Jason Stoneback, MD, spends a good portion of his days at University of Colorado Hospital treating patients with serious orthopedic issues. He finds innovative ways to help them deal with badly damaged arms, legs, knees, hips, and shoulders and improve their ability to use them.
But while he’s skilled as an orthopedist specializing in trauma, Stoneback recognizes that he alone can’t handle the breadth of limb problems that patients face. It’s why he spearheaded the launch of the Limb Restoration Program at UCH and Children’s Hospital Colorado in March. It’s a multidisciplinary program that brings together the skills of specialists spanning orthopedics, vascular and plastic reconstructive surgery, wound care, rehabilitation medicine, oncology, and more. They handle complex issues that range far beyond broken bones: tumors, bone non-unions, bone infections, limb ischemia, amputations, and peripheral artery disease, to name a few.
The name of the program, the only one of its type in Colorado, is important, Stoneback said.
“Historically, this kind of work has been called ‘limb salvage,’” he said. “That’s not the way I think of this program. We see our job as restoring limb form and function. There are patients out there with problems that have persisted because no one has taken care of the whole problem. Our job is to find ways to help patients live better with their conditions.”
Many hands for damaged limbs
The Limb Restoration Program follows a model established by other programs at UCH, notably Oncology, that emphasize integrated care and clinical discourse between specialists. As care coordinator, Kristin Loker, MSN, NP-C, plays the pivot. She sees patients during the program’s half-day Wednesday clinic. Often she and Stoneback review cases and select ones that might require input from more than one specialist – a limb fracture with a bone infection or vascular damage, perhaps.
Loker also organizes regular meetings for specialists with the program to go over the cases together and develop a plan of care. She then gathers the information and works with schedulers in the clinics that will be involved so that patients ideally see all the specialists involved in their care and get necessary images, lab tests and other work completed in a single day or as short a period as possible.
Since the program’s March 1 debut, Loker said she’s had individual contacts with more than 100 patients. The aim is basic. “Our job is to make patients better when they leave than they were when they came in the door,” Loker said. But the Limb Restoration Program deals with few, if any, clear-cut cases, and they can involve difficult decisions.
“If a patient is unable to use his or her leg, for example, amputation may be the quickest road to recovery,” Loker said. “It’s our job to help them understand that that is not giving up or failing. We make the decisions with the patient’s best interests at heart.”
A matter of trust
For many of the patients the Limb Restoration Program sees, hobbling, painful injuries and conditions have become a fact of life, said certified athletic trainer Dan Ruedeman, ATC. Ruedeman is the first point of contact for many of the program’s patients. He assists with scheduling their clinic visits and meets with them regularly to explain their treatments and answer their questions.
It is vital that patients trust that their team of providers understands their issues and will work together to address them, Ruedeman said.
“We have to show empathy for the patient and have a sense of where they are at,” he said. “There is a mental side of trauma that has an overall effect on life. I try to make sure that patients feel comfortable seeing their physicians and that they have a positive experience. Many of them have been dealing with their problems for years.”
A matter of inches
One such patient is Trayvon Cathren, 35, of Aurora. He suffered a gunshot wound to his left leg when he was a 13-year-old living in Los Angeles. The shot damaged the growth plate in the tibia, the long bone between his knee and ankle. Because of that, the left leg didn’t grow normally and ultimately was more than 2 inches shorter than the right one. Additionally, the abnormalities in the growth plate caused a severe deformity and alignment problem in the left leg. Cathren grew up with a severe limp, his left knee became unstable and he began to develop arthritis. He also had spine problems as he tried to correct for the imbalance caused by the leg-length difference.
In 2015, Cathren saw a Denver spine specialist who referred him to UCH to address the underlying left-leg problem. He saw orthopedic trauma surgeon Melissa Gorman, MD, who referred him to Stoneback. In May 2015, Stoneback recommended a procedure to correct the deformity and misalignment and simultaneously lengthen the left leg. Cathren agreed.
The procedure, called distraction osteogenesis, was far from a quick fix. Stoneback first performed a corticotomy: a surgical fracture of the outer part of the bone that left the vessels and membrane intact. He then drilled pins and wires into Cathren’s tibia to attach a hexapod circular ring fixator – a bulky device consisting of six color-coded, calibrated struts attached at various angles to top and bottom metal rings.
After attaching the device to stabilize Cathren’s leg, Stoneback took measurements and input the data into software that generated a 3D model of the bone deformity and the corrections needed to fix it. The program also produced a prescription that showed Cathren how much to turn knobs on each strut to gradually lengthen them each day – in his case 1 millimeter. The idea was to slowly pull the two fractured pieces of bone apart, thereby lengthening the leg and straightening his tibia. When the separation reached the desired length and the bone pieces were aligned, Cathren began a lengthy period of “consolidation” to allow new bone to grow and fill in the gap.
All told, Cathren had to wear the ring fixator for 14 months. When he finally got it off last July, he also had a procedure to lengthen his Achilles tendon so he could put his left heel to the ground. In early September he was still using crutches while recovering from that, and had some pain, but for the first time in more than two decades, he could put two feet to earth evenly.
“I’m still sore, but I can stand straight,” Cathren said.
The long process gives him a functional limb and much brighter prospects, Loker said. “He’s avoided knee replacement or even amputation,” she said.
No quick fixes
Cathren is grateful for the care he received from the hospital, but also matter-of-fact about the challenges of the procedure. It “put a strain” on his girlfriend, who had to help him with many everyday tasks and learned to make adjustments on the ring fixator, he said. He was out of work for a long period before getting on with a call center, which accommodated him with a wheelchair. Cathren said he cut around the seams of his pants to get them over the big, ever-present device attached to his leg.
Those kind of challenges make it essential for patients to get consistent, integrated care that helps them through discouraging patches, Ruedeman said. He met with Cathren and his girlfriend every week from the beginning of the process, teaching them how to adjust the struts, replacing them as needed, and checking to make sure they remained stable during the consolidation period.
“It’s like a NASCAR pit stop,” Ruedeman said. But the maintenance work is laced with deeper meaning, he added.
“The biggest challenge for Trayvon and all patients is that they have to truly understand the program,” Ruedeman said. “This kind of procedure isn’t just a bump in the road. It’s something that changes your life and can affect your family and your friends. It’s not a brace or a cast. It’s something that is with you in everything you do, every single day, for a long period. Without a support system, it won’t work.”
Just six months into the program, Loker and Stoneback are working with UCHealth’s Physician Relations team to broaden the Limb Restoration Program’s reach to more community providers. Adding a social worker, nutritionist and psychologist to the team is another future possibility, Loker said.
“We’re here to provide patient-centered care and those services are integral to tackling other problems,” she said.
To contact the Limb Restoration Program, call 1-844-800-LIMB.