UCHealth’s Limb Restoration Program: Returning Patients to Their Optimal Self
September 2019 Issue
Early every Wednesday morning in the Anschutz Inpatient Pavilion on the Colorado Anschutz Medical Campus in Aurora, Colorado, a team of multidisciplinary professionals meet to review and discuss complex cases of patients who face a host of serious orthopedic issues from infections and amputations to deformities.
Jason Stoneback, MD, is the director of the Limb Restoration Program at the University of Colorado (UC) School of Medicine and UCHealth. He started the program in 2012, and it began treating patients in 2016.
Stoneback is the team's trauma surgeon focusing on complex fractures, wounds, leg length discrepancies, and infections. In addition to performing complex and revision amputations and osseointegration (OI) surgery, he oversees the coordination of care for patients referred to the program. "The goals of the program are to be a worldwide resource for patients with extremities at risk or who are having difficulties with their extremities," he says.
Stoneback recruited Kristin Loker, DNP, NP-C, as the nurse practitioner for the program in 2016. Her primary role is to care for the patients with amputations. "It is inclusive of the entire pre-operative period from conducting the initial visits in clinic with patients who are considering amputations to participating in the surgeries and caring for them post-operatively while they are in the hospital and the clinic," she says
Other conditions the limb restoration team treat include congenital anomalies, problems with bone healing or deformities, or severe trauma from accidents. Treatments may range from lengthening bones and short residual limbs, straightening a crooked bone, targeted muscle reinnervation, or amputation.
Thousands of patients worldwide have gone through the limb restoration program at UCHealth. Stoneback says, "Our programmatic approach is to take a concerted multidisciplinary approach to these challenging conditions and restore patients to their optimal selves."
A Multidisciplinary Approach
The limb restoration team is composed of more than 20 experts in specialties including musculoskeletal infectious disease, limb lengthening and orthopedic reconstruction, vascular conditions and rehabilitation, and amputation and wound care.
The multidisciplinary approach is beneficial in myriad ways, Stoneback says. "Optimal treatment of complex problems requires all aspects of the patient's care," he says. "Reviewing complex cases prior to the patient traveling to our institution allows us to assure they see the right providers in a coordinated fashion, so we do not waste time getting them to their desired functional status."
When a patient begins treatment in the limb restoration program, one of the first things they hear is the voice of Lauren Lewis, BSN, RN. As the nurse navigator for the program, she is a liaison between the patient and the multidisciplinary team, from the patient's first telephone encounter to their last clinical evaluation.
It is Lewis' responsibility to ensure patients are seen by all appropriate providers in a timely and efficient manner when their care begins. After that initial evaluation, Lewis presents the case to the multidisciplinary team for a collaboration of care. "We do this to confirm we have the best possible treatment plan for each patient," says Lewis, who also works to reduce other barriers to a patient's care, such as coordinating travel, insurance, and family support prior to the start of treatment. It is her job to anticipate and prioritize patients' needs. "As a patient's needs change from day to day so do my duties and responsibilities," she says. "That could range from calls, triages, emails, new referrals to nurse visits."
Kelly Anne Bultemeier, MEd, ATC, CES, is an athletic trainer on the limb restoration team. She collaborates with providers inside and outside the clinic to provide preventive services, clinical diagnoses, therapeutic interventions, and rehabilitation of injuries and related medical conditions. "A typical week for me focuses on clinic preparation," she says. "Knowing who we are seeing in clinic and ensuring our team has the appropriate medical history and intake can ensure a smooth visit."
Christopher "Topher" Edgar, BS, is the program's outpatient clinical care coordinator. "A typical week for me is supporting my team," he says. Coordinating with multiple departments and physicians to ensure timely patient care is his daily focus.
While everyone on the limb restoration team comes from his or her own unique professional background, each one agrees that an amputation isn't a failed procedure.
"We do all sorts of things to save people's limbs, but sometimes the best answer is amputation," Stoneback says. "We don't see that as a failure. We see that as a critical tool and component for the right patient at the right time. It's more about what's the right move that would restore a patient's optimal function."
