Doctors gave Army Sgt. Jacob Richardson a difficult choice after a gunshot to the thigh while on patrol in Iraq in September 2010 shattered his femur and frayed the surrounding nerves and tissue.
They could amputate and outfit him with a high-tech prosthetic. Or they could try to save his leg with no guarantees. He opted to "salvage" his leg and endured a drawn-out series of surgeries and therapies. Even then, he had to leave his eight-year military career and couldn't run.
"I was going from the infantry, where I was running five miles every other day, to being relegated to a wheelchair," said Richardson. "I was really limited in what I could do."
But a Johns Hopkins-coordinated military study has given Richardson renewed hope. Hopkins is reviewing a brace and physical therapy program, developed at the Center for the Intrepid at Brooke Army Medical Center in San Antonio, that has shown promise in restoring function to legs long after they stopped improving from their grievous injuries.
Almost 1,600 service members have lost one or more limbs in the wars in Iraq and Afghanistan. At least three times as many are estimated to be living with salvaged arms and legs, mangled from blasts and other trauma and often still painful and debilitating.
Many of the hundreds of wounded service members treated in Texas in the last several years returned to running and high-impact sports, and even active duty.
The brace, called an intrepid dynamic exoskeletal orthosis, or IDEO, is different from a standard fixed metal or plastic support. The carbon fiber is molded to a service member's leg, and incorporated struts absorb the impact from motion, as well as some of the pain, and send the energy back to the limb as muscles normally would.
Officials overseeing the Hopkins study said if they can prove that San Antonio's success can be standardized and replicated in other military hospitals, the program could save more service members — and eventually civilians — from amputation and allow them to return to active lifestyles.
The study is funded by the Department of Defense and coordinated through the Major Extremity Trauma Research Consortium, made up of dozens of U.S. trauma hospitals, military facilities and other sites, all coordinated by researchers at Johns Hopkins University's Bloomberg School of Public Health.
The consortium's mission is to improve limb care for service members wounded in combat and translate the technology for civilians, said Ellen MacKenzie, a consortium co-director at Johns Hopkins.
She said researchers are recruiting about 100 service members wounded one or two years ago. They may have faced the agonizing amputation question immediately or after other therapies failed, and now they are no longer improving.
They will go to San Antonio, Walter Reed National Military Medical Center in Bethesda or the U.S. Naval Medical Center San Diego, which have in-house orthotic and prosthetic production capabilities and rehab centers.
Service members and veterans will be fitted with a brace and undergo an intensive month-long rehabilitation program, called Return to Run. They also will report their progress over the next year.
"We've seen service members whose lives were changed dramatically," MacKenzie said. "They would have difficulty walking and in constant pain, and they'd put this brace on and start running. But the IDEO device has only been available to folks in San Antonio."
She said researchers are motivated to help those with salvaged limbs, who haven't always benefited from the attention, technology and intensive rehabilitation afforded military amputees. Past studies suggested amputees were better off physically, and mentally, because they get state-of-the-art prosthetics and a quicker return to activities.
But amputation comes with its own enormous set of inconveniences, pain and sense of loss, and researchers and therapists believe more would choose to salvage limbs if outcomes were better.
The brace and rehabilitation program was created about five years ago by a prosthetist, surgeon and physical therapist in San Antonio. They were frustrated by an "epidemic" of service members who resolved to amputate their legs a year or more after their injuries because they were so disabled.
"One guy told me he wished his leg was blown off in theater so he didn't have to make this decision," said Johnny G. Owens, the physical therapist on the project.
He said hundreds of service members have been outfitted and instructed on how to use the brace. Users quickly learned to run, jump and climb. But as they returned to active duty or their lives, the facility lost track of many, leaving no proof of long-term benefit.
Owens said he wanted to show the brace can help return more service members to active duty, even special forces, which requires jumping from airplanes, scaling walls and carrying 80 pounds of gear for miles.
Twenty-four-year-old National Guardsman Storm Aguilar wants to join the Army.
The reservist was injured on his first deployment in Afghanistan two years ago when a bomb-laden vehicle exploded near his armored Humvee while he was headed back to his Kandahar base.
He faced the amputation question but took the salvage route, which meant multiple surgeries and rehabilitation of his severely broken leg. He watched amputees working out in the gym as he endured months in a special scaffolding-like frame that slowly pulled apart his leg to promote new bone growth.
Recently, he was fitted with an IDEO brace in San Antonio and said it helped the stability of his foot, which is missing all but one of the ligaments attaching it to his shin.
"Whenever I push and flex the strut, I honestly feel like I can take off," he said. "This is after not being able to run at all. I can sprint."
The IDEO's inventor, Ryan Blanck, wanted civilians to have that experience. He left San Antonio with the Defense Department's permission to launch a private program at Hanger Inc. in Washington State.
He said people come from all over the world to test the brace in the new facility. They not only have salvaged legs from car accidents and other injuries, but they have spine and nerve damage and even degenerative diseases such as muscular dystrophy.
Recently, Blanck said he treated a 50-year-old man who was hurt as a teenager in a tractor accident. He was able to run for the first time in decades.
Blanck said he's working on several studies to prove the long-term benefits in civilians, as is Dr. Joe Hsu, the trauma surgeon who initially collaborated on the IDEO program.
At the Carolinas Medical Center in Charlotte, N.C., Hsu puts his salvaged limb patients through a similar rehab program as Return to Run. But he said insurers aren't willing yet to pay for the IDEO.
Hanger charges $10,000 for the brace and rehab program, about the same as a basic prosthetic.
It's generally considered cheaper to salvage than amputate legs because of the cost of prosthetics, and Hsu hopes research will show the IDEO to be cost effective. Moreover, Hsu said those with salvaged limbs would likely become more productive and physically fit, cutting down on other costly health problems.
Influencing insurers, however, will be time-consuming, said Dr. Andrew Pollak, chair of the University of Maryland School of Medicine's orthopedics department and chief of orthopedics for the University of Maryland Medical System.
"We need to get the costs down and make it accessible to the general public," Pollak said. Now it's really a dream."
But for some who have made it to Texas, the dream seems real, and the agonizing amputation decision a memory.
Richardson plans to head home soon with his IDEO after a month in physical therapy. He's now 28, enrolled in welding school and living in Hillsboro, Mo., with his wife and two young children.
"I really want to go hiking with my family," he said. "My kids love the outdoors. I have a dog. I want to walk with them through the woods."