The analysis includes 31 children and adolescents treated for pediatric sarcomas who participated in a skiing camp between 2011 and 2016. The characteristics of all included participants are represented in table 1. All participants received chemotherapy regimen and any local therapy (surgery and/or radiotherapy).Twenty-eight out of 31 participants underwent surgical interventions.
Characteristics |
n (%) |
Mean ± SD |
Median |
Range |
Age at first participation (years) |
31 (100) |
14 ± 6.5 |
15 |
5-36 |
Gender |
Male |
15 (48) |
|
|
|
Female |
16 (52) |
|
|
|
Time since diagnosis at first participation (months) |
31 (100) |
30.0 ± 17.7 |
26 |
12-91 |
Cancer type, age (years) and location |
31 (100) |
|
|
|
Bone tumor |
24 (77) |
15.2 ± 6.2 |
15 |
6-36 |
Ewing’s sarcoma |
10 (32) |
|
|
|
Osteosarcoma |
12 (39) |
|
|
|
NOS |
2 (6) |
|
|
|
Lower limb |
17 (55) |
|
|
|
Trunk/upper limb |
7 (23) |
|
|
|
Soft-tissue sarcoma |
7 (23) |
9.7 ± 5.9 |
7 |
5-20 |
Trunk/head |
5 (16) |
|
|
|
Lower limb |
2 (7) |
|
|
|
Local therapy |
31 (100) |
|
|
|
Surgery |
28 (90) |
|
|
|
Tumor endoprosthesis |
12 (39) |
|
|
|
Resection only |
6 (19) |
|
|
|
Amputation |
5 (16) |
|
|
|
Rotationplasty |
4 (13) |
|
|
|
Hemipelvektomy |
1 (3) |
|
|
|
Radiation |
11 (35) |
|
|
|
Table 1: Participants medical characteristics (n=31).
N ((Number), NOS ((Not Otherwise Specified). The soft-tissue sarcomas were located at the kidney (n=1), at the lower limb (n=2), at the bladder (n=2), in the middle ear and the parotid gland (n=2). All participants received chemotherapy. N=2 participants received proton radiation, n=3 participants received radiation without any surgery and n=8 participants received additional radiotherapy.
The participants attended the skiing camps on average 2.6 times (range 1-7 times). They all made relevant progress in skiing. The variation of participations is not representing learning curves. All ended up with different but increased skiing skills. As a standard the participation had been limited to 1-2 courses due to limited places. Families with children with a higher need of support were invited more often. This could be due to the need of technical skiing materials (outriggers, sit ski…) or to complex functional impairments. Four participants died in the meantime.
The most suitable skiing technique was applied for every participant after discussion of impairments, evaluation of risk and experience in skiing (explanation of skiing techniques in the section of skiing methodology). During specific conferences with the local Department of Orthopedics and Tumor Orthopedics options, risks and limits were discussed prior to the skiing camp for every single participant. Applied techniques for the analyzed participants after treatment for pediatric sarcomas are presented in table 2.
|
Tumor Localisation Lower Extremity |
Tumor Localisation Upper Extremity/Trunk/Head |
Skiing Technique |
Endoprosthesis |
Resection |
Amputation |
Endoprosthesis |
Resection |
(n) |
Proximal Femur |
Distal Femur |
Proximal Tibia |
Proximal Humerus |
Conventional upright skiing |
2 |
|
|
|
1 |
2 |
8 |
13 |
Upright skiing with tools |
|
|
|
1 |
|
|
1 |
2 |
One-leg skiing with outriggers |
|
|
|
|
8 |
|
|
8 |
Bi-ski/Dual ski accompanied |
|
3 |
1 |
|
|
|
|
4 |
Bi-ski/Dual ski/Mono ski accompanied on their own |
|
2 |
|
|
|
|
|
2 |
Bi-ski/Dual ski accompaniedupright skiing |
1 |
|
1 |
|
|
|
|
2 |
(n) |
10 |
1 |
9 |
2 |
9 |
31 |
Table 2: Applied skiing technique for the participants (n=31) between 2011 and 2016.
N (Number), Amputation included rotationplasty and resection included hemipelvectomy. Tools: Ski tip holder (flexible device to hold the ski tips in a controlled wedge position), elastic retaining band (Varioband). Two participants after amputation of the lower limb (n=1) and endoprosthesis (n=1) had the recommendation for one-leg skiing and skiing in sitting position, but with respect to their own wishes, conventional upright skiing on both legs was taught with 1:1 supervision with lower limb prosthesis and endoprosthesis. Two participants with endoprosthesis changed from sit ski to upright skiing. One participant after hemipelvectomy used tools (Edgie-wedgie, outriggers).
We do not advise skiing upright on both legs with an artificial limb after rotationplasty. The changes in joint and bone structure make it difficult to evaluate and control the biomechanical function of the lower limb during skiing. We have been informed of a fracture occurring following upright skiing of a participant with a rotationplasty. For these reasons we recommend one-leg skiing for participants with amputation including rotationplasty.
