Lion Project Newsletter – June update

13 July 2026

In June, the BSSH LION team said goodbye to Sean Walsh (T &O consultant), & Isobel Fairways (hand therapist) and welcomed Grey Giddins (T &O consultant), Valdone Kolaityte (plastics trainee), Leanne Moon (hand therapist). Grey is a returning consultant having spent time in Malawi in 2024.

 

The BSSH team outside the LION Lucius, Val, Grey, Leanne, Ali & Mway

Clinical activity

June was another very busy month. Across nine clinics, 240 patients were reviewed, with between 17 and 35 patients seen per clinic. The available records showed a mixture of new referrals, postoperative follow-up, ward reviews and dressing appointments.

Dressings formed a major part of the clinic workload, with 128 dressing reviews, representing just over half of all attendances. Patients were divided early in the morning into new cases, follow-ups and dressing reviews. The nursing team managed the dressing stream extremely efficiently, allowing the clinical team to focus on assessment and decision-making and helping the clinics run smoothly despite the high numbers.

The clinics included a mixture of open and closed hand injuries, although open trauma, infection and postoperative wounds generated the greatest follow-up burden. Common presentations included fractures, tendon and nerve injuries, soft-tissue loss, infections, stiffness, contractures, malunion and chronic dislocations.

Encouragingly, early postoperative infection appeared relatively uncommon among patients returning for review. Many wounds were progressing well, and a number of patients could be discharged after satisfactory wound and hand-therapy assessment. This reflected careful peri-operative patient management, the close collaboration between surgeons, nurses and therapists, as well as the importance of clear postoperative plans and reliable follow-up.

A total of 45 patients were booked for surgery from clinic, equivalent to approximately to 51% of new patients and 19 % of all clinic attendances. Most were acute cases that proceeded to theatre within days or during the same week, while a smaller number were placed on the elective or cold case waiting list.  The close link between clinic and theatre allowed urgent injuries and infections to be managed promptly.

A key challenge was communication across cultural and language differences. The support of the local team was invaluable in helping us communicate clearly with patients and their families, understand expectations and ensure that treatment plans were properly explained. Their input made the clinical work safer, more respectful and far more effective.

 

       

Val, Ali and Mway operating together in A & E theatre & Post op – fillet flap with IF amputation

Operative activity

The recorded operative log included 43 procedures.

The operative workload was dominated by open trauma, infection and delayed presentations. Cases included open fractures, flexor and extensor tendon injuries, digital and major nerve injuries, vascular injuries, complex soft-tissue defects and injuries requiring terminalisation.

Several patients required soft tissue reconstruction. Debridement was followed by skin grafting, local flap reconstruction or use of NovoSorb BTM for more complex wounds where immediate definitive coverage was not appropriate.

Local reconstructive options included hatchet, fillet, Venkataswami and Foucher flaps. These cases highlighted the value of using reliable techniques that could provide durable coverage while remaining practical within the available resources and follow-up arrangements.

More complex cases included:

• A severe circular-saw injury involving near-total amputations, tendon and nerve injuries and the need for revascularisation and reconstruction.
• Spaghetti-wrist injuries requiring repair of multiple tendons and major nerves.
• Complex forearm malunions requiring osteotomy, fixation and tendon or nerve reconstruction.
• Revision distal-radius fixation with extensor tendon reconstruction using grafts.
• Infected hand wounds requiring repeated washout, debridement and later full-thickness skin grafting.
• Dorsal hand defects reconstructed using BTM and skin grafting.
• Thumb soft-tissue loss reconstructed with a Foucher flap.
• Chronic tendon injury managed using tendon grafting, together with excision and burial of a symptomatic neuroma.
• Bi-lateral circular saw injury (right hand) – nerve repair& grafts, amputation of LF & near total amputation of IF, MF and RF, FDP repair, revascularisation. Left hand injuries to be updated in July newsletter
• Distal radius # k-wire, wrist ligaments, all hand & wrist flexors, ulnar artery & nerve, ECU, all EDC

Most cases were managed in the A&E minor operating theatre, with main theatre reserved for more extensive reconstruction and multi-structure injuries. Where theatre capacity was available, the team stayed after clinic to operate on urgent cases, and on some days divided into parallel teams to increase throughput. This flexibility was important in ensuring that acute injuries were treated promptly despite limited theatre access. The month reinforced the challenges associated with delayed presentation and interrupted access to specialist care. Several patients presented with established infection, stiffness, malunion, chronic dislocation or soft-tissue loss, requiring more complex treatment than would have been necessary at the time of the original injury.