As an example, the team treated a patient who was involved in a scooter accident in Thailand. By the time the patient was seen in Colorado, he had a serious infection in both legs and was a candidate for a hip disarticulation in his left leg. To save more of his leg, physicians did a procedure that is more often used to treat patients with sarcomas: a turn-up plasty, Stoneback says. Surgeons amputated the patient's femur, knee, and foot, but preserved a portion of his femur to provide a better basis for a prosthesis.
It's rare that the team can't help a patient in their program, Stoneback and Loker agree.
"We can almost always help them," Loker says. "Either through surgery, pain management, or repairs to a prothesis."
And while care is centered around the adult population, patients of all ages have also been treated, Stoneback says. "When patients come here, they've been dealing with these issues for a long, long time and they're pretty savvy," he says. "They're ready for the next step they hope will help them."
ATV Ride Changes Everything
Tim Barr, who lives in Keenesburg, Colorado, first came to UCHealth in August 2014. Barr was a heavy-equipment operator who shattered his right ankle and broke his leg in an ATV accident in July 2014.
The injuries to his lower leg failed to heal and continued to get infected. His first visit to UCHealth was surgery, a debridement of his ankle.
After another procedure to remove roughly three inches of bone in his lower leg, Stoneback fitted Barr with a Taylor Spatial Frame, an orthotic device he wore for a year to try and lengthen the bone. There was, however, no improvement. After more than two years of trying to save his leg, which included enduring more than 20 surgeries, as well as receiving hyperbaric oxygen therapy treatments, Barr and his wife, Andrea, began to discuss the possibility of an amputation.
"Dr. Stoneback told us you could keep going for more surgeries, or we can take it off and you can get back to what you were doing in three months," Andrea says.
The Barrs agreed that an amputation was best the route, and Barr had a transtibial amputation in September 2016. Barr wears a total surface bearing transtibial prosthesis incorporating a silicone liner and quick disconnect locking mechanism and a Freedom Innovations Renegade AT foot, says his prosthetist, Christopher Hoyt, CP, with BioDesign, Denver. "Tim chooses not to have his prosthesis cosmetically shaped and opts for a custom lamination and the addition of a spoke protruding from the foot," Hoyt says.
The device has allowed Barr to return to work full time as well as to the active lifestyle he had before his accident. "I do awesome," he says. "The only trouble I have now is in the shower."
Osseointegration and Beyond
The limb restoration team is expected to perform its first OI procedure at UCHealth in September, Stoneback says. OI clinics have been held at UCHealth to consider viable candidates for the surgery, says Stoneback, who has performed the procedure numerous times overseas. Stoneback is anticipating at least six patients will be ready for the procedure in September. "They've already been through a multidisciplinary evaluation by the team," he says. "They know what's involved."
Fully Functioning Lives
Lewis' career took on new meaning when she started with the limb restoration team more than a year ago. When she interviewed with Stoneback, and he gave a presentation of the program and how advanced the technology has become, Lewis said she was in awe.
"I had no idea we had the capability of restoring limbs to this level," she says. "The great thing about orthopedics is the witnessed journey back to health. More times than not you see the patients at their worst state of physical function, disheartened and [with a] loss of hope of ever getting better. Then we come into the picture with a strategic plan, execute it, and then have the joy of watching them come back to fully functioning lives. It's extremely rewarding."
Barr's decision to have an amputation wasn't easy to make. "Tim's decision may seem incomprehensible until you understand how many surgeries he had undergone, how much pain he experienced on a daily basis, and how he didn't want to be limited physically while raising his two young boys," Hoyt says. "He also did his homework, taking the time to choose the team members who would help him through this difficult time."
Betta Ferrendelli can be contacted at firstname.lastname@example.org.
The O&P EDGE will be following UC Health's first patients through the OI process. Watch for further coverage in late 2019 and 2020.