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 October 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.

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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.

1. Gun shot wounds prevail

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.

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2. Frozen shoulders

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.

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3. The Latarjet procedure

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.

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4. Good things....

Good things come to those who wait

No appointment times are given in orthopaedic clinic, patients arrive and wait patiently to be seen. When we queried this, it seemed to be because patients may have huge distances to travel with an often unreliable public transport system (something commuters with southern rail may have sympathy for). Therefore, people find it very difficult to turn up at an allotted time. How well do you think this system would be looked upon in the UK?No appointment times are given in orthopaedic clinic, patients arrive and wait patiently to be seen. When we queried this, it seemed to be because patients may have huge distances to travel with an often unreliable public transport system (something commuters with southern rail may have sympathy for). Therefore, people find it very difficult to turn up at an allotted time. How well do you think this system would be looked upon in the UK?

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5. Links between surgeons

Links between surgeons and therapists are vital in ensuring patients achieve optimal outcomes

Surgeons are pro physio, but once discharged from local state hospital, communication between the 2 disciplines remains an issue. Also, at odds with current practice in the UK there is no physio presence in state run orthopaedic clinics, and no physio presence in national shoulder and elbow society, as only surgical members allowed. Again something very different from the BESS meetings and membership. We think this highlights one of BESS’s unique values, in that it encourages contributions from it’s AHP membership, and it is probably the only specialist society that would give an AHP the opportunity to apply for such a prestigious fellowship.

6. Be prepared

Be prepared to be a myth buster

One of the first discussion points we encountered was from one of the orthopaedic consultants in a trauma conference, stating that “with elbow fractures, physiotherapy can cause heterotopic ossification”. Val said a silent thank you to Jo Gibson and David Stanley, who asked her to write a review article on the management of stiff elbow conditions for Shoulder and Elbow 6 months earlier. She was able to refute this statement politely but firmly! The British contingent had arrived and were not apologetic about sharing our understanding of current literature for the rest of the trip. By the end of the fellowship it became a standing joke that physio’s cause H.O., prosthetic loosening, cuff re-tears, earthquakes and most other natural disasters. We had lots of healthy debate regarding the need for early mobilisation post-surgery, functional rehab involving the whole kinetic chain, the use of splinting in the stiff elbow etc. In fact it was an interesting observation that although on the whole the South Africa approach to post operative mobilisation was somewhat conservative, they would not consider an external fixator after a complete release for elbow stiffness even in the face of on table instability. Someone, who shall remain nameless, suggested that if Val had her way rehab would start before the wound had been closed in theatre! The benefits of the overhead mobilisation position for elbow conditions was discussed in depth, which was new to Steve and Basil, but they were both extremely receptive to the idea, and both seemed to have adopted it by the end of the fellowship.

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7. Cerebral complications

Cerebral complications of beach chair arthroscopy might be lessened by using a cerebral oximeter

This provoked some interesting discussion as a device was used on most patients undergoing beach chair arthroscopy to monitor cerebral oximetry. Due to some cases of symptomatic cerebral hypoxia with associated complications the association of anaesthetists in South Africa have agreed that beach chair arthroscopy should not be done in positions where the patient is sat erect and cerebral blood flow monitoring is used in all cases. In some clinics, beach chair arthroscopy was almost being performed supine they had so little angle of inclination. In the UK our knowledge of current practice relating to beach chair positioning is very limited. This made us reflect on our practices and although there seems to be very little research or validation of this method of non invasive monitoring for detecting reduced cerebral blood flow, it remain a potential issue that perhaps could be under recognised in the UK. We left compelled to look into this further on our return to our hospitals.

This provoked some interesting discussion as a device was used on most patients undergoing beach chair arthroscopy to monitor cerebral oximetry. Due to some cases of symptomatic cerebral hypoxia with associated complications the association of anaesthetists in South Africa have agreed that beach chair arthroscopy should not be done in positions where the patient is sat erect and cerebral blood flow monitoring is used in all cases. In some clinics, beach chair arthroscopy was almost being performed supine they had so little angle of inclination. In the UK our knowledge of current practice relating to beach chair positioning is very limited. This made us reflect on our practices and although there seems to be very little research or validation of this method of non invasive monitoring for detecting reduced cerebral blood flow, it remain a potential issue that perhaps could be under recognised in the UK. We left compelled to look into this further on our return to our hospitals.

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”Beach chair position” South African style

8. Walking clinics

Walking clinics

A patient with a traumatic pneumothorax is seen in a walking clinic. They remain seated in chairs and have their chest drains inserted. A physiotherapist then mobilises the patient around the department, up and down the stairs etc, until the lung reinflates, the chest drain is then removed and the patient is then sent on their merry way.

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9. Groote Schuur

Groote Schuur – a hospital where history was made

Now this was not just because our current President of BESS, Mike Thomas, spent some of his formative orthopaedic career working there, and had many interesting stories to tell, but it was also the site of the first ever cardiac transplant, undertaken 50 years ago this year. We were able to visit the museum on site, where Christiaan Barnard performed the surgery, with the patient Lewis Washkansky surviving 18 days after surgery. Basil’s extremely efficient and capable theatre sister, Sandy Bryant, who was a unique lady, had actually worked with Barnard in theatres, and was able to give us some fascinating insights about the man.

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10. Make time

Make time for team building

When we were shown the orthopaedic department facilities at Tygerberg hospital, one of the things that stuck in our minds, was they had an outside seating area with a barbeque, where everyone got together on a Friday afternoon after work. We been able to put into action quite a few things since returning to the UK but sadly not this. Some might blame the weather but we think our requests for funding for this project might go unanswered for some time. Our trip to Tygerberg hospital, South Africa’s second largest hospital with 1899 beds, informed us about the South African management structure in hospital. How different to our UK facilities in that in this hospital with 1938 nurses and 577 doctors only had 26 managers. We also leant us about how to get ‘busy’ UK weekend on calls into perspective. Our host there had been working all weekend and for a pretty average/ quiet weekend had seen 90 referrals, performed 30 operations of which 25 were major. They do not class intramedullary nailing in the major category.

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and finally

As Nelson Mandela famously said “ education is the most powerful weapon which you can use to change the world”. This trip certainly enables a worthwhile and thought provoking exchange in education between our two countries and we hope that what we have learnt will be disseminated worldwide a lot of which has been already through national and international teaching commitments by the Copeland fellows.

We would like to sincerely thank our hosts Basil Vrettos and Steve Roche who clearly worked tirelessly not only in preparation for our visit, but also during our time in South Africa attending clinics, theatres, educational meetings and the odd beer and dinner! We were very fortunate to be hosted by Sean Pretorius, Ajmal Ikram and Rory Harvey at their respective hospitals as well as Abe Lambrecht for his kind invitation for social engagements on the weekend we explored the sites of South Africa.

Chris and Val would like to add a personal thank you to Mike Thomas for ‘escorting’ them on the visit, Jenny Copeland who presented the awards in Dublin and so graciously agreed to the fellowship being awarded in Steve’s name and finally to BESS council and the membership who have been very supportive. We would be very happy to discuss the trip in further detail with all members and hope to have an opportunity to do so in Coventry later this year.

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