To clarify individual approaches of applied techniques regarding different impairments four representative cases of adaptive skiing techniques are presented in the following section in categories: (A) One-leg skiing, (B) Mono-ski highly sportive, (C) Sit ski to upright skiing and (D) Skiing with special tools.
(A) A seven year old girl, diagnosed with Ewing’s sarcoma at the left distal femur was treated with EURO-EWING 99 and underwent rotationplasty Type B III a according to Winkelmann with maintenance of the vascular system at the age of three years (Figure 1). Post-operative chemotherapy was applied following surgery according to treatment regime. Prosthetic care enables walking on two legs in everyday life. To prevent injuries of the residual limb and due to preservation of the exoprosthesis, one-leg skiing was taught. Problems often occur due to uncommon load on one leg. Participants are used to walk on both legs in everyday life and skiing on one leg requires increased muscular strength.
Figure 1: Post-operative radiograph of rotationplasty and one-leg skiing technique.
After five years of participation, intensive training with an adaptive skiing instructor and security tools (elastic retaining band), autonomous one-leg skiing is possible with only slightly further assistance (Figure 1). The girl gained a lot of self-confidence in skiing which made her choose a secondary school selectively that conducts a school ski trip.
(B) A 13 year old boy, diagnosed with an osteosarcoma at the left distal femur underwent neoadjuvant chemotherapy according to EURAMOS-1/COSS prior to surgery. Surgical procedure included tumor resection and implantation of endosprosthetic replacement (Figure 2). Following surgery post-operative chemotherapy was applied and further surgical intervention was necessary due to metastatic suspected pulmonary nodules in the lungs, infection of the endoprosthetic replacement and following revision and implantation of a new endoprosthesis.
Figure 2: Post-operative radiograph of endoprosthetic replacement of the distal femur distinct shielding at the prosthesis stem and picture of sit ski technique. (Enneking score was 27 in the first camp).
After five years of continuous support and intensive training with experts in sit ski technique, the boy is now skiing completely autonomously and on a very sportive level owing his own Mono-ski. He decided to continue skiing in a sitting position even though upright skiing would be possible regarding muscular status and stability of the femur and prosthesis.
(C) A 15 years old girl was diagnosed with an osteosarcoma in the right proximal tibia. After undergoing standard neoadjuvant chemotherapy according to EURAMOS-1/COSS, broad partial extra-articular tumor resection and an endoprosthetic replacement of the proximal tibia including transposition of M. gastrocnemius and reconstruction with mesh-graft plastic were performed ((Figure 3). Following surgery post-operative chemotherapy was applied in accordance with treatment regime.
Figure 3: Post-operative radiograph of endoprosthetic replacement of proximal tibia and picture of the girl in the second year of skiing (Enneking score 26 at the first camp).
One year after finishing anticancer therapy the girl participated in the skiing camp for the first time. In the first year, she started in the sitting position to slowly get used to skiing and to minimize the risk of injury due to missing muscles and the ongoing rehabilitation process shortly after cessation of treatment. The girl was accompanied and guided by an adaptive ski instructor and always secured with an elastic retaining band. Due to personal reasons she could not finish the week after two days in the skiing camp. In her second year, she started skiing in an upright position with conventional skiing poles accompanied by an adaptive ski instructor. To maximize safety aspects like length of the ski, fixation and torque as well as active observation of fixation release were considered to prevent injuries as far as possible. Additionally, a physiotherapist from the Department of Pediatric Oncology was part of the ski team. This physiotherapist oversaw the home-based physiotherapy scheme and was able to continue additional physiotherapy during the skiing camp. Ski biomechanics were also analyzed in collaboration with the ski teacher and the physician.
(D) A 17 years old girl diagnosed with a bone sarcoma (NOS) originating from the os sacrum with paravertebral expansion and infiltration of the lamina L5/S1 was treated according to EURO-EWING 2008. After surgery including internal hemipelvectomy and hemisacrectomy, spinal decompression and bone defect reconstruction (Figure 4), post-operative chemotherapy following CWS-Protocol and radiation was applied. This severe surgical treatment caused a peronaeus paresis as well as the loss of sensitivity and control in the lower limb and half of the upper limb in the left leg. These complex physical impairments required testing of different techniques of adaptive skiing (Figure 4).
Figure 4: Post-operative radiograph of the surgical intervention around the os sacrum and presentation of testing different techniques with tools (Enneking score 17 at the first camp).
After the first approaches in a sitting position and security measures with ropes, the final solution required a ski-tip holder to control the positioning of the skis and outriggers to ensure stability. After two years of training skiing technique and balance, this girl is now skiing with conventional ski poles optimized by a wedge of about one centimeter beneath the affected foot. This heel rise helps to reduce the tendency to load through the dorsal part of the foot.
Based on our experience, we deduced a concept to enable decision making on skiing with handicapped participants after treatment for pediatric sarcomas. Figure 5 represents strategies to succeed in teaching how to ski despite serious functional impairments considering the individual back ground. Aspects like analysis, technical and didactic hypothesis, checks and balances, reflection and discussing the next step describe this iterative process.