{"id":19892,"date":"2018-12-12T11:18:28","date_gmt":"2018-12-12T18:18:28","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=19892"},"modified":"2023-09-28T16:03:06","modified_gmt":"2023-09-28T22:03:06","slug":"keeping-her-leg-required-steely-determination-and-an-expert-surgeon","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/keeping-her-leg-required-steely-determination-and-an-expert-surgeon\/","title":{"rendered":"Keeping her leg required steely determination and an expert surgeon"},"content":{"rendered":"
<\/div>

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 \u2013 the marine equivalent of a motorcycle \u2013 with her fianc\u00e9, 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 \u201cWhere\u2019s Stacey?\u201d slowing way down as he did.<\/p>\n

\"A
Dr. Jason Stoneback examines Connie Judge\u2019s right leg, which he and many others at UCHealth played a big role in repairing over nearly two-and-a-half years.<\/figcaption><\/figure>\n

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.<\/p>\n

Burnett hammered forward so hard he broke the jet ski\u2019s 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 \u2013 they happened to be husband-and-wife emergency medical technicians (EMTs) out with their kids.<\/p>\n

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.<\/p>\n

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.<\/p>\n

\u201cWe\u2019ve got this\u201d<\/strong><\/h3>\n

The flight and the night that followed were a blur. The next morning one team after the next stopped in \u2013 specialists in orthopedics, plastic surgery, vascular surgery, and infectious disease.<\/p>\n

\"Connie
On Nov 5, the day before her final surgery \u2013 cosmetic liposuction and contouring by UCHealth plastic surgeon Dr. Tae Chong \u2013 Judge describes how the ring fixator helped her own body regenerate new tibia bone to make up for bone lost in the accident and subsequent infection over a period of several months.<\/figcaption><\/figure>\n

\u201cInfectious disease was a big one because my leg was open in lake water,\u201d Judge says.<\/p>\n

On the orthopedic side, Dr. Jason Stoneback<\/a>, chief of Orthopedic Trauma and Fracture Surgery at University of Colorado Hospital and head of the\u00a0UCHealth Limb Restoration Program<\/a>, would take the lead. He examined Judge\u2019s 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. \u201cWe\u2019ve got this,\u201d he thought to himself.<\/p>\n

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\u2019s 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\u2019s leg.<\/p>\n

They would clean it out surgically and administer antibiotics. The cleanout involved several procedures over the first two weeks of Judge\u2019s monthlong hospitalization. Then Stoneback\u2019s orthopedic trauma surgery colleague, Dr. Melissa Gorman<\/a>, 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\u2019s calf muscles. Stoneback placed bone graft using bone from Judge\u2019s femur into the large defect where the antibiotic spacer had been placed. At first, everything looked good.<\/p>\n

Plan B<\/strong><\/h3>\n

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 \u2013 and, if given the chance, tissue and bone.<\/p>\n

\u201cIt\u2019s a very bad bacteria, and so the only way to completely get rid of the infection is to treat it like a cancer,\u201d Stoneback says.<\/p>\n

\"At
At right, an X-ray taken the day of the accident on June 26, 2016. At left, six weeks into the distraction osteogenesis on June 14, 2017. The idea was to close the gap at the point of injury by creating gap higher in the shin that would, with time, fill with new bone.<\/figcaption><\/figure>\n

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.<\/p>\n

First, Chong would move skin and tissue from Judge\u2019s thigh and transfer it to her lower leg. Technically, that\u2019s called an anterior lateral thigh flap (ALT).<\/p>\n

\u201cWhenever we\u2019re looking to provide limb salvage, it\u2019s all about whether or not there\u2019s soft tissue coverage over the bone,\u201d Chong says. \u201cIf you don\u2019t have some sort of stable skin over the bone, it\u2019s not salvageable.\u201d<\/p>\n

Second, once that healed, Stoneback would cut around the hard outer layer of Judge\u2019s 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\u2019s lower leg with a circular ring fixator to commence the process of bone transport via distraction osteogenesis.<\/p>\n

That last bit is a mouthful, but it\u2019s 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 \u2013 to make sure the stubborn pseudomonas were truly erased \u2013 and also cutting the edges of the damaged shinbone at the injury site so they would come together flush.<\/p>\n

There was, in short, a lot involved. Stoneback reminded her that amputation was still an option \u2013 and might become a necessity.<\/p>\n

\u201cIt wasn\u2019t an easy decision for anybody,\u201d Judge says. \u201cThey 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.\u201d<\/p>\n

It had already been hard. For nine months now, she and her fianc\u00e9 had been leaving the dogs with Judge\u2019s parents and driving 16 hours round-trip from Colstrip down to UCH once or twice a month \u2013 more accurately, Burnett drove, because Judge couldn\u2019t drive, any more than she could put weight on her right leg. She had been in a wheelchair the whole time.<\/p>\n

But she could still wiggle her toes. The leg, the foot \u2013 they were alive. She wasn\u2019t about to give up.<\/p>\n

\u201cThat was my main deciding factor, I think,\u201d Judge says. \u201cWhen I was like, I want to try. I want to do it.\u201d<\/p>\n

\u2018A magician\u2019<\/strong><\/h3>\n

Stoneback told her she would have to quit smoking \u2013 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\u2019s foot could have died.<\/p>\n

\"\"
At right, the gap in Judge\u2019s lower leg had closed by Aug. 10, 2017, and bone is thickening in the gap higher in the shin. At left, Judge\u2019s tibia and fibula had fully healed by this July 2, 2018 X-ray.<\/figcaption><\/figure>\n

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.<\/p>\n

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.<\/p>\n

By mid-July 2017, the gap at the original wound site had all but closed and the bone transport, as it\u2019s called, complete. Stoneback took bone marrow from Judge\u2019s 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.<\/p>\n

PT and such things as routine X-rays and exams happened in Coltrip. For that, Lauren Lewis, the UCHealth Limb Restoration Program\u2019s 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.<\/p>\n

\u201cWe want them to get back to their optimal selves in their home communities,\u201d he says.<\/p>\n

Walking again<\/h3>\n

By the summer of 2018, she was walking without assistive devices. By early November, you\u2019d miss her slight limp if you weren\u2019t looking for it.<\/p>\n

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 \u201cto get people back in their cowboy boots,\u201d as Chong puts it, filling in tissue below scars provides padding so they\u2019re not as prone to break down. Judge and Burnett drove in from Montana to meet with Stoneback the evening before the procedure.<\/p>\n

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\u2019t 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 \u201cfor 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.\u201d She calls Stoneback \u201ca magician.\u201d<\/p>\n

\u201cI would never go anywhere else,\u201d she says. \u201cThis guy changed my life.\u201d<\/p>\n

She tears up and hugs her surgeon.<\/p>\n

\u201cThis is all you,\u201d Stoneback says. \u201cYou came through this like a champ.\u201d<\/p>\n

\u201cI couldn\u2019t have done it without you.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

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 \u2013 the marine equivalent of a motorcycle \u2013 with her fianc\u00e9, Jerry Burnett, at the helm. They had come from Colstrip, about an hour and a half north of the […]<\/p>\n","protected":false},"author":23,"featured_media":19895,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[93,565],"class_list":["post-19892","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-limb-restoration-program","tag-trauma-services"],"acf":[],"yoast_head":"\nKeeping her leg required steely determination and an expert surgeon - UCHealth Today<\/title>\n<meta name=\"description\" content=\"Keeping her leg took determination, many surgeries and the expertise of a UChealth surgeon. 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