There have been several discussions regarding the importance of protecting the surgical site by wearing a brace after rotator cuff repair, and a lot of research has been conducted on how long the patients should wear the brace. (Denard et al. 2011; Gallagher et al. 2015; Houck et al. 2017; Parsons et al. 2010) Furthermore, significant research has been conducted on the rehabilitation plans after surgery. (Denard et al. 2011; Gallagher et al. 2015; Thigpen et al. 2016) However, there is limited discussion about the postoperative management in terms of patient compliance, and whether patients wear the brace as trained at the hospitals. This means that the true effect of braces is hypothetical. In one study, a heat sensor was installed on the brace to analyze the patient's actual compliance, and it was confirmed that the compliance was much lower than the self-reported time. (Grubhofer et al. 2019) In our research, only 35% of the patients met the standard of Group A, indicating that the general compliance of wearing braces is much lower than expected. Therefore, when assessing guidelines for postoperative management, it should be considered that the actual compliance would be much lower than expected.
Based on the abovementioned observation, the guidelines for braces need to be reconsidered. At our hospital, we instruct the patients to wear the brace all the time for 6 weeks, except when they change clothes or take a shower. Despite poor compliance, re-tears were reported only in 4 patients. This result implies that mitigating the guidelines can be possible, such as allowing patients to remove the brace when they can control and limit shoulder movement carefully during simple daily activities.
This study did not reveal any statistically significant risk factors for re-tears, except for the type of surgery. Open surgery was the only statistically significant risk factor for re-tears. However, this does not directly imply that the open surgical technique itself is a risk factor. Open surgery was indicated in patients with rotator cuff tears, which seemed difficult to repair with the arthroscopic technique. Thus, the characteristics of the tear itself could affect the results. However, the tear size did not show a significant relationship with the occurrence of re-tears in this study. Additionally, self-removal time was not a statistically significant risk factor for re-tears, and there was no significant difference in self-removal time among the three groups. However, there was one patient with severe re-tears requiring reoperation in Group C, and he almost never wore the brace after discharge. Moreover, he did not bring the brace when visiting the outpatient clinic for follow-up. This indicates that poor compliance can cause catastrophic results in patients; hence, wearing the brace to protect the surgical site is important.
Compliance with wearing the brace was not related to the patient's educational status or sex. Even though the patients were well aware of the importance and reasons for wearing the brace, only 35% of them wore it as instructed. This shows that awareness and education status might not be the most important factors for compliance. Therefore, other factors that cause patients to remove the brace, regardless of their awareness, should be noted, such as the patient’s subjective discomfort.
This study focused on the patients’ subjective discomfort. Initially, abduction braces, which are made of hard materials, were thought to be more uncomfortable than the sling-type brace. However, there was no difference in the compliance between the two braces. Furthermore, the discomfort reported by the patients was similar between the two braces. The most common discomfort reported was during sleeping, and the actual removal of the brace was done mostly when sleeping. Patients complained that the brace itself was too bulky and difficult to position while sleeping, and it was the most common complaint with both the brace types. New and modified types of braces could be the solution to this problem, but it is difficult to design comfortable and efficient new braces immediately. Thus, simple nighttime braces could be the solution. In the knee department of our hospital, patients who undergo anterior cruciate ligament reconstruction additionally use a detachable lightweight splint when sleeping, because the cruciate ligament braces are bulky and difficult to wear. In patients undergoing rotator cuff surgery, it may be helpful to develop an additional lightweight brace for nighttime, such as a simple sling brace without an abduction pillow.
Other discomfort reported by the patients included irritation in the neck or armpits, heat sensation when wearing the brace, and improper size of the brace, which caused the patients to remove the brace. Additionally, there was an interesting point regarding the reasons for self-removal. Nine patients answered that they took off the brace because their pain had relieved. This shows that not only pain and discomfort, but also pain relief can cause patients to be less alert and remove the brace. This part should be emphasized on when educating the patients on the importance of wearing the brace. It should be explained to the patients that pain relief does not mean that the repaired cuff has healed.
This study has some limitations. First, the patient compliance was analyzed based on a questionnaire that was filled out subjectively by the patient. It was impossible to determine the compliance objectively and accurately after the patient was discharged from the hospital. Therefore, the questionnaire evaluated the compliance based on the patients’ answers. To overcome the limitations of subjective data, we attempted to design the questionnaire in the most efficient form. We used simple and easy terms in the questionnaire for the elderly patients because too many requirements and complexities in the questionnaire could have distorted the results.
Second, although the questionnaire evaluated for the time and frequency of the brace removal, it was difficult to assess how the patients behaved after removing the brace. For example, some patients may have behaved carefully after the brace removal, while others may have used their arms roughly. Therefore, the same amount of removal time in patients does not indicate the same degree of compliance.
Third, only one size of each brace was available for the patients. Even though braces can be adjusted to some extent, they may not fit all patients appropriately. Therefore, the same brace may fit differently in different patients, and this could be one of the factors causing discomfort to the patient. Availability of the brace in various sizes could help in reducing the discomfort in patients having trouble with ill-fitting braces.
Fourth, ultrasonography was used to evaluate the rotator cuff only postoperatively. Although current research has shown that ultrasonographic examination of the rotator cuff is comparable to magnetic resonance imaging, it remains subjective to the examiners. (Lee et al. 2018) In our study, we tried to increase the objectivity by saving the images in our database to be re-checked if needed.