JOINT BASE SAN ANTONIO, Texas -- Brooke Army Medical Center surgeons performed their first above-the-elbow arm replant on a 22-year-old trauma patient last year and almost 10 months later the patient is thriving.
Kelsey Ward's right arm was severed when a guardrail pierced the passenger-side window of her SUV in a car wreck. San Antonio firefighters administered a life-saving tourniquet and were fortunate enough to find her arm in the wreckage. They packed it in ice and brought it to BAMC, one of two Level I Trauma Centers in San Antonio.
April 20, 2016, Lt. Col. (Dr.) Joseph Alderete, chief of surgical oncology, was the trauma surgeon on-call when Ward was brought to the emergency department.
"Most of the time when someone has a limb amputated in the field the odds of replantation are minimal because the limb is crushed and not viable for replantation," Alderete said, noting the likelihood of success for nerve regeneration decreases the higher the amputation.
"The first responders were extremely smart in making sure she didn't bleed out and that they put the limb on ice as fast as they could," he said.
Once he realized the arm was viable, a surgical team that included Alderete, two vascular surgeons, a hand surgeon, a back-up hand surgeon on-call and a plastic surgeon, quickly mobilized. The surgeons were able to reconnect Ward's ulnar nerve, but her median and radial nerves had to be grafted. They took skin from one of her legs and a vein from the other to splice together the two nerves and muscle from her back to reshape her arm.
"The data we have found shows only 82 above elbow replantations have been performed around the world since the first case was reported in the 1960's," Alderete said.
"I don't remember too much about the wreck," Ward, a San Antonio native, said. "But I do remember waking up and them telling me my arm was cut off in the accident. Then they told me they reattached it and I thought, 'wow.'"
"Looking at her tissue and making that decision, it was an amazing opportunity to give Kelsey her arm back and probably her life back," Alderete said. "For the first 10 hours of surgery we were all working on her at once. This was truly a team effort."
"Reliable nerve grafting without harvesting a nerve from the leg has only recently become a reality in the last 10 years," he explained. "From Kelsey's case, we are learning a great deal about what is possible with nerve grafting."
These types of trauma cases are vital to military readiness, Alderete said. They prepare us for the complex injuries military providers will see as they continue to deploy to combat zones throughout the world.
Once Ward recovered from her surgeries, she began her rehabilitation five days a week at the Center for the Intrepid. Alderete is also the medical director at the CFI so he continues to see Ward regularly to track her progress. Christopher Ebner is her occupational therapist.
"I vividly remember the first day the director came up to the OT clinic and briefed me on her case," Ebner said. "I didn't know what to expect, so I dived into the literature to see what had been done from a rehab standpoint.
"Rehab is being creative and thinking outside the box," Ebner said. He started using some of the same equipment they use on amputees to see what was happening below the skin. About three month into Ward's rehab Ebner was able to detect slight muscle movement in her elbow, which was much sooner than he had anticipated.
"From that day forward we were constantly thinking two steps ahead about what was next," he said.
As Ward's nerves continue to recover, Ebner is focusing on strengthening and keeping her joint motion as supple as possible in her right arm and helping her improve her dexterity in her left hand and arm. The use of a myoelectric orthotic device has also helped Ward gain more function with her right arm and hand.
"She has done fairly well in adapting to things and learning new strategies," Ebner said.
"[The rehab] is the hardest, most difficult, most exhausting thing I have ever had to do but I want my kids to know that there is nothing in this world that they are not capable of doing," the young mother of a 4-year-old daughter and 2-year-old son said.
Ward credits the support of her children, her grandmother and her boyfriend for helping her get through the long, grueling healing process.
"As a direct result of Kelsey's dedication coming to rehab for the last nine and half months and working prolifically on her home exercises, she is in a good spot right now to have a good opportunity later on for those nerves to recover," Ebner said. "We don't know what her recovery is going to look like a year or two down the road. Time will tell."
Ebner conducts several diagnostic tests regularly to monitor her progress and help anticipate what her recovery will be.
"We know that nerves typically recover their function about a millimeter a day, about a centimeter a month, but that varies a lot on the terms of the repair," Ebner said. "Grafted nerves typically take longer.
"Kelsey's progress thus far and the gains that she has made have surpassed the vast majority of cases that have been documented in the literature in terms of recovery," the OT said. "I'm extremely optimistic about her case because she has surpassed every goal and objective that we have set in front of her."
Ward said she is thankful she is able to continue her rehabilitation at the CFI. "They are like my family; I share my life with them."
Ebner said from an occupational therapy standpoint they are learning a great deal from Ward's recovery process.
"She has taught us so much about medical recovery post-replant," he said. "In the military and our medical environment here, we have a lot to learn from her case."
Ward tearfully admits there were times when she inwardly didn't think she could make it through, but today she is proud of how far she has come. "It has made me more confident, it has made me happier, it has made me in all aspects a better person," she said.