Limb lost, love found

A serious accident put Josh Bryan’s life on a surprising new path
January 24th, 2017
Josh Bryan and Melissa Keller with nurses during the last week in the hospital on Koh Samui in the Gulf of Thailand.

It was New Year’s Day 2016 and Josh Bryan was off to a fast start. He’d turned 27 the day before and was atop a scooter a long way from Aurora, where he co-owns a residential contracting business. With his younger brother ahead and older brother behind, he raced down a road on the island of Ko Pha Ngan in the Gulf of Thailand. He gripped the handlebars and leaned in as he turned the scooter around a corner.

A patch of loose gravel sent the scooter and his life spinning out of control. Bryan wiped out. The femur in his left leg shattered, while the right one snapped in two. There were no health care facilities in Ko Pha Ngan that could handle his injuries. He endured a ferry ride to neighboring island Koh Samui – a relatively short trip unless you’re in excruciating pain, as Bryan was.

His troubles were only beginning. The hospital in Koh Samui was ill-equipped to deal with his traumatic injuries. Surgeons tried to stabilize his shattered left femur with plates and screws and attempted to join the broken bones on the right side by inserting a straight slotted metal nail. The results were disastrous. The left femur had massive sections of dead bone triggering a massive infection. The nail in the right femur failed to provide the stability necessary for them to heal properly. After the surgeries, Bryan drifted in a fog of pain and suffocating heat that was relieved only by an oscillating fan.

Limb Restoration Director Jason Stoneback removed the straight nail inserted in Bryan’s right femur in Thailand (foreground) and replaced it with one secured by screws and curved to better fit the bones together.

Halfway around the world in Denver, Melissa Keller got a call the day of Bryan’s accident. She and Bryan had known each other for a decade and dated for a time before going their separate ways. But they’d rekindled the relationship after a chance meeting. Keller, a charge nurse in the Oncology/BMT Unit at University of Colorado Hospital, decided to fly to Koh Samui to help Bryan through the ordeal.

Lost and found

The struggle continues, but with help from providers with UCH’s Limb Restoration Program, Bryan is piecing his life back together. He continues to take antibiotics to fight off the last vestiges of the massive infections that followed the surgeries on Koh Samui. He has endured eight more surgeries after returning to the States – one of them exceedingly rare – to repair and recover from the devastating injuries. After months in a wheelchair, he is at the beginning of a grueling rehabilitation regimen aimed at getting him permanently upright once more.

But even more than the plates, screws, nails and reconnected tissue that hold together his damaged limbs, the linchpin of Josh Bryan’s life is Melissa Keller. Bryan puts it simply: “Melissa saved my life.”

After learning of his injury, Keller got the okay from her nurse manager, Jamie Nordhagen, to head for the Gulf of Thailand and Bryan’s bedside. Keller booked a one-way flight to Koh Samui. She arrived two days later, a week after the accident.

Keller found Bryan in tough shape, suffering through pressure ulcers, dermatitis and poorly controlled pain. For the next six weeks, she became his personal nurse, sleeping on a couch bedside his bed. She changed his dressings; helped to manage his pain with additional medications, ointments, music and movement; checked his IVs; and served as a medical liaison with his physician.

Most of all, Keller focused on keeping Bryan from slipping into septic shock. She saw abscesses on his left leg that were “red flags” of infection. “I’m not an ortho nurse,” she said, “but I see many patients with poor immune systems. I immediately started doing preventive nursing.”

Into the fire

Stoneback used an antibiotic cement space (center of image) to bridge the gap created by the dead bone he removed from Bryan’s left femur. He also inserted a new plate and screws.

Two months after the accident, Keller and Bryan’s younger brother carried him out of the hospital in Koh Samui and on to the airport for a heavily sedated 48-hour trip back to the States. He chose UCH for its orthopedic expertise and because it would be easier for Keller to keep an eye on his progress.

