Skiing Knee Injuries with Prof McNicholas

Skiing is a popular sport with over 1.3 million skiers in the UK each year. 

Whilst it is a potentially hazardous sport, it remains a safe activity with an incidence of two in a thousand for any injury. Snowboarders suffer half the rate of injuries of alpine skiers. Skiing off-piste raises the risk of injury 8 fold. Whilst there are 2.07 skiing/snowboarding fatalities per million participants, to put this in perspective, that is 14 times less than bicycling and 35 times less than swimming. In fact, twice as many people die from being struck by lightning in the USA compared to skiing and snowboarding there each year!

Helmets are known to reduce the risk of minor head injuries but not proven to do so for serious or fatal injury.

The commonest injuries in skiing and very common in snowboarding are to the knee, followed by snowboarders ankle injuries, skiers thumbs, snowboarders wrist fractures and head and spinal injuries.

In the knee, the medial collateral ligament (MCL) and 
anterior cruciate ligaments (ACL) are those most commonly injured, meniscal injuries and fractures are next most frequent and more complex injuries with complete knee dislocations do occur, but fortunately very rarely. Medial collateral injuries can be treated by physiotherapy, with bracing for periods of up to 3 months in the more severe cases. Surgical reconstruction is sometimes required in isolated MCL injuries.

The improvements in design of boots and quick release bindings have dramatically reduced the risk of lower limb fractures in skiers, but knee soft tissue injuries remain a problem. Ill fitting boots are an issue in 50% of those suffering from knee injury. Concepts, such as mechatronic binding designs have the potential to decrease knee injuries that traditional bindings cannot prevent. 

The percentage of ACL injuries linked to skiing had soared, from 9% in 1994 to 28% in 2004. Over the last 5 years Carving skis and the growing popularity of snowboarding have reduced the incidence of ACL injury slightly.

28% of British skiers classify themselves as beginners and inexperience is linked to serious knee ligament injuries, known by some as "half-term syndrome." This is a problem especially in females who are perhaps not physically as fit as they could be, going on a skiing trip with no prior preparation. 90% of ACL injuries in skiers in the UK are seen in women, at an average age of 40, with 2.5 times the risk in females over the age of 25. Prevention is always better than cure and physiotherapy guiding skiers through a five step, three month fitness program can significantly reduce the risk of injury.

For those unlucky enough to suffer a significant knee injury, they are very well served at the local medical facilities at the resort, who will generally exclude fracture with radiographic investigations and then supply analgesia, appropriate splintage and subcutaneous injectable antithrombotic prophylaxis to cover patients for their journey home.

An urgent orthopaedic review is indicated for any patient presenting with an injury with knee swelling within an hour of injury. 70% of these will have a torn ACL most of whom will describe a pop in the knee at the time they fell. 25% will have a peripheral tear of the meniscus: repair of such injuries is very successful and protective against future osteoarthritis. The remaining 5% will have an osteochondral injury which may be amenable to arthroscopic reduction and internal fixation.

The treatment of a torn anterior cruciate ligament can be conservative, with satisfactory outcomes to be expected in the majority of patients. This depends upon active participation in a structured rehabilitation program under the supervision of an experienced physiotherapist.

Outcomes in a prospective randomized trial by a Swedish research group based in Lund have shown no difference in outcome scores or reoperation rates at two and five years follow-up. The difficulty is that it is not yet possible to predict who will cope with the injury and avoid any surgical intervention. There are exceptions to this conservative approach in adolescents, professional or elite athletes and others whose occupations demand a reliable knee, such as those in the armed forces and fire and rescue or police services.

The outcomes for 
ACL reconstruction are very reliable allowing over 90% to return to sport and up to 80% at previous level. Arthroscopic techniques are satisfactory and using hamstrings can allow excellent cosmesis with donor wounds as small as 15mm, two arthroscopy portals each less than 5mm and a pin prick on the distal, lateral thigh. The procedure takes less than an hour and is usually performed as a day case. Whilst the risk of thromboembolic complications is low, subcutaneous injectable antithrombotic prophylaxis is usually employed to cover patients for a fortnight post operatively.

Experienced physiotherapists employing standardized milestone driven rehabilitation protocols are extremely important in enabling return to all desired activities which can be expected within six to nine months postoperatively.

Patients of forty years and older can improve their function even more than those younger. My eldest patient for ACL reconstruction was a 64 year old female who was enjoying skiing double diamond black runs five months after her surgery!

The most common multiple ligament injury pattern in skiing is a combined MCL/ACL injury, which is best managed by using physiotherapy and a brace to allow the MCL to settle followed by surgical management of the ACL if necessary.

Injury to the posterolateral corner of the knee needs to be excluded by careful examination as if missed will give poor results from ACL reconstruction, but when addressed surgically can allow excellent outcomes and safe return to sport.

The most severe knee injuries I have treated were a man in his forties who had suffered dislocations of both of his knees skiing. After bilateral autograft reconstructions he returned to the slopes after missing just one season.

If osteoarthritis is causing problems after conservative treatment is exhausted, intra articular local anaesthetic and steroid or hyaluronic acid injections can be successful.
If skiing becomes impossible due to certain patterns of osteoarthritis, then for those willing to learn to snowboard, return to the slopes can be possible as it places less stress on the knees. Joint preserving options such a high tibial osteotomy or distal femoral osteotomy can allow comfortable return to challenging skiing, ultimately it is permissible for experienced skiers to ski “gently” on unicompartmental and total joint replacements, and some designs such as the Medacta GMK Sphere have advantages as they are shaped differently to other designs and reduce stress on the plastic element of the replacement in the typical skiing position.

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