Report Of The Juvenile Amputee Ski Program
William F. Stanek, M.D.
In planning any athletic program for the juvenile amputee, certain basic considerations must be observed. Of prime importance is that the child must not only be physically capable of carrying out the activity, but he must also be able to do so with sufficient skill to make it interesting to him and increase his ability to compete with his peers. A second important consideration is that of safety.
Knowing that amputees have been involved in skiing for many years, the staff at Children's Hospital Amputee Center felt that, for the amputee without multiple defects, skiing would be a worthwhile program; one which could be sponsored as a group activity and observed as to its physical effects.
The organization of an amputee ski program presents problems, particularly if it is to be undertaken as a recreation-rehabilitation project. The majority of the amputees will not have skied before, though some who were skiers prior to the loss of the limb will be most anxious to resume the activity. The amputee, his parents, and others who might be connected with the project will have considerable qualms as to its safety, and express worries concerning the possibility of fracture in the remaining limb. Transportation expenses must be anticipated. While ski organizations have been most generous with contributions of equipment, certain other expenses still must be met.
The problem of expense need not be discussed here. The problem of safety is one which cannot be ignored.
Emphasis on Safety
The best assurance of safety is excellent ski instruction. In our program we were most fortunate to have elicited the enthusiasm of Willy Schaeffler, the leading ski instructor in Colorado and, through him, the services of his most competent instructors. These instructors spent several weeks prior to the opening of our ski classes learning to ski "three-track"; that is, with one ski and two outriggers, so that they could demonstrate techniques with this equipment to the beginning amputee skiers.
A second facet of amputee ski safety involves the total involvement of the ski area. The necessity for close supervision cannot be overemphasized. This is particularly true in regard to getting on and off the tows. One of our worries was that upper-extremity amputees might get their terminal device caught in the poma or chair lift mechanism. Amputees were assisted on and off the tows until they had demonstrated their competence in using them. In order to obtain such individual attention, the ski area must not be crowded. For this reason, periods in the middle of the week were chosen for the amputee ski sessions, thus avoiding vacation and weekend crowds.
Dearth of Special Problems
Beyond the general knowledge that amputees ski, and that outriggers of some type aid above-knee amputees, we had no direct knowledge of the special problems which might be encountered by the various groups of amputees, no knowledge of special equipment which might be necessary for upper-extremity amputees or for those skiing with below-knee prostheses, and no information concerning any physical problems which might be encountered.
Throughout the season we were impressed by the fact that few difficulties arose and by the ease with which the amputee skier could use ordinary ski gear. The skiers must be provided with good equipment and ski clothing. Beyond the obvious physical values of such a provision is the psychological value of making the skier aware that he is expected to ski well and that this activity is not merely a "try-and-see-if-you-can-do-it" program.
The amputee skier begins with the handicap of an absent limb. However, he has two advantages: he appears to have better than normal balance; and he has already had experience with crutches and with prostheses. The fact that he has mastered these devices keeps him driving until he succeeds in mastering his ski equipment. Some of the amputees were rather hesitant at the beginning of the program. All tried harder than the usual beginner, and all became ski enthusiasts. This enthusiasm was proven by the low absentee rate and by the fact that all absences had a logical explanation.
For the above-knee amputee, two pieces of special equipment are needed. First, a leather protector for the stump, which can be made at small cost by a prosthetist or a leather worker, is most desirable. In the event of a fall or an attempt to rise from the snow, the stump, particularly the long above-knee stump, can be subjected to considerable force. Skiers with moderately fresh amputation stumps who have not been afforded this protection have experienced stump breakdown. The leather protector provides increased safety to the skier and considerably increases the confidence of a beginner.
For many years above-knee amputees have skied with the usual poles. However, outriggers, fitted with short skis and Lofstrand or similar type crutches, are a great improvement. Hinges have been developed for the base of the pole on short outrigger skis by the amputee ski group in Portland. These hinges must be set so that the extremes of motion are avoided (Fig. 1 ). In addition, a plunger device must be provided to bring a spike down into the snow when a three-track skier is progressing over
flat snow or up a small hill (Fig. 2 ). The development of satisfactory plungers has proven to be one of our more difficult problems. Those in use during the past year have been modified and several other types are now being tested. The most advanced design provides for hand control of the plunger through the shaft of the outrigger (Fig. 3 and Fig. 4 ). Its cost, however, has been prohibitive. Models which can be operated by pressure from the opposite outrigger are less expensive, but to date freeing the plunger of ice has proven to be difficult. It will probably be another year before a model that is completely satisfactory from both operational and cost viewpoints can be provided.
Patients with amputations at the hip-disarticulation level, as well as those with above-knee stumps of various lengths, have participated in the program. Children with congenital limb deficiencies and traumatic amputations, and those with amputations resulting from malignancies, have all been included. The latter group was the one whose physical problems concerned us the most.
