Reply to the Letter to the Editor

Abstract

To the editor, We would like to thank Drs. Rhon and Hando for their interest and insightful comments regarding our recently published study. While we would wholeheartedly agree that a period of immobilization longer than the 3 or 4 weeks employed in our study and others [1–3] would be beneficial to soft tissue healing, the practicalities of doing so may limit its utility. According to our (as well as Professor Itoi’s) observations, compliance with brace wear was a time-limited phenomenon. In fact, only 53% of patients were compliant with full-time sling use for 3 weeks in the Itoi et al. [2] study. The unfortunate reality is that the exact patient group who would potentially benefit from longer immobilization (young, active patients), and who are at highest risk of recurrent instability, is the group that can least tolerate a prolonged period of time away from full participation in studies, family demands, work, or sport. Strategies to improve compliance with immobilization have not been fully explored. An interesting (albeit anecdotal) observation from our own study was that some patients preferred the externally rotated position because it permitted keyboard use and positioned the hand of the affected shoulder in a more functional position in front of the body. One patient even continued to work as a waiter with his tray positioned on his brace during the immobilization period. While the externally rotated position may not considered to confer significant benefit in terms of reducing recurrence versus sling immobilization, there may be some merit to its capacity to allow a more functional position of the ipsilateral hand. We are enthused that our work has generated discussion and thought regarding nonoperative approaches to reduce the relatively high rate of recurrence in young patients following primary dislocation. There are still many questions to be answered — not the least of which are the best position and duration of immobilization. However, any discussion of either question must take into consideration the practical issue of compliance in the target population.