It was June 26, 2016, a glorious summer Sunday on the Tongue River Reservoir in southeastern Montana. Connie Judge rode a Sea Doo jet ski – the marine equivalent of a motorcycle – with her fiancé, Jerry Burnett, at the helm. They had come from Colstrip, about an hour and a half north of the reservoir, with friend Stacey Martin and two jet skis. With all the noise and splashing, they lost track of their friend. Burnett turned a bit so Judge could hear him and yelled “Where’s Stacey?” slowing way down as he did.

Stacey had been right behind them on the other jet ski, but in a blind spot at just the wrong moment. The jet skis collided.

Burnett hammered forward so hard he broke the jet ski’s handlebars on his way into the water. Judge had gone in, too. Stacey Martin muscled Judge out by her lifejacket onto his jet ski as judge held tight to her lower right leg, which had taken a direct hit. It was in tatters, a bloody mess, bone exposed, the whole thing held together by her calf muscle. Boaters who had seen the accident came to the rescue – they happened to be husband-and-wife emergency medical technicians (EMTs) out with their kids.

The EMTs did the right things, and so did orthopedic surgeon Dr. Brenton Millner, who was on call at Sheridan Memorial Hospital in Sheridan, Wyoming, about 30 miles south. He set the leg as best he could, but it was clear that there were two options: amputate somewhere below the knee in Sheridan or be airlifted to UCHealth University of Colorado Hospital at the Anschutz Medical Campus to see if they could save the leg.

Judge was on heavy painkillers and in and out of consciousness. She was just 24 and loved the outdoors, whether it was riding four-wheelers, snowmobiling, snowboarding, camping or fishing. Despite the mental fog, she went for the UCH option without hesitation.

“We’ve got this”

The flight and the night that followed were a blur. The next morning one team after the next stopped in – specialists in orthopedics, plastic surgery, vascular surgery, and infectious disease.

“Infectious disease was a big one because my leg was open in lake water,” Judge says.

On the orthopedic side, Dr. Jason Stoneback, chief of Orthopedic Trauma and Fracture Surgery at University of Colorado Hospital and head of the UCHealth Limb Restoration Program, would take the lead. He examined Judge’s leg. The tibia just above the ankle had been crushed; the fibula, broken in three places, was in better shape. It was bad, but he had seen worse. “We’ve got this,” he thought to himself.

Every orthopedic trauma case is different. But there are rules of thumb: clear out dead tissue and bone, wipe out infection, get the wound closed, stabilize the bone, reconstruct the soft tissue, reconstruct the bone. Doing all that takes diverse expertise. Care for an injury like Judge’s can involve vascular specialists, plastic surgeons, wound-care specialists, musculoskeletal and interventional radiologists, rehabilitation medicine specialists, prosthetics specialists, infectious disease experts and others. Among the ways they work together is in the Limb Restoration Multidisciplinary Meeting, which happens three Wednesdays a month. Here, experts ask other experts questions such as how to approach infection, which, given the immersion in lake water, had a high probability of infesting Judge’s leg.

They would clean it out surgically and administer antibiotics. The cleanout involved several procedures over the first two weeks of Judge’s monthlong hospitalization. Then Stoneback’s orthopedic trauma surgery colleague, Dr. Melissa Gorman, stabilized the bone with screws and plates and placed an antibiotic spacer to prevent infection. UCHealth plastic surgeon Dr. Tae Chong provided coverage over the bone with a muscle flap and skin graft from Judge’s calf muscles. Stoneback placed bone graft using bone from Judge’s femur into the large defect where the antibiotic spacer had been placed. At first, everything looked good.

Plan B

Burnett drove Judge home, an eight-hour drive north. But her medical journey was just getting started. The infection they feared crept in: the UCH infectious disease team identified it as pseudomonas. It thrives in water – and, if given the chance, tissue and bone.

“It’s a very bad bacteria, and so the only way to completely get rid of the infection is to treat it like a cancer,” Stoneback says.

All the grafts, skin, tissue and bone had to come out again. The metal plates and screws would reignite infection, Stoneback and colleagues knew, so that hardware, too, was removed, leaving Judge with a gap in her shinbone as intravenous antibiotics did their work. The Limb Restoration team came up with a new plan.

First, Chong would move skin and tissue from Judge’s thigh and transfer it to her lower leg. Technically, that’s called an anterior lateral thigh flap (ALT).

“Whenever we’re looking to provide limb salvage, it’s all about whether or not there’s soft tissue coverage over the bone,” Chong says. “If you don’t have some sort of stable skin over the bone, it’s not salvageable.”

Second, once that healed, Stoneback would cut around the hard outer layer of Judge’s tibia (called a corticotomy) a couple of inches below the knee. Doing so would leave the blood vessels and other tissues inside and outside the calcified bone intact. Then Stoneback would fit Judge’s lower leg with a circular ring fixator to commence the process of bone transport via distraction osteogenesis.