CASE I; J.B.
At the age of ten years, J.B. had a mid-thigh amputation (Fig. 5 ) for an osteogenic sarcoma of the lower femur. Postoperatively he had intermittent treatment with Actinomycin D and 12 months following the amputation had a partial lung resection. Approximately one month later the patient began skiing with the Three Track Ski Club and completed the eight sessions of the program (Fig. 6 ). Soon thereafter he had a further lung resection, following which he participated in the Eighth Inter-Ski at Aspen. The patient died July 14, 1968 (19 months after his amputation) of pulmonary metastases.
In evaluating this patient for the ski program, the danger of injury to the stump and the possibility of respiratory difficulty with vigorous exertion in the cold and at the high altitude (10,800-12,500 feet) were considered.
Since the remaining portion of the femur showed no osteogenic sarcoma and there was no evidence of other bony metastases in the body, it was felt that with adequate protection to the stump skiing by this patient was warranted. The boy's action on the slopes was our only guide to his pulmonary response.
Careful observation during the ski sessions revealed no ill effects attributable to skiing. He was one of our most active and enthusiastic skiers, participating in every activity, and his enthusiasm for skiing remained until the day of his death.
CASE II; K.K.
This 16-year-old girl had a fibrosarcoma at the ankle with a resultant short below-knee amputation. A good-looking teenager, she had been extremely upset by the loss of the limb, by the knowledge of her condition, and by her feeling that the prosthesis was unsightly and that she could not compete in activities with her peers.
It was felt that there would be no untoward effects from her skiing participation. She had no pulmonary or other metastases. The advantages of skiing were those of providing her with an activity which we felt she could undertake safely. When this patient is observed on the ski slopes, in a well-fitted pair of stretch pants and skiing on two skis, it is virtually impossible to diagnose her as an amputee without close observation.
Skiing Following Amputation for Malignancy
From our experience with J.B. and other patients whose amputations were necessitated by malignancies, we feel that these individuals can successfully undertake a ski program, provided there is no evidence of local recurrence in the amputated limb and no bony metastases. In the case of J.B. it was felt that the pulmonary metastases might cause difficulty in breathing and reduce endurance, but this prognosis proved to be incorrect. Where bony metastases are present, with possible increase in the danger of fracture, our belief is that skiing is contraindicated.
In weighing the dangers of skiing for an individual of this type, the psychological benefits of not being considered an invalid, and the opportunity to live a more normal life, regardless of life expectancy, must be considered. The amputee ski program gave this boy many more months of active participation in sports and provided an interest in life which he would not have had otherwise.
Adequacy of Circulation
A second problem which gave us concern had to do with the adequacy of stump circulation in both upper- and lower-limb amputation. This was particularly true in the case of children with Syme's amputations.
CASE III; T.V.
At the age of six years this boy was dragged beneath an automobile sustaining a rent in the right lower abdominal wall with tearing of the right femoral artery, vein, and nerve. The patient was originally treated with debridement and a Teflon graft to bridge the femoral artery tear. Subsequent to the grafting, normal dorsalis pedis and posterior tibial pulsations were restored. However, the graft later clotted, became infected, and was removed. No attempt had been made to repair the vein or the nerve. Subsequently the distal portion of the foot became gangrenous and a mid-tarsal amputation with split thickness graft was done. When this patient was first seen at the Children's Hospital Amputee Clinic, the stump was unsatisfactory and a Syme's revision was carried out (Fig. 7 ). The patient's final stump showed no circulatory deficiency under ordinary circumstances. There was an adequate volume of soft tissue in the stump but a continued loss of quadriceps function. The patient had been fitted with a Syme's-type prosthesis with a PTB fitting at the knee, side bars, thigh cuffs, and an elastic strap attached to a waistband to stimulate knee function.
As a potential skier, T.V. presented two problems: first, was the circulation of the stump adequate?; and second, would the lack of extensor power in the quadriceps prohibit the use of two skis? During the season no difficulty was encountered with the stump and the boy was able to ski satisfactorily using his prosthesis (Fig. 8 ).
CASE IV: A.S.
This patient, age six, has a Syme's amputation, the result of a surgical revision for congenital absence of the fibula. The leg below the knee was extremely small with little or no soft tissue covering the bone. This is the only lower-extremity amputee in whom any evidence of circulatory difficulty was found. In extremely cold weather the patient complained and had to be taken off the slopes. He also had difficulty in handling the prosthesis with the ski attached. He has been more successful in skiing "three-track" with a stump protector, which not only protects against injury, but also provides adequate insulation against the cold.
CASE V: P.K.
