How This Leg Was Saved

In March 2010, David, a U.S. Army special Forces deputy commander in Afghanistan, was injured when a 160-lb. bomb tore through his left leg. Over the next year, he underwent 23 surgeries, mostly to carve out small hunks of dying tissue; in one major procedure, doctors at Walter Reed removed 4 in. of his tibia because of an infection. He endured the painful stretching of the remaining bone, using a vise that, as it expands, pulls the ends of the bone apart. The daily sessions lasted six months, extending his tibia 1 mm a day to get to the point where the two pieces of bone were close enough to be fused together.

A year after his injury, David–who requested that TIME not print his last name because of the secret nature of his missions–could walk, but only very slowly and with intense pain. His doctors at Fort Lewis in Washington State sent him to Brooke Army Medical Center (BAMC) in San Antonio to see Lieut. Colonel Joe Hsu, an orthopedic surgeon and the director of a rapidly expanding program for limb salvage. “I was pretty much expecting him to tell me to cut my leg off,” David says. “I had kind of come to terms with it. It’s that simple. If I can’t do the things I want to do, then take it off.”

Instead, David was outfitted with a brace called the Intrepid Dynamic Exoskeletal Orthosis (IDEO). “It was night and day,” he says. “After the first five minutes, I could walk at a normal pace.” He quickly graduated to jumping on and off boxes and sprinting. A free-fall parachutist, David returned to his unit and plans to start high-altitude parachute jumping again. “Two years ago they’d have cut the leg off and sent us on our way,” he says.

Because of the number of bomb-blast injuries in Iraq and Afghanistan, doctors in the U.S. have gotten very good at saving limbs. For every amputee from those wars, there are now an estimated five or six limb-salvage patients. But saving a severely damaged limb is a grueling process that requires as much physical therapy as an amputation, if not more. Although the overwhelming majority of limb-salvage patients learn–through extensive rehabilitation–to walk again, many suffer from chronic pain and loss of function. Yet it’s worth the effort for several reasons. For one, doctors can always cut it off later, but once a leg is gone, there’s no bringing it back. And while prostheses have improved dramatically in recent decades, every amputee who leaves the hospital leaves with a wheelchair. Prostheses break, amputees suffer infections, and many experience real pain in phantom limbs, which can be hard to treat.

The Patient’s Choice

The practice of limb salvage isn’t confined to military hospitals. Because of greater use of seat belts and air bags, more people are surviving car wrecks with more-severe limb trauma, says Dr. Andrew Pollak, president of the Orthopaedic Trauma Association. Typically, he says, if a patient makes it through the first night without needing an amputation, he or she gets to choose whether to try to salvage the limb. “You begin a very difficult series of conversations with the patient and the family about what those two paths look like,” says Pollak, who is also an orthopedics professor at the University of Maryland Medical Center. “Someone who works as an accountant in a chair in an office has dramatically different demands than someone who was in construction before and will be up on his feet all day long walking around. The accountant may be able to tolerate ongoing operations–and an inability to walk–and still do his job. The guy in construction may say, ‘I simply can’t put food on the table that way. I need an amputation so I can get a prosthesis and get back to work.'”

It sounds counterintuitive: cut off a leg to increase mobility. But it speaks to the advances in prosthetics technology over the past two decades. Many troops requested amputations so they could get a prosthesis nicknamed a cheetah leg, a curved carbon-fiber blade invented in 1984 and made famous in recent years by Oscar Pistorius, the South African double amputee who is one race away from qualifying to compete in the London Olympics.

For wounded troops, a severe injury can be a ticket out of the military. But for some limb-salvage patients who want to return to service, cheetah legs start to look pretty attractive as the months of rehab drag on.

“The reason why we had all these guys who wanted their legs cut off was that they wanted to run,” says Johnny Owens, a physical therapist who is the director of limb-salvage rehab at BAMC. For high-performing troops, running separates those who can do their jobs from those who can’t. On any given day at BAMC, dozens of amputees can be seen jogging on cheetah legs along the palm-tree-lined streets. As part of their recovery, many are training for triathlons and other endurance races.