That last bit is a mouthful, but it’s simple enough in concept: with help from erector-set-style hardware (the circular ring fixator) screwed into the tibia above and below the point at which Stoneback cut and again high and low on the tibia to provide stability. Judge would slowly grow another four centimeters (1.57 inches) of shinbone to close the gap the accident had left down low. The plan also involved planting antibiotic beads at the injury site – to make sure the stubborn pseudomonas were truly erased – and also cutting the edges of the damaged shinbone at the injury site so they would come together flush.

There was, in short, a lot involved. Stoneback reminded her that amputation was still an option – and might become a necessity.

“It wasn’t an easy decision for anybody,” Judge says. “They talked to me a lot about all my options and made sure I wanted to do this and I would do it. Because they knew it would be hard.”

It had already been hard. For nine months now, she and her fiancé had been leaving the dogs with Judge’s parents and driving 16 hours round-trip from Colstrip down to UCH once or twice a month – more accurately, Burnett drove, because Judge couldn’t drive, any more than she could put weight on her right leg. She had been in a wheelchair the whole time.

But she could still wiggle her toes. The leg, the foot – they were alive. She wasn’t about to give up.

“That was my main deciding factor, I think,” Judge says. “When I was like, I want to try. I want to do it.”

‘A magician’

Stoneback told her she would have to quit smoking – it constricts the tiny blood vessels she would need to regrow bone. Chong told her to stay away from caffeine, which could also limit blood flow and affect the flap. Without tissue coverage, there could be no bone repair and she would lose the leg. Unlike the abdomen or the thigh, the lower leg has very little skin to spare. It would be a challenging procedure, Chong recognized, one complicated by an anatomical quirk: Judge has only two arteries reaching into her lower leg, and one of them was damaged. Most of us have three lower-leg arteries that supply the lower leg and foot. Chong would use the undamaged artery and vein to provide blood flow to the thigh flap. While the vessels can be small (less than 2 millimeters in diameter, about the thickness of a nickel) they keep the flap alive and facilitate wound healing. Because of the anatomic variant, had Chong damaged the artery to which he was grafting the thigh flap, Judge’s foot could have died.

In a delicate, eight-hour procedure in January 2017, Chong transferred the thigh flap. Judge stayed at UCH for a month, with nurses checking blood flow every hour. Had the flap not survived, it would have meant amputation.

It did survive, and by May, it had healed to the point that Stoneback could get to work, installing the ring fixator. For nearly three months, Judge adjusted the ring fixator three times a day, slowly separating the tibia where Stoneback had cut. She and Burnett moved into an apartment near UCH so Stoneback could keep close tabs on her during this critical phase.

By mid-July 2017, the gap at the original wound site had all but closed and the bone transport, as it’s called, complete. Stoneback took bone marrow from Judge’s hip to complete the repair at the injury site (her own body had regrown the four centimeters of bone higher up). The ring fixator, left in place to support her tibia as it healed, came off in November 2017. She started physical therapy.

PT and such things as routine X-rays and exams happened in Coltrip. For that, Lauren Lewis, the UCHealth Limb Restoration Program’s nurse navigator, is largely to thank. Among her other duties in smoothing the complex care paths of limb restoration patients, she helps patients arrange local care wherever possible. Being the only such program in the region, it attracts patients from far afield, including internationally, Stoneback says. Enabling patients to take care of medical business as much as possible close to home eases the personal and financial burdens on families, he says.

“We want them to get back to their optimal selves in their home communities,” he says.

Walking again

By the summer of 2018, she was walking without assistive devices. By early November, you’d miss her slight limp if you weren’t looking for it.

On Nov. 6, Judge was back at UCH for what was expected to be one last procedure of more than 20 in total. Chong would use liposuction to reduce the size of the tissue flap over the wound and apply some of the harvested fat below an area of thin scar tissue. In addition to improving the contours of the lower leg “to get people back in their cowboy boots,” as Chong puts it, filling in tissue below scars provides padding so they’re not as prone to break down. Judge and Burnett drove in from Montana to meet with Stoneback the evening before the procedure.

Stoneback had come straight from the operating room, the faint impression of surgical-cap elastic still fading from his forehead. He told Judge that she was, from his perspective, in the clear: fully healed, no restrictions. It had taken nearly two-and-a-half years. She still couldn’t quite stand on her toes because foot ligaments also took damage that summer day on the reservoir and muscle was sacrificed for that first flap. But she had kept her leg, her foot, her toes. She is deeply grateful to Chong and Stoneback “for believing that I could do this and for taking all the time and energy they did to totally reconstruct my leg. I truly believe if I hadn’t gone to UCH, I would have lost my leg two years ago.” She calls Stoneback “a magician.”

“I would never go anywhere else,” she says. “This guy changed my life.”

She tears up and hugs her surgeon.

“This is all you,” Stoneback says. “You came through this like a champ.”

“I couldn’t have done it without you.”