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Balance is important in lifesaving competitions. We aimed to investigate the relationship between dynamic balance and physical characteristics and functions in elite lifesavers by measuring the foot muscle cross-sectional area, ankle joint muscle strength, toe grasp strength, plantar superficial sensation, and dynamic balance (Y-balance test). In this observational study, we measured the foot muscle cross-sectional area, ankle dorsiflexion, plantar flexion, external flexion, isometric muscle strength, toe grasp strength, and superficial foot sensation of 15 adult lifesavers (12 males). The results show that toe grasp strength and ankle plantar flexion isometric muscle strength are particularly important for the dynamic balance of elite lifesavers working on sandy surfaces. Sand training improves intrinsic muscle strength and dynamic balance function. However, high training intensity may reduce plantar surface sensation; this needs to be verified through sand training interventions in the future. [ABSTRACT FROM AUTHOR]

Category: Midfoot/Forefoot Introduction/Purpose: There is no established surgical treatment for severe hallux rigidus (HR). Hamilton suggested capsular interposition arthroplasty (CIA), performed using an articular capsule and extensor hallucis brevis as a biologic spacer, as an alternative to metatarsophalangeal (MTP) joint fixation to treat severe HR. CIA is a preservation procedure that relieves pain and maintains joint function. We present the results of CIA performed at our facility to treat severe HR. Methods: In the present study, we further divided Hattrup’s grade II HR into two subtypes on the basis of joint space narrowing of 1stMTP. We recorded the severity of patients’ condition using our modified Hattrup’s classification. In this study, we did a follow-up of 8 cases in which CIA was performed to treat severe HR. The cases were followed up for 1 year or longer. The mean age of patients at surgery was 63.8 years, and the mean follow-up period was 7.1 years. Surgery was performed using a modified Hamilton method, which involves making an incision on the dorsal instead of the medial side and a manipulating the articular capsule in a different manner. Clinical outcomes were evaluated using the Japanese Society for Surgery of the Foot standard rating system (JSSF) scale. We investigated the pre- and post-operative ROM of the MTP joints and verified the presence or absence of complications. Results: It was observed that pain had reduced significantly in all cases after surgery. Following CIA, the mean ROM at extension was noted to have improved from 27.5° to 48.8° and the mean ROM at flexion had improved from 11.9° to 21.9°. The mean JSSF scale score has improved from 59.5 to 97.5 points. No complications were observed. Conclusion: This procedure is beneficial for pain relief and acquisition or maintenance of articular ROM and is a better choice for patients desiring preservation of ROM and articular function. It is imperative that patients follow proper rehabilitation for ROM and muscular strength preservation.

Category: Midfoot/Forefoot Introduction/Purpose: Chronic Lisfranc fracture dislocation had been commonly treated with arthrodesis, but were these treatments suitable? The Lisfranc joint has sagittal motion with articular cartilage and functioning as a shock absorber. We reported the middle-term outcomes after performing Lisfranc ligament anatomical reconstruction surgery (LARS), using an optimal route of reconstruction based on anatomical measurements of and biomechanical experiments with cadavers. The purpose of this study is to determine the usefulness of LARS for chronic Lisfranc injuries to preserve the joint function. Methods: We underwent LARS for 8 cases of Chronic Lisfranc injuries (6 males, 2 females) from May 2012 to June 2017. Average age at surgery 26.1 years (18-38), average follow-up period is 28 months (2-46). The reconstruction route was via a burr hole created at a position 6 mm distal to the tarsometatarsal joint on the 2nd metatarsal, and at a depth of 10 mm. A burr hole was then created from the medial cuneiform bone to the 2nd metatarsal bone in a plantar and horizontal direction. The graft tendon was guided through the burr hole from the medial cuneiform bone to the 2nd metatarsal (double-layered side), was looped, and was guided back around the dorsum of the medial cuneiform(single layer) to reconstruct the dorsal ligament. We examined Myerson classification, Kaar evaluation and the postoperative clinical evaluation using Japanese Society for Surgery of Foot (JSSF) midfoot scale. Results: In Myerson classification, Type B2 6 cases and Type C1 2 cases. In Kaar evaluation, transverse instability (TI) 6 cases, longitudinal instability (LI) 2 cases. The average time from injury to surgery is 156 days on average (37-404). JSSF scores averaged 95 points (90-100). X - ray evaluations were almost good, but in 2 cases with weight bearing, a slight diastasis between the base of the first cuneiform and second metatarsal was observed. But there were no clinical symptoms such as pain. In the surgical procedure, scar is mediated in chronic cases. Therefore, we had to take time to obtain the reduction. Conclusion: Arthrodesis is gold standard for chronic Lisfranc joint injuries, but decline in foot flexibility is inevitable. LARS is beneficial for maintaining anatomical reduction, preserving the joint function, and shortening the post-therapy period. LARS gave stable results against Chronic Lisfranc joint injuries. LARS for chronic Lisfranc joint injuries is a useful procedure.

Category: Ankle Arthritis Introduction/Purpose: There are few reports describing conservative therapy for ankle osteoarthritis. Hiflex Foot Gear (HFG) is a custom-made polyethylene ankle–foot orthosis developed to permit slight mobility of the ankle while providing adequate ankle support. The purpose of this study was to validate the hypothesis that HFG improves the quality of life (QOL) in patients with ankle osteoarthritis.Subjects and methods. Methods: Ten ankles from eight patients (one man, seven women) diagnosed with ankle osteoarthritis at this hospital, prescribed an HFG, and observed for follow-up for at least 3 months were included in this study. The patients’ mean age was 69.9 (range: 46?85) years. Patients were classified as Takakura–Tanaka stage IIIa (2 ankles), stage IIIb (2 