Dugan Smith loves playing sports -- baseball, basketball, football, you name it. So when the 13-year-old lost part of one leg to bone cancer, he was faced with the prospect of being sidelined as a spectator for the rest of his life.
Instead, Dugan opted for a rare and what to many would seem a radical operation that has allowed him to return to the field like almost any other kid.
Known as a rotationplasty, his surgery involved removing a large section of his right leg that surrounded the tumour -- from below his knee to about mid-thigh -- then reattaching the lower limb to the shortened upper thigh.
The twist, so to speak, is that Dugan's lower leg was rotated 180 degrees and sewn on backwards.
His ankle now acts as his knee, his calf has replaced the lower part of his thigh and his backwards-facing foot slips into a prosthetic and powers the reversed muscles and joint with an up-and-down motion.
"I'll be able to play basketball and baseball -- baseball's my favourite sport," says Dugan, a seventh grader who pitches and plays first base on his junior high school's baseball team in Fostoria, Ohio. "Just knowing I would be able to play those made my mind go straight at it."
Dugan was just 10 when he was diagnosed with a softball-sized tumour, an osteosarcoma, above his right knee. The cancer is the same type that led to Terry Fox's amputation at age 17 more than 30 years ago.
Dugan could have had a similar amputation and been fitted with a full prosthetic or had his leg rebuilt with fragile cadaver bone or a metal rod, but either option meant that participating in high-level athletics would have been out for good.
While the decision was left entirely to Dugan, his parents hoped he would choose rotationplasty because they knew giving up sports would make their son miserable.
"As soon as I explained to him, 'You know, Dugan, this is what's going to allow you to play sports and do whatever it is you want to do,' he was all for it right there," explains his father, Dustin Smith, a teacher and athletics coach at Dugan's school. "I would say it was a no-brainer."
That's not to say it was easy, either physically or psychologically.
Dugan had to undergo 10 weeks of chemotherapy before the operation and adapt mentally and emotionally to having a shortened and backwards leg.
"It takes parents and a kid with a good psychological background to be able to tolerate it," says Dr. Joel Mayerson, an orthopedic oncologist at Ohio State University in Columbus who performed the roughly 14-hour rotationplasty, a surgery originated by a Dutch doctor in 1950. Only about a dozen are performed in North America each year.
"It's not a very common operation in the United States and Canada, probably because of its cosmetic issues that have psychological issues to go with it. It's also something that doesn't work well in adults and only really works well in growing children.
"And so you have to have the right patient in the right age group to get it done," says Mayerson, explaining that the ideal candidates are children aged five to 14, although some older teens may also be considered for the surgery. "It would probably be difficult if someone was 25 or 30."
Compared with adults, children are typically more psychologically adaptable and their brains are better able to form new circuitry and muscle memory.
"That's the beauty of being a child," enthuses Mayerson. "They really are able to learn and that's probably why it doesn't work nearly as well in adults, because we don't have that same plasticity in our brain."
Even though Dugan was able to wiggle his toes almost immediately after the operation, it took him about 18 months of intense rehab to adjust physically and mentally to his altered leg.
Initially he experienced phantom pain, but that has now disappeared, he says. And when he began walking with his prosthetic, his gait was stiff-legged and he had to concentrate on every movement.
"And then one day I could walk. Now I don't have to think about it. It's like a regular leg. That was a cool thing."
Still, the physical challenges are just one part of the equation; dealing with people's reactions has been a major hurdle.
"Dugan had some issues with his classmates when he first had the operation," says Mayerson. "Kids can be mean, and it can be common that young kids don't understand. A 10-year-old child doesn't understand why someone has to have their foot turned around."
At first, Dugan kept his leg covered when out in public.
"It bothered me how people stared and walked away and just kept staring and didn't really ask me anything," he says. "That's why girls don't get it because they're looking and just think you're crazy when you talk to them about that."
But over time, he's adapted to his reconfigured physique and isn't shy about showing off his limb and explaining the benefits of his surgery.
"I wear shorts a lot now because I don't care really anymore."
Mayerson says Dugan will need continual adjustments to his prosthetic for some time. Despite having a man-sized body at 13 -- he's five-foot-10 and 160 pounds -- Dugan is still growing and will become more muscular as he ages.
"And there are psychosocial issues that all of us have to deal with as we go through puberty, and obviously there are going to be some challenges with dating and those types of things."
Yet three years after his cancer diagnosis and surgery, Dugan's mother, Amy Miller, says her son "is doing great."
"I think his challenges are pretty much behind him," she says. "I think it's just going to get easier. Ten years from now, he's going to have a better prosthetic that's going to get easier for him."
Dugan recently returned to the pitcher's mound for his school team, and his dad figures that within a couple of years he'll be able to run almost as well as he did before the surgery.
In the stands videotaping his young patient that first game was the surgeon who helped give Dugan the future he longed for.
"I unfortunately have some very difficult conversations with children, talking about cancer and life-threatening issues, and to see him catch and run and just be a normal kid was a tremendous feeling, it really was," says Mayerson, sounding much like a proud father.
As for Dugan, his sights are set on the big leagues.
"I want to be the first (person) with a prosthetic to make it to pro baseball ... And showing all the people that just because you have a prosthetic leg, that doesn't mean you can't do it. Just go out there and do it."