The operating environment was strongly educational. Cases were supervised directly by the visiting consultants, with frequent discussion of operative planning, fixation, tendon and nerve repair, soft-tissue reconstruction and postoperative management.

Mway, the local resident doctor, progressed to performing procedures including Dequervain’s release, trigger thumb release, hand laceration repair and tendon repair under direct supervision. Ali, the T&O fellow, took on increasingly complex reconstructive work, including local flaps and tendon repairs requiring grafts. Val, the plastic surgery trainee, was closely involved in the management of mangled hand injuries, contributing to local flap planning, soft-tissue reconstruction and BTM use, while also building confidence in fracture fixation and the management of delayed nerve injuries. The strength of the month was the shared learning across the team, with each member taking on greater responsibility while maintaining close consultant supervision and safe patient care. The caseload also reinforced the impact of delayed presentation and interrupted access to specialist care. Several patients presented with established infection, stiffness, malunion, chronic dislocation or soft-tissue loss, requiring more complex treatment than would likely have been necessary at the time of the original injury.

The efficiency of the minor operating theatre was another major strength. The staff were highly experienced, well organised and anticipated what was needed, allowing cases to run smoothly with rapid turnover. This was particularly important on high-volume days and when urgent cases were added after clinic.

 

         

Main theatre team :Ali, Val, Sean, Mway and Amanda             Val & Ali working on spaghetti wrist in main theatre

 

Hand therapy activity

Leanne has been working closely with local hand therapist Lucius Wesley. 172 patients have been treated this month which were a mixture of chronic and complex orthopaedic and plastics hand and wrist injuries.

Communication between departments remains problematic, meaning many patients experience delayed treatment. Therapists are continuing to complete ward rounds and identify patients that have no treatment plan for hand injuries and discuss with the BSSH or red/green ward teams.

 

Education:

Education remained a central part of the visit. Sean Walsh delivered a well-attended session on the management of extensor tendon injuries, linking operative principles with evidence-based practice. The therapy team planned a follow-up session on extensor tendon rehabilitation, reinforcing the importance of coordinated surgical and rehabilitation pathways.

Ali Mohamed, the BSSH T&O fellow, delivered teaching on tendon transfer principles. Professor Grey Giddins also provided focused sessions for senior residents preparing for their examinations, using case-based discussions around decision-making, fixation, tendon and nerve reconstruction, and the management of complex trauma.

Learning was highly practical and collaborative throughout the month. Formal teaching was complemented by continuous clinic- and theatre-based discussion, as well as shared case reviews during trauma meetings with the wider Trauma and Orthopaedic department. The mix of different training levels and specialty backgrounds created a strong culture of shared learning alongside service delivery.

 

          

 

The hand therapists will be following up this training early July on extensor rehab  

Some interesting cases seen in clinic this month: mirror hand, radial dysplasia and arthrogryposis in an 11-month old

 

Social

Outside the hospital, the team enjoyed spending time with local colleagues and exploring Malawi. One highlight was a visit to the Chongoni Rock Art Area near Dedza, where a local guide explained the history and meaning of the ancient paintings.

The team also visited Liwonde National Park, Cape Maclear, Zomba Plateau, Dedza Mountain and Senga Bay, experiencing very different parts of Malawi and making the most of time together outside work.

 

       

 Victor, Grey, Leanne, Val & Mway with guide Simeon at site 1 

 

Leanne Moon is running 5 ultramarathons this year and in the process is raising funds for BSSH.  She has completed 3 so far and raised £380.  Her training is continuing in Malawi, where she is visiting local mountains.  You can follow her progress, donate or share by clicking on this:  link: https://www.justgiving.com/page/leanne-moon-1774984405283?utm_medium=FA&utm_source=CL

Overall

June demonstrated both the scale of need and the strength of the LION Hand Unit team. The service managed a high volume of clinic reviews, dressings, therapy appointments and operations, including several complex reconstructive cases.

Despite limitations in equipment – using a 22 blade which blunts on contact with the skin, imaging, theatre access and follow-up, the team was able to provide timely and practical treatment. The efficiency of the nursing and theatre teams, combined with close collaboration between surgeons and therapists, made a particularly strong impression

Driving without a working car horn in Malawi has been interesting, particularly as there has been an increase in police presence over the last few weeks. We have been stopped and checked several times but everything has been in order and I’m pleased to say we now have a working horn!  Traffic lights have recently been introduced on the main roads and as we sit there patiently waiting for the green light the locals whizz through them unless there’s police present.

The month highlighted how much can be achieved through good teamwork, sensible use of available resources and a shared commitment to improving hand care in Malawi

Val, Leanne & Grey  

 

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