Date of operation, operation type, closure method (presence/absence of clips), presence/absence of surgical complications, and scar location.

Questionnaire design
To assess PSS satisfaction, the author obtained permission to use the POSAS questionnaire.As this study only examined patient PSS satisfaction, the "Observer" section was omitted.The total score ranged from six to 60 with a lower score indicating a better scar.
To assess the QoL impact of PSS, the author obtained permission to use the EQ-5D questionnaire.The EQ-5D score ranged from -0.594 to +1 with a higher score indicating a better QoL.
To further assess QoL impact, several six-part Likert scales were designed by the authors.They asked questions pertinent to the objectives of the study that were not addressed in other scar assessment scales.Similar Likert scales have been used in previous surgical literature [12].

Data analysis
All statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, New York).Descriptive analysis was performed on patient demographic characteristics, smoking and diabetic status, operation-related variables, and Likert scale responses.Values pertaining to PSS satisfaction (POSAS and EQ-5D results) were reported as the mean and 95% confidence intervals.
Regression analysis investigated the association between several factors and patient POSAS, EQ-5D, and Likert scale responses.Spearman's rank correlation coefficient evaluated the internal correlation of Likert scale responses.

Results
Descriptive analysis

Follow up
N=61 patients completed the second questionnaire, with 30 patients (33%) being lost to follow-up.There were no significant differences in patient demographics or mean POSAS (p=0.771) and EQ-5D (p=0.131)scores in the participants lost to follow-up.

Likert scale analysis
In the initial questionnaire, 20.88% of patients (n=19) agreed with the statement, "The scar is affecting my quality of life."At six months post-operative, only 8.2% of patients (n=5) agreed with the statement.Initially, 21.98% of patients (n=20) agreed with the statement, "The scar is worse than my expectations for it".In the second questionnaire, 18.03% of patients (n=11) agreed with the statement (Figure 6).

FIGURE 7: Correlation between patient age and POSAS scores for n=91 patients
Rho=-.237, p=0.024POSAS: Patient and Observer Scar Assessment Scale

Surgical Complications
There was a statistically significant difference in the mean POSAS and EQ-5D scores between patients with surgical complications (p=0.043,p=0.019) and those without (Figures 9, 10).This difference also existed at six months post-operative (p=<0.001,p=<0.001).

Scar Location
No association was found between scar location and POSAS scores (p=0.897).An association was found between scar location and EQ-5D scores (p=0.006)(Figure 11).

Discussion
Most patients were satisfied with their PSS, according to the POSAS scores.This satisfaction increased between the initial baseline questionnaire and the follow-up telephone questionnaire at six months postoperative.These findings allow physicians to educate and reassure patients about the expected healing benefits of time.
Similarly, most patients reported a favourable QoL, according to the EQ-5D and Likert scales.An improvement in QoL was also observed between the initial visit and six months post-operative.This knowledge can be equally motivating for patients.Moreover, it can guide physicians in determining the appropriate timing for interventions that mitigate QoL impact.Interventions such as scar massage therapy and moisturisation may be recommended shortly after the operation, whereas scar revision surgery may be considered at a later stage when QoL improvement is not anticipated physiologically [11].
Pearson's correlation coefficient revealed a significant correlation between patient POSAS and EQ-5D scores (Rho=-.317,p=0.002) indicating patients who rated their scars poorly were more likely to report a poorer QoL.This underscores the need for physicians to prioritise PSS satisfaction.
In the initial questionnaire, younger patient age (p=0.024) was associated with poorer POSAS scores.This is consistent with established surgical literature from other specialities [8,13].Therefore, it is appropriate to consider a lower threshold for interventions in this population to achieve improved cosmetic outcomes.
We did not find an association between patient gender and mean POSAS or EQ-5D scores.This is consistent with previous scar satisfaction literature [8,[14][15][16] and contradicts widely held gender stereotypes.It is important that physicians are aware of this to avoid male patients with scar concerns being overlooked.
Unmet patient expectations for their PSS were associated with poorer POSAS scores (p<0.001), as well as poorer QoL according to the Likert scale (p<0.001).This association has not been previously examined within PSS satisfaction literature.It highlights the potential significance of patient scar expectations as a determinant of post-operative QoL outcomes, therefore warranting greater attention and examination.

Limitations
In total, 30 patients (32.97% of the original sample) did not complete the second questionnaire.This may be attributed to participants' reluctance to answer calls from unknown numbers.
While the EQ-5D is a validated tool to measure QoL in patients, it did not specifically assess the impact of PSS on patient QoL.Accordingly, its results may have been confounded by the effects of the initial patient injury on patient QoL.However, we included several Likert scales that specifically addressed the impact of PSS on patient QoL.

Future recommendations
This article was previously presented as a meeting abstract at the Irish Orthopaedic Association Annual Meeting on June 18, 2022, the 9th University Hospital Waterford Research Meeting on January 20, 2023, and the 48th Sir Peter Freyer Surgical Symposium on September 2, 2023.This article was previously presented as a poster at the Irish Surgical Training Group Research Symposium on November 19, 2022, the 12th International Conference for Healthcare and Medical Students on February 10, 2023, the 2023 Student Medical Summit on February 11, 2023, and the 24th EFORT Annual Congress on May 26, 2023.

FIGURE 1 :
FIGURE 1: The General Information Questionnaire

FIGURE 8 :
FIGURE 8: Correlation between scar age and POSAS scores Rho=.249, p=0.018POSAS: Patient and Observer Scar Assessment Scale

FIGURE 9 :
FIGURE 9: Difference in mean POSAS scores between patients with and without surgical complications POSAS: Patient and Observer Scar Assessment Scale

FIGURE 10 :
FIGURE 10: Difference in mean EQ-5D scores between patients with and without surgical complications EQ-5D: European Quality of Life 5 Domain

TABLE 2 : Surgical characteristics of patients
ORIF: open reduction internal fixation; IM: intramedullary nail