In 2009, Owens and other specialists at BAMC noticed that an alarming number of patients were coming to the center asking for a “late” amputation–i.e., one performed months or even years after the injury. Most had conditions such as fused ankles and severe nerve and muscle damage that made it hard to walk, let alone jog. Their requests led Ryan Blanck, a prosthetist at BAMC, to design the IDEO. It fits into a patient’s shoe and runs a carbon-fiber strut up the calf to a cuff that attaches just below the knee, acting as a cheetah-like springboard for an ankle that can’t flex and muscles that no longer exist.

Once a patient gets this custom-made orthosis, he–almost all of the limb-salvage patients at BAMC are men–walks over to the rehab gym, where Owens mixes sports-medicine techniques into the regimen, teaching guys to run by landing midfoot instead of on their heels, using the same barefoot running style that’s becoming popular even among noninjured runners. The result: patients who were in such pain that they could barely walk 10 ft. are, within a week of starting special training, jumping and sprinting.

Running Speed

More than 200 troops have gone through BAMC’s Return to Run program since 2009; of those, 97–including Navy SEALs, Rangers and Special Forces soldiers–have sought and received the go-ahead to return to active duty, where they are jumping out of planes and fast-roping out of helicopters.

The BAMC specialists have been so successful in treating limb-salvage patients that they’re now inundated with requests, but Blanck’s shop can handle only about 25 cases at a time. “The problem is, this is not an official program, so there’s been no initial funding,” Hsu says.

The Return to Run team, which has applied for grants to fund larger studies, hopes to replicate its training platform at other military bases and eventually create a version that can be used in the civilian world. If the clinical trials are successful, insurance companies might take an interest in their work. According to a study conducted at the University of Michigan, when prosthesis-related costs are taken into account, the lifetime health care cost for patients who undergo an amputation can be two to three times as high as that of limb-salvage patients, depending on how long they live. Because each IDEO is custom-made, they would be expensive in the civilian market but would likely cost less than prostheses in the long run.

BAMC already knows its program can work on non-war-related injuries. Sergeant William Porter, a helicopter mechanic in the Marine Corps, had returned from his third Iraq tour when a dirt-bike crash near Miramar, Calif., resulted in partial paralysis in his left foot. Porter’s orthopedic surgeon told him about BAMC, where Blanck fitted him with an IDEO, and Porter was soon back to running more than three miles. He passed his physical-fitness exam and has returned to full duty. “Had I not done that, I’d probably be on my way out of the Marine Corps,” Porter says.

Returning to active duty isn’t the only goal. “It’s about getting back to life,” Blanck says. “Playing softball. Just being a coach for their kid’s soccer or T-ball team. It’s amazing how demoralizing that can be if you can’t do that.”

For Ryan, a Green Beret sergeant who requested that TIME not print his last name out of concern for the safety of his unit, keeping his leg was the first battle. On Sept. 11, 2010, he stepped into a doorway to fire at an insurgent in Afghanistan’s Helmand province and had both bones in his lower right leg blown out by an improvised explosive device. The eruption tore off the bottom of his foot and mangled 95% of the flesh below his knee. Eight days after his injury, Ryan landed in front of Hsu. “It was week by week whether I’d have an amputation for six months,” Ryan says.

After Hsu saved his leg, Ryan attacked his rehabilitation with the same fervor that had driven him to the Special Forces in the first place. He tried walking while still in a stabilizing brace with pins and screws in his bones, but he could muster only “a very aggressive walk,” he says, “and that would ruin me for the rest of the day.” Then Blanck fitted Ryan with an IDEO. “I couldn’t believe it,” Ryan says. “All of a sudden I can walk normally. I can jog. I can sprint and jump. It was a really weird feeling because I was limited for over a year. It was something else.”

This spring, Ryan is back with the Special Forces in Afghanistan, leg and all, running three or more miles at a time and hauling 100-lb. rucksacks with his fellow Green Berets. For the past few months he has been conducting combat patrols over rough terrain. With his orthosis and a lot of training, he’s back to about 90% of his former strength. “Given an injury of this significance,” he says, “it’s the best of a worst-case scenario.”

FOR MORE STORIES BY NATE RAWLINGS, GO TO time.com/battleland