After the minimalist Thailand accommodations, Bryan saw his room at UCH as a “five star hotel.” But the accident and the surgeries in Thailand left him with many problems. The most immediate issue was the infection in the left leg. Orthopedic surgeon Melissa Gorman, MD, surgically removed infection from the left femur.

The problem, however, was deep-seated. In subsequent surgeries, Jason Stoneback, MD, director of the Limb Restoration Program, removed the infected hardware along with bits of dead, infected bone from Bryan’s left femur, ultimately leaving a gap of about 6 inches. Bryan wore an external fixator attached with antibiotic-impregnated cement beads to stabilize the leg. Stoneback put a new plate in the femur, secured it with longer screws than the originals and bridged the gap between the bones with an antibiotic cement spacer.

There was no choice but to remove the bone, said Carla Saveli, MD, an infectious disease specialist at UCH. Bryan’s leg was under attack from multiple drug-resistant organisms, and there was no blood flow to the dead tissue or to the original hardware, which itself harbored infection. Infection-fighting antibiotics were stymied.

“Without blood flow, there was no good way to treat the infection,” Saveli said. With the dead bone and tainted hardware removed, Saveli and a team of providers inserted a PICC line to deliver a steady infusion of antibiotics to Bryan to keep the infection from spreading further. They regularly monitored his condition with clinic visits and worked with a home health service to ensure the PICC line was properly maintained.

Meanwhile, about six months after the accident, Stoneback also removed the outdated metal nail from Bryan’s right leg which had failed to heal. He described the procedure as “a calculated move by the Limb Restoration Team to assure his right femur healed to provide him with ‘a leg to stand on’ for the long left leg rehabilitation to come.”

Infectious disease specialist Carla Saveli treated a serious bone infection in Bryan’s left femur.

Stoneback compared the original nail to a “toothpick in the bone,” and implanted a new rod that was stronger and curved to conform to the shape of the broken femur, allowing it to heal correctly.

Left still not right

But the left-leg problems were unsolved. The gap in Bryan’s femur was too big to heal on its own, and the cement spacer bridging it was not made to take the physical stress of moving. “Without the bones healing, the plates and screws would have pulled out,” Stoneback said.

In addition, Bryan couldn’t move his left foot because of nerve damage. That made taking grafts from his fibula, the smaller of the two lower leg bones, to restore the missing bone an uncertain option at best.

The medical dilemma led to a multidisciplinary conference among providers with the Limb Restoration Program, organized by nurse practitioner and care coordinator Kristin Loker, MSN, NP-C. Bryan’s options were limited. If his foot had been serviceable, he might have considered a rotationplasty: amputating the lower part of the femur but and then attaching the foot and ankle to the bottom of what remains – but rotated 180 degrees to act as a joint and the point of attachment for a prosthesis.

That wasn’t an option for Bryan, said Nate Donaldson, DO, an orthopedic surgeon specializing in musculoskeletal oncology who was among the providers at the conference. “Without a functioning foot, rotationplasty isn’t worthwhile,” he said.

rare turn-up plasty procedure by orthopedic surgeon Nate Donaldson preserved a portion of Bryan’s damaged left leg, providing a better base for a prosthesis.

Another alternative was amputating the left leg at the hip, an emotionally daunting choice with serious technical challenges, said Guy Lev, PT, DPT, supervisor of outpatient physical therapy services at UCH.

“You need a certain amount of limb muscle to act as a lever to move the leg,” Lev said. “When you amputate at the hip, the patient has no lever for the mechanics to push a prosthesis forward and hold it in during walking. You have only the pelvis.”

Road less traveled

Donaldson suggested a middle path – a rare procedure most often used to treat patients with sarcomas called turn-up plasty. Donaldson would amputate the damaged portion of Bryan’s femur, his knee, and his foot. He would preserve the tibia – the long lower leg bone that forms the shin – rotate it 180 degrees and reattach it to the remaining portion of the leg to establish the foundation for an above-the-knee prosthesis.

Donaldson had learned the turn-up plasty procedure during his fellowship at the University of Miami. This would be his first since coming to the Anschutz Medical Campus, but his explanation and confidence impressed Bryan and Keller.

