This report has been written by Chris Peach (Surgeon representative) and Val Jones (AHP representative) who joined Michael Thomas (former President 2015-2017) on the inaugural Copeland fellowship to South Africa in 2016.

Top ten lessons learnt by the Copeland fellows in South Africa

Val Jones, Chris Peach

The Copeland travelling fellowship afforded us all a great opportunity to learn from and exchange views with our South African colleagues, and on our return we both have been able to disseminate our new ideas to both surgeons and AHP’S regionally and internationally. It was a unique opportunity to observe current concepts and treatment practices in another country, and to observe similarities and differences in practice, which in turn has provoked evaluation of our current practice in the UK.

Our hosts Basil Vrettos and Steve Roche were so generous of their time and their expertise. Every day there were opportunities to exchange ideas via case discussions, theatre and clinic visits, and local and regional clinical meetings, where we had an opportunity to present our current practice and research in the UK to both surgeons and physios. There were also visits to the research facilities including the Biomechanics lab at the University of Cape Town and the “state of the art” Sport Science Institute of South Africa.

Having reflected on our experiences we describe our top 10 lessons we learnt from our fellowship in no particular order.

Gun shot wounds prevail

We were all a little apprehensive when we saw the no guns sign as we entered Groote Schuur and we were dumbstruck after sitting in our first trauma conference. There are over 1000 gunshot wounds seen per annum at Groote Schuur. Key points in gunshot management were that there was no need to remove bullets as lead in bullets is now not an issue and they see no significant infections with retained shrapnel. Bullet removal is only performed if the bullet is adjacent to the fracture being treated or if intra-articular and blocking joint movement. Frightening statistics depict that a teenager admitted with gun shot wound will have a 50 % chance of dying within next 2 years. The registrars we saw in theatre were very accomplished at managing these injuries and their associated comminuted fracture patterns because of their high exposure to this group of patients. An interesting case was fixation of an acromion fracture caused by a gunshot, fixed on the registrar’s trauma list. There were also new phrases to learn community assaults, which was a polite term for a group beating for someone who had broken the law, and Panga attacks, a Panga being a type of machete.

Frozen shoulders are left out in the cold with most surgeons we saw

Supervised neglect was the order of the day, which was at odds with the views of the British contingent. All of us Brits sang from the same hymn sheet on this one, extolling the benefits of active intervention including capsular releases. But this reflects that they are so stretched in terms of resource and manpower that with a favourable natural history, there was no availability for early intervention. However, unlike the UK, ruling our TB which can present like a frozen shoulder was necessary and if detected a difficult one to treat. TB is an increasingly challenging problem in South Africa with both multi-drug resistant TB and ‘extremely’ multi-drug resistant TB being endemic.

The Latarjet procedure was the procedure of choice with rugby players with instability

It was evident that this is a high volume procedure and possibly because of experience, the surgeons were happy to mobilise immediately post operatively and sent home the patients without slings. Surgical tips for successful surgery included using a Cobb elevator to divide subscapularis (actually the Cobb elevator was used by most surgeons for most operations and Chris has now rescued several from the old spinal trays for the shoulder and elbow trays in Manchester). Those who find this procedure difficult due to exposure should note that the top technical tip was to use a Fukuda and a glenoid neck retractor only to expose the glenoid and take all other soft tissue retractors out when fixing the bone block. This clearly demonstrated a fine approach to the technique and has benefitted Chris’ patients already with better exposure and reduced operative time.