Watching Dugan Smith pitch, it is easy to imagine he is like any other 13-year-old on the baseball field. He's one of the best players on his team, and it's only a limp that causes him to favor his right side that hints that something might be wrong with his leg.
Look closer, and it becomes apparent that Dugan's right leg is on backward, with his ankle where his knee would ordinarily be -- the result of a rare surgery that allowed him to survive cancer, and play ball with his teammates.
Dugan, from Fostoria, Ohio, was 10 years old when he limped for a different reason. He chalked it up to some knee pain from baseball practice, but after a battery of tests and doctor visits, Dugan received a sobering diagnosis: He had osteosarcoma, a cancerous bone tumor that usually develops during adolescence.
"I was really scared," said Dugan, now 13. "I thought I was never going to play sports again and never be able to run again. It was a lot of pressure bottled up."
After 10 weeks of chemotherapy while wearing a full cast on his right leg, doctors gave several options for surgeries and treatments. But Dugan could think of only one thing: baseball.
So Dugan decided on a rare surgery called Van Nes rotationplasty in which the infected part of the leg is removed, and the remaining limb below the cancerous portion is rotated 180 degrees and reattached, with the ankle acting as the knee. His other options included full amputation or a surgery that would replace his femur, or thighbone, with a cadaver or metal bone.
Doctors told the family that an amputation above the knee would require Dugan to use about 75 percent more energy to walk or run than with a normal leg. With the rotationplasty, it would take only about 30 percent more energy.
"It was the best option," said Dustin Smith, Dugan's father. "It got rid of that bone and that part of his leg. Plus, what was most beneficial is he can now do whatever he wants."
Dr. Joel Mayerson, an associate professor of orthopedic surgery and director of the musculoskeletal oncology at the James Cancer Hospital at Ohio State University College of Medicine, performed the surgery on Dugan. Only about a dozen rotationplasties are performed in the United States each year.
The procedure took 21 hours. Doctors fused the bones together and sewed together muscles and blood vessels. Dugan's toes could then slide into the prosthetic, which acts as the lower half of his right leg.
"Baseball is my favorite sport in the whole wide world," said Dugan. "I was worried it might not work, but I just had to put that aside and think of good things. I was just thinking, 'Let's just get this over with.'"
"You can run better and you can be more active when you undergo this surgery," said Mayerson. "If you're a bookworm or not concerned about high activity, people often choose to replace the bone because it is a more cosmetic operation. But once Dugan realized that he'd be able to play baseball with this surgery, he didn't look back.
"Plus, by doing the rotationplasty and taking out the muscles, it decreases the chance of recurrence of the tumor, and gave more functionality to the leg," said Mayerson.
Still, the surgery didn't come without risks, including a danger of clots developing when reconnecting the blood supply, a recurring tumor, infection and damage to the nerves when twisting and stretching the leg.
According to the American Cancer Society, there are about 900 new cases of osteosarcoma in the United States each year.
Osteosarcoma has a five-year survival rate of 50 or 60 percent, Mayerson said. There is a 10 to 15 percent chance that the osteosarcoma could come back, and, even though the leg is gone, there is about a 50 percent chance that the cancer could recur in the lungs.
Dugan missed almost his entire fifth grade year because of surgeries and treatments. Today, he is in seventh grade, and he has been cleared at every one of his follow-up visits. The teenager is focused on school and sports, and has no intentions of letting a twisted leg get him down.
"People used to stare and it kinda bothered me," said Dugan. "But now I'll just wear shorts like nothing is even there. I don't care if people stare."
And his long-term goals?
"I want to be the first player in the major leagues to have a prosthetic leg," said Dugan. "I'd play for the Cleveland Indians."