Medical Device Daily Contributing Writer

AVORIAZ, France — Snow is falling in the high alpine valleys leading down from Mont Blanc to Lake Geneva. At the Centre Médical Les Pas du Lac the radiology suite is up and running, while helicopters are standing by at a nearby station.

Everything is in place for the start of the skiing season.

More than 8.5 million people are expected again on the slopes in France, the overwhelming majority being 6.5 million downhill skiers.

Last year 140,000 downhill and cross-country skiers suffered knee injuries, far exceeding other categories at 34%, according to a report by Médecins des Montagnes (MdM; Mountain Doctors), which has tracked epidemiology for winter sports since 1992. Among these injured, 14,500 skiers suffered a season-ending rupture to the anterior cruciate ligament (ACL), with many requiring surgical intervention.

The figures from the database are consistent with annual findings from North America, according to Jean-Dominique Laporte, MD, a physician practicing in the Pyrenees who is the current president of MdM. "We compare constantly with Bob Johnson and we have exactly the same numbers coming from the groomed slopes."

Robert Johnson, MD, emeritus professor of orthopedic surgery at the University of Vermont (Burlington), has run the benchmark study for winter sports epidemiology since 1979. He is the author of "Skiing Trauma and Safety, Fifteenth Volume," published in 2005.

According to Johnson's report to the International Society for Skiing Safety (ISSS;, the overall rate of ski injuries is half what it used to be due to improvements in equipment, yet in the last 15 years "there has been no further improvement and, more recently, a tendency for the lower leg injury rate to start going up again."

While there is international agreement that a woman skier is 3.5 times more likely to experience a knee injury, the French and American physicians are at odds regarding steps to take to promote prevention.

"We are having a dispute with our American colleagues," said Marc Binet, MD, who served for 25 years as president of MdM and is a driving force behind the annual French report.

Binet runs the medical offices at Les Pas du Lac in the heart of the Porte du Soleil, the world's largest ski area with 650 kilometers of marked trails. The privately run center serves more than 25 ski stations and officially covers the northern region of Haute-Savoie in coordination with the Gendarmerie (national police) and the national Service d'Aide Médicale Urgente (SAMU; public medical emergency service), which covers the southern region.

"Last year I treated 2,000 patients myself, a little more, actually," Binet, a specialist in sports trauma medicine, told Medical Device Daily. "You can be sure my associates saw the same number." The staff at the center includes three other physicians and a team of eight nurses, therapists and radiologists.

Since 1992 Binet has built up the Epidemiologic Network for Winter Sports Accidents within the MdM winning participation from 70 physicians among the estimated 300 who cover France's ski resorts. The resulting database ( today holds 400,000 dossiers, the largest in the world for winter sports injury, and is unique in that it is compiled by treating physicians.

"When you depend upon hospitals, you have far fewer cases," he said. "And the ski patrol in France is a paid service that many people may wish to avoid if they can. Only one-third of our patients come in with the ski patrol."

To address the high rate of knee injuries, France in 2000 replaced the ISO standards for ski settings with new standards reducing the setting values and taking into account gender. After two years, a significant reduction of 26% was observed in the incidence of anterior cruciate ligament sprains and a reduction of 38% in other knee sprains, for both men and women.

Nonetheless, the findings Binet presented to the ISSS were mixed.

"While a statistical link can be made between the improvement in the setting values and the decrease in the incidence of knee injuries, causality cannot be proven," he reported. "The benefit of the revision of the standards remains to be demonstrated."

Binet added that "a complementary case-control study showed the positive influence of a correct binding setting on all alpine ski trauma. An analysis of the results by gender shows that the influence of the setting "is only significant among women."

The ISSS summary of Binet's report was "improvement in ACL rates is independent of the binding settings as it appears ACL injuries are not a function of binding release."

"Yet for us it is clear," he told MDD. "We need to change ISO standards for ski bindings. We will take up the discussion again in Scotland in May (2007 ISSS meeting) but we do not have much hope."

Binet's agenda for Scotland also includes a "petite polémique" over helmets. Again there is international agreement that helmets reduce or relieve the severity of head injuries on the slopes.

Thanks to awareness campaigns, 80% of children skiing in France wear helmets, according to Laporte. But among adults it is a different story.

Some 25% of adults in the U.S. wear helmets, far higher than among French adult skiers, according to Binet. Skiers from northern Europe skiing in France, especially the Nordic countries, also equate helmets with safety. The problem is among adults from southern Europe who resist such an encumberance. More than 78% of skiers in France come from France, Spain, or Italy.

Binet says progress in safety awareness among this population has been frustrated recently by arguments put forward by colleagues.

"Some Americans have promoted the idea that adults wearing helmets tend to take greater risks believing they are protected. This may be somewhat true. In all cases the rate of injury in skiing depends heavily on the behavior and choices of the skier," he said. "But when one suggests this idea to a Latin skier, it is a disaster."

He added, "This nuance is debatable in regions where helmet use is widely accepted but among a population that resists, it provides an argument for not wearing the helmet."

Binet said Greece is a good example. "Winter sports are just starting to become popular. And though people immediately equate the helmet with safety, when they hear an argument against it they quickly refuse to wear one."

Protective gear for snowboarders is an area where Binet finds unconditional agreement, and even praise, from his colleagues at ISSS.

The 2006 report from MdM says that the 1.3 million snowboarders in France accounted for 42,500 accidents and shows an increase in both fractured legs and head injuries among this group, though the incident rate slowed from 27% to 24% last year. Yet among the injured, one in two suffers a fractured wrist.

Binet said he observed snowboarders using their inline skating protection on the slopes. While encouraging, the wrist guards were inappropriate. "Too short, too rigid," he said. "In most cases the injury was less severe than if they had no protection. But we noted the shock of the energy was transferred higher up, 2 cm above the wrist, a very fragile point."

After an early experiment that was "absolutely rejected by the market," Binet developed Flexmeter, a reinforced glove that does not block the wrist and is made with a plastic that absorbs the energy. While he has since seen users of the Flexmeter in his office. "The patient did not experience a fractured wrist."