Jonathan Bartlett walks on his new prosthetic legs for the first time in the physical therapy lab at Walter Reed Army Medical Center in Washington. On the right is John Costello, the prosthetist who fitted Bartlett with his new legs.
They were born more than a century apart, but Jonathan Bartlett and James Edward Hanger have much in common.
Both are Virginians and came of age during wars – Bartlett in Iraq, Hanger in the War Between the States. They were teenagers when they lost legs.
An improvised explosive device shredded Bartlett’s lower limbs in Fallujah last fall.
One was removed above the knee, the other below.
Hanger, the first amputee of the Civil War, was struck by a cannonball in 1861.
Now the 19-year-old Bartlett, recovering at an Army hospital in Washington, hopes to do what Hanger did after being injured: design a better prosthetic leg.
The Maury High School graduate would do well to follow Hanger’s example. The Confederate soldier from Churchville whittled himself an artificial leg with a hinged knee, patented it, and started a business that continues today.
At Walter Reed Army Medical Center, Bartlett is learning how to walk on legs that Hanger only could have dreamed of.
He and nearly 200 other active-duty amputees wounded in Iraq have been fitted with the most advanced artificial limbs available, their recoveries propelled by the latest research, aggressive therapy and their own refusal to slow down.
“It’s a new approach to the rehabilitation of injuries,” said Joseph A. Miller , Walter Reed’s head prosthetist and prosthetics researcher.
Typically, patients start with a basic artificial limb, and if they master that, may graduate to an advanced prosthetic.
“This has never been done before,” Miller said. “We’re going straight to the new technology. ”
In putting the latest computerized limbs to the test, Bartlett and his comrades – most in their 20s and otherwise healthy – are blazing a new path for amputees around the world.
“Obviously you don’t want to see fellow soldiers being injured,” said Miller, a reservist. “The other side is that every one of these guys and women is extremely motivated, and they’re somewhat computer savvy. ... They just absorb it, and they do it.”
Worse wounds, better funding
Better body armor protects them from some attacks, and advanced trauma care means more troops in Iraq are surviving severe combat injuries that might have killed them in earlier conflicts.
But 6 percent of those wounded become amputees, twice the figure of previous wars.
Congress cited that percentage in last year’s defense appropriation bill, explaining an additional $19.2 million it allocated to military amputee care and research at Walter Reed.
To deal with the influx of patients, a 29,000 -square-foot amputee clinic is under construction at Walter Reed. Opening in December, the clinic will have a high-tech lab to study the physics and motion of an amputee’s gait, a running track, rope- and rock-climbing walls and military vehicle simulators for amputees who want to stay in the service.
Bartlett, one of 25 double-amputees from Iraq treated at Walter Reed, is too pre occupied with his own progress to think about the improvements happening around him.
On a cold Friday in early December, for the first time since the September blast that shattered the Humvee he was driving, Bartlett returned to his feet.
Like his new legs, the feet are made of carbon fiber, a lightweight but durable material used in high-end bicycle frames. First, he rolled a soft silicone liner onto each stump. A metal pin protruding from the bottom of the liner locked into the custom-made “socket” molded to fit his stump.
The pieces locked together with a metallic snap.
Embedded in the hydraulic “knee” of Bartlett’s left leg are two tiny computers that gauge his gait and stiffen or loosen in “predicting” his next step. The C-Leg, manufactured by Otto Bock , a German company, is one of the most advanced devices around; it became available in the United States in 1999 . Including a knee, foot, fittings and prosthetist fees, its price tag approaches $50,000.
With the C-L eg on one side and a standard prosthetic foot and ankle on the other, Bartlett was almost giddy to leave his wheelchair behind.
“Look at that,” he said as he stood up. “That is … cool.”
Someone asked Bartlett his height.
“I was 5 feet 11 inches ,” the teenager replied.
“You want to be 6-foot-7 ?” asked John Costello , the prosthetist fitting him with the new legs.
The simple act of standing up was a challenge for the former high school runner, but he was eager for more.
With his visitors rushing to keep up with him, Bartlett wheeled himself to the physical-therapy lab and headed straight for the parallel bars. He wasn’t allowed to take his first steps without strapping on a belt for a spotter to hold.
Then Costello plugged a cable into a laptop computer and Bartlett’s C-Leg and had the teen take a few steps.
Bartlett stepped gingerly at first, unsure of himself.
“Separate your feet, and I think you’re taking too long strides,” Costello said. “When you get on your toe, that’s when I want you to flex your hip.” Bartlett’s bare arm muscles fluttered. “God, this is a workout,” he said. “I didn’t realize I was sweating that much.”
Closest thing to a human knee
Costello explained the basics of walking as he programmed the computers with Bartlett’s movements.
In swing phase – when he kicks out the leg to start a new step – the knee’s resistance decreases, making it easier to move.
In stance phase, when most of his weight is on the hydraulic knee, its resistance increases so it can bear his weight.
Alt hough hydraulic knees have been in use for years, the C-Leg is the first to pair it with microprocessors that continuously assess the leg’s position – as many as 50 times a second – and adjust the knee joint to match.
That makes the C-Leg far more stable than its predecessors. When it senses the wearer is about to stumble, the joint locks into place, preventing the knee from buckling.
“It’s probably the closest thing to the human knee that we have in prosthetics right now,” Costello said.
Still, what the body does unconsciously, Bartlett had to think about with each step: shifting his weight, keeping his balance, moving from heel to toe, not dragging his leg or lifting his hips.
After traversing the parallel bars a few times, he needed a break.
“I’m about pooped,” Bartlett said.
Had he lost his legs in Vietnam, he would not have come this far, this fast. During that conflict more than 30 years ago, it took an average of four weeks for soldiers to arrive at the Army’s now-shuttered amputee center outside Philadelphia.
Today, hospital officials say evacuated soldiers arrive at Walter Reed within about seven days.
Once there, these combat amputees are put on a fast track, fitted for prostheses within weeks of limb loss.
Everything is done under one roof.
State-of-the-art computer equipment, run by commercial prosthetics companies on contract with the Army, turns digital scans of amputated limbs into custom molds that connect stump and prosthesis.
Better molds mean more comfortable sockets and better mobility.
Alt hough the process appears seamless to Bartlett, it’s a new approach for Walter Reed. In late 2003 , Miller helped organize a conference that brought Pentagon and Veterans Affairs officials, prosthetics experts and companies like Otto Bock to the medical center.
They found ways to improve care, evaluate new products and coordinate research.
The result: amputee soldiers get to try out the latest developments. They benefit from unprecedented access to experimental technology; researchers gain instant feedback to their improvements.
Foot and leg amputations are more common than arm or hand loss in Afghanistan and Iraq. The Army estimates 30 percent of the 233 combat amputees treated at its hospitals – 70 people – lost hands or arms.
But the most advanced prosthetic arms are even more complex – and pricier – than artificial legs because fine motor skills are harder to mimic than walking.
One hand being tested at Walter Reed is not yet available on the commercial market. Another externally-powered “myoelectric” arm, which senses and converts muscle impulses into movement via an electric motor, can cost upward of $75,000 .
Fast track to mobility
The arms and legs soldiers use in the lab would amaze more than just Hanger, the Civil War’s first amputee- turned-innovator. His company has 600 facilities – including patient care centers – across the United States , including four in Hampton Roads.
They also amaze veterans like John Rotan, who was a Marine corporal in 1967 when a mine exploded in a Vietnamese rice paddy. The blast killed his best friend and another comrade. Doctors amputated his leg above the knee.
Rotan’s prosthetic leg is made of the same material Hanger used in the 1860s – wood – and weighs about three times as much as Bartlett’s eight-pound C-L eg.
Coated in flesh-colored fiberglass, it attaches with a leather strap and a belt that curves around his waist. It is similar to Bartlett’s C-Leg in one way – it has a hydraulic knee, although no computers adjust the resistance for him.
An avid hunter, fisher, swimmer and scuba diver, Rotan has had more legs than he can remember. His first leg got so soggy in the ocean – he didn’t know not to get it wet – that the wood expanded and locked up the knee, forcing him to get a new one.
The years of activity caught up with him. Rotan’s remaining leg, also wounded in the explosion, has ankle and tendon problems. Part of his spine has fused, and he recently had surgery to unblock four vessels in his heart. He still wears the prosthetic leg, but now relies on a wheelchair to get around.
Even if he were walking, Rotan isn’t sure he’d want to exchange his wooden leg for a carbon fiber one.
Years ago, when he could still walk with ease, Rotan tried switching to a lighter plastic socket but couldn’t get used to how fragile it felt.
“It was too light and flimsy,” he said. “I had to have a leg that would keep up with me.”
Bartlett has no such anxiety about what’s to come.
Still getting used to his new legs, he wears them just a few hours each day. Already, he envisions improvements: a prosthetic permanently fused to his residual femur, wired to his nerves and powered by simulated muscles.
Unlike his current leg, it wouldn’t have to be separated from his body and charged overnight.
Bartlett gets impatient just thinking about having to do that every day. That’s why he wants to get a degree in engineering – he plans to start out at Old Dominion University – and work for a company designing prostheses.
In the meantime, the former member of the high school track team has another objective. He plans to be running again by April 4 – his 20th birthday.
Last week , he came closer to that goal.
He began walking, unaided, around his room in the outpatient lodge at Walter Reed.
It’s just a few steps, and he still falls occasionally. Longer distances still require a cane or crutches.
But after weeks of struggling to keep his balance, thinking through each movement, Bartlett said he had a kind of a revelation.
Something just clicked, he said – and it seemed to have less to do with the computers in his knee than the synapses in his brain.
“I woke up and said, 'I can probably do this,’ and I did,” he said triumphantly. “Nobody tells you that.”
Reach Kate Wiltrout at 446-2629 or kate.wiltrout@pilotonline.com.
photo VICKI CRONIS PHOTOS/THE VIRGINIAN-PILOT.
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