“He showed why he thought this was a better option than trying to reconstruct all the way to the hip,” Bryan said. “It would give me a better chance for a good result with a prosthesis and for a good quality of life.”

Marker outlines the area of Bryan’s damaged left leg that Donaldson operated on in the Sept. 16 turn-up plasty procedure.

Keller agreed, saying quality of life takes precedence over “grieving the loss of a body part.”

After deciding on the turn-up plasty surgery, she and Bryan took what they jokingly called a “last leg” vacation with friends and families at the end of August, to Burning Man in the Nevada desert.

Donaldson performed the five-hour procedure on Sept. 16, shortly after they returned. The surgery went well, and in early November, he said Bryan’s recovery is “proceeding normally.”

On to the next

Bryan after the procedure. Donaldson rotated the tibia and reattached it to the remaining bone and muscle of the upper leg. That put the tattoo that had been on the back of Bryan’s calf on the front of the leg.

There are no certainties. The bones and tissue Donaldson connected still need time to heal. Bryan has had the PICC line removed, but he takes oral antibiotics while Saveli monitors his infection closely. He wears a compression device over the end of his shortened limb to shape it in preparation for attaching a prosthesis, Lev said. And even if all goes well, Bryan will still need another surgery for Donaldson to remove plates and screws he inserted to hold the bones together during the healing process.

The work that lies ahead for Bryan was evident during a physical therapy appointment with Lev in early November. After rolling into the rehab gym in the Anschutz Outpatient Pavilion, Bryan hoisted crutches under his arms and thrust himself down a clinic corridor for a two-minute walk that Lev timed while counting his steps. He reached the end of the corridor and returned, breathing heavily but happy.

“That’s as much as I’ve done in a year,” Bryan said. The last time he’d tried the walk, Lev said, Bryan had gone 53 feet. This time he covered 310. “My cardiovascular has improved tons,” Bryan said.

Lev then took him through a series of exercises to improve the strength and range of motion in the left leg. He practiced moving from a sitting to a standing position, stood on his right leg in a corner without crutches, and lifted the leg as he lay on his stomach, grunting while he did so.

“It might make you sore, but it’s going to make you stronger,” Lev said.

Dragging out a cushioned mat, Lev then showed Bryan how to manage a fall. The key: flinging aside the crutches to avoid hitting them on the way down. “It’s a question of when, not if, a fall is going to happen,” Lev said. Bryan tried it successfully a couple of times.

“I feel like you’re telling me that you’re building confidence,” Lev said. Getting out of the wheelchair and walking with crutches at home “is not risk-free, but it is super beneficial,” he added.

Bryan starts a two-minute walk during a rehab session with physical therapist Guy Lev in early November.

A solid foundation

All of this work is essential for reversing the limb atrophy caused by months of sitting in a wheelchair and preparing for more work and challenges that will come when he gets a prosthesis and learns to use it as naturally as possible, Lev said.

“Josh will need balance training so that he is confident operating the equipment and does not put all his weight on his sound limb,” he said.

Not all the obstacles will be physical, Lev added. “We know from the evidence that all amputees will experience grief and sometimes long-term depression,” he said. But he noted that Bryan has a lot going for him, notably a Limb Restoration Program team that communicates and has developed a long-term treatment and recovery plan.

An even bigger asset is at home. “The most important aspect of recovery is the support of family, peers and loved ones,” Lev said. “With that a patient stands a good chance of success.”

Bryan and Keller look forward to the days ahead.

Bryan has made sure to cement the strongest bond in his life. During the trip to Burning Man, he proposed to Melissa, who accepted. His next goal is to be able to walk down the aisle on their wedding day.

If a positive attitude is any indication, his chances of meeting that goal seem pretty good. “The accident put my life in perspective,” he said. “It changed my outlook. I was moving too fast and was in a rush and it played out against me. I’m a lot happier now.”

 

About the author

Tyler Smith is a freelance writer based in metro Denver.