This 17-year-old patient originally had a limb deficiency which was probably an absence of the fibula, though no adequate records are available. He had been treated by a below-knee amputation. He had a history suggestive of an occasional lateral subluxation of the patella, but had had no treatment for this condition. The stump was extremely pointed and somewhat tender on the end. The patient, by choice, wore a conventional below-knee prosthesis with thigh lacer, refusing to change to a PTB prosthesis because he thought that he would like security when he engaged in athletics. This patient is an accomplished gymnast without his prosthesis, and has been a rodeo rider with it.
In this instance no particular problems were present. The patient's desire was simply to add to his athletic accomplishments. His success in this is measured by the fact that by his third lesson he was placed in a regular ski class, where an unsuspecting instructor could find only one fault: the patient could not bend his prosthetic ankle.
Problems of the Below-Knee Amputee
It may be stated with a reasonable degree of confidence that a unilateral below-knee amputee can usually ski satisfactorily with two skis and an unmodified prosthesis. All of our prostheses have been fitted with SACH feet so we have had no experience with other types of foot mechanisms. Patients with PTB's do not require modifications of the prosthesis. We thought initially that the SACH foot might require modifications, but the need has not arisen. We might have suspected that the patients could ski on the ordinary SACH foot, since skiing can be accomplished with a surgically fused ankle.
Only minor problems have been experienced with stump circulation. Patients and their parents have been instructed to check the stump at the end of the day and not to send a child skiing if there is any suggestion of stump difficulty. It would be advisable to inspect stumps both before and after skiing, but the problems of an active group, winter clothing, and oftentimes below-freezing temperatures, have made this difficult as a routine measure. However, if the skier has complained of pain or coldness in the stump, he has been removed from the slope and the stump has been inspected immediately. This has led to removal of the prosthesis and use of the "three-track" technique in only one below-knee amputee.
Anticipated problems of unilateral upper-extremity amputees were those of holding the ski poles. A few examples of terminal-device modifications used to hold poles were inspected, but none was found to be satisfactory. Two problems were encountered: adequate holding of the poles, and a device which would permit getting rid of the poles when necessary to avoid accidents.
All of the upper-extremity amputees wore their prostheses when they skied. This usage appeared to be necessary for balance, afforded some protection to the stump, and provided warmth and protection against circulatory difficulties. Again, where there were complaints in cold weather, the stump was immediately inspected and the skier was kept off the slopes until the problem had disappeared.
Most of the upper-extremity amputees skied using only one pole (held in the good hand) for balance. However, it was found that the rubber handle of a pole could be gripped in a terminal device with sufficient force to permit at least moderate use for balance and in turning. If the patient started with two poles, he continued using them; but attempts to get a patient who had started skiing with one pole to use two have not been successful.
Little special equipment has been necessary, except as previously noted. The modern buckle boot is far superior to laced boots for all amputees, particularly those with upper-extremity problems. It makes getting into the boot much easier and diminishes the skier's need for dependence on another person.
There are many types of safety bindings, each with its individual advocates. Good safety bindings are a definite necessity. Those that do not require sole plates have an element of superiority because of the lack of need to modify the boot. In all instances safety bindings which can be adjusted by the instructor, and which will stay in adjustment, should be used. Likewise, those that can be stepped into by the amputee with a minimum of difficulty are preferred.
Multiple Amputation Problems
Amputees with multiple handicaps have not been included in our program. From our experience we believe that bilateral below-knee amputees and bilateral upper-extremity amputees can be given an opportunity to try skiing using their prostheses. With bilateral upper-extremity amputees the main problem would be that of using the tows.
The question has been raised as to the feasibility of skiing for the bilateral above-knee amputee. Dr. Ernst Dehne, in a personal conversation, reported an Austrian skier who had achieved this objective with some type of spring device which would stabilize the prostheses with the knees bent. More practical, probably, are the experimental techniques now being studied at Arapahoe Basin, Colorado, by Colonel Paul Brown and Mr. Ed Lucks, Chief Instructor for the amputee program. These experiments involve the use of short prostheses with no knee mechanisms. The outcome of this program will be reported later by Dr.
Brown and Mr. Lucks. At this time it can only be stated that the major element of success will be in the instruction given. Mr. Lucks has been skiing with splints on his legs to keep from bending his knees in order to develop a definite technique.
The results of the first year of an organized juvenile amputee ski program have been reported. For the unimembral amputee, no problems which could not be surmounted have arisen. Children with congenital limb deficiencies, traumatic amputees, and patients with amputations resulting from malignancies have all learned to ski. No fractures occurred in the group and there were no serious complications from circulatory problems in the stumps.
Emphasis must be placed on providing expert ski instruction by instructors who have obtained experience in amputee-type skiing. The total involvement of the ski area is essential and the program itself must be undertaken with the realization that a considerable amount of organization is necessary.
It is hoped that in the near future a ski manual will be available and that advanced models of the plungers will be perfected.
William F. Stanek, M.D. is associated with the Children's Hospital Denver, Colorado