Saving an arm with the help of a leg

The Limb Restoration Program team at UCH uses a complex bone graft from a Colorado man’s leg in a bid to save his ruined arm
June 7th, 2017
a picture of Michael Klement'’s reconstructed left arm after the May 5 procedure
Michael Klement’’s reconstructed left arm after the May 5 procedure. The oval piece of light-colored skin that runs to the joint is the flap taken from the tibia in his left leg. The Limb Restoration Program team is monitoring the graft to ensure it is holding; if this skin is alive, they know the transplanted bone is getting an adequate blood supply.

A well-worn expression holds that something of great expense costs an arm and a leg. A Colorado man severely injured in a car accident this spring hopes that a complex surgery will give those words new meaning. In his case, his leg may save his arm.

Michael Klement, 56, was driving his wife and son to Brighton along Riverdale Road in Thornton the evening of April 6 when a car headed in the opposite direction crossed the dividing line and clipped the driver’s side door of Klement’s Blazer. The impact caved in the door, which pinned Klement’s left upper arm. His car careened into a ditch.

His wife, whose knees were injured in the crash, called 911. Klement went in and out of consciousness until firemen arrived to take off the car door and free him for transport to a nearby hospital. Emergency providers there looked at his badly damaged arm and quickly decided to transfer him via air-lift to UCHealth University of Colorado Hospital, where he would receive care from a multispecialty team that comprises the Limb Restoration Program. The program is one of the few in the state equipped to handle complex limb-threatening injuries such as Klement’s.

The “beautiful arm,” as Klement ruefully described it, was an open mass of devastated muscle, bone, vessels and nerves. The crash had not only broken Klement’s humerus – the long bone of the upper arm – it had sheared away four inches of it, said Jason Stoneback, MD, orthopedic surgeon and head of the Limb Restoration Program at UCH. The violent collision had also severed the radial nerve, which in its descent through the arm wraps around the humerus and allows the wrist and fingers to extend and the hand to turn palm up.

Bold action

An X-ray image of Michael Klement’s left humerus
An X-ray image of Michael Klement’s left humerus after orthopedic surgeons Melissa Gorman and Jason Stoneback surgically cleaned out wound debris and stabilized the bone. The large gap shows about four inches of bone Klement lost in a massive car accident.

Klement says he awoke the next morning in the intensive care unit at UCH “scared to death.” Looking down, he realized instantly that “this was no ordinary broken arm.” Stoneback and his team, he said, “laid it on the line” in explaining what they would have to do to try to save the arm, and soon Klement was in surgery.

Stoneback’s team stabilized the arm with an external fixator to minimize movement. There were multiple operations to clean the wound, which was littered with glass and other debris from the accident, and stabilization of the elbow joint followed. The next question was how to replace what turned out to be four inches of lost bone in the humerus – about the width of a light switch plate cover.

To measure the precise amount of bone loss, Stoneback took calibrated X-rays of the damaged area. He then took the same kind of X-rays of Klement’s good right arm. These pictures would serve as a “template” – an anatomical guide during surgical reconstruction of the left humerus, Stoneback said.

For less severe injuries, a bone graft might be used to bridge the gap. But Klement’s mishap had made a shambles of the surgical playing field, which was a mass of dead blood vessels, tissue and muscle. An ordinary graft therefore couldn’t take hold, said Ashley Ignatiuk, MD, a plastic and reconstructive surgeon at UCH. It would be like planting seeds in barren soil.

“A graft is dead bone,” he said. “The bone has to come back to life.”

His own donor

The team decided that Klement’s best chance lay in bone flap surgery. Ignatiuk would use the fibula in Klement’s lower left leg as a graft source, but in addition to the required length of bone, he would also take arteries and veins to feed it. These would serve as the blood supply to invigorate the bone when Ignatiuk grafted it to Klement’s damaged humerus.

It was a bold approach, undertaken by few hospitals in Colorado, said Stoneback, who noted that it requires collaboration between a large multidisciplinary team before, during and after surgery. He said he’s done only three or four of the procedures in the past several years. It was Ignatiuk’s first of this type, although he said he’d done other fibula flaps on injured jaws.

Klement said he understood the seriousness of the procedure, but agreed to it as a chance to regain a functioning arm. “I knew it was a big job, but I said, ‘Let’s do it.’”

The surgery is, in effect, a transplant, with the donor being the patient himself. Ignatiuk said the team first used Doppler ultrasound to listen for the blood supply flowing through the peroneal artery, which feeds blood to the back side of the fibula. He needed both bone and blood supply for a successful graft.

Ignatiuk dissected the living blood vessels and cut the bone to fit the gap in Klement’s humerus properly and align it with Stoneback’s framework. Scans of the arm revealed the remaining viable vessels in the arm that would serve as the connectors for those to be transplanted. In painstaking microvascular surgery, he connected the arteries and veins, listening all the while in real time with Doppler for the sounds of blood flow, the signal of a lifegiving connection filling what had been a dead void. After many hours of work, the welcome whoosh emerged.

Hard road ahead

Klement’s humerus post-surgery.
Klement’s humerus post-surgery. Stoneback used calibrated X-rays to determine how much bone would be needed to restore the lost bone, then used X-rays of the right humerus for a “template” used during reconstructive surgery led by Ashley Ignatiuk.

It’s far too early to call the May 5 surgery an unqualified success, Ignatiuk said. It will be months before the team can be sure the graft has held and established a blood supply that reliably nourishes muscle and tissue growth. Klement’s arm resembles a tangle of randomly running train tracks through a badly damaged landscape. He’s working through physical therapy, provided at home, to help him recover from swelling in his left leg – the residue of the flap resection, which left a 15-inch scar.

Stoneback is similarly cautious about the surgery but said in an email that “if the fibula incorporates we anticipate that he will be able to fully weight bear and have complete return of functional stability.” He added, however, that Klement will need to work through elbow stiffness caused by having the arm immobilized for weeks and the severe tissue damage he suffered in the crash. He has a steel plate and 15 screws in the arm.

He also needed another surgery June 2 to address the nerve damage from the accident. In that one, Ignatiuk performed a nerve transfer. He calls it a “state-of-the-art technique” that involved using parts of Klement’s functioning median nerve, another major component of the upper arm, to replace the radial nerves that were destroyed in the accident. If it’s successful, that surgery too will require many months of physical therapy for his left hand.

“He’ll need to work very hard,” Ignatiuk said, noting that in therapy Klement will have to retrain his brain to adapt to “new circuitry.”

The accident and its still unfolding aftermath also cloud Klement’s future as a concrete worker, which he’s been most of his working life. He said he’s hopeful of returning in some capacity, but realizes he’s not close to 100 percent and probably won’t be for some time.

“I’m an impatient person,” he said, “but I don’t want this to get me down. I’m not giving up. I’m taking it one day at a time.”

Klement said he takes heart from the encouragement of Stoneback, Ignatiuk and his other providers, who encourage him with positive news about the progress of his healing.

“I’ve gotten very good care,” he said. “The surgeons have been phenomenal, very good and kind. I don’t know of another hospital I’d rather be in. My life changed in a heartbeat, but I’m ready to continue on.”

 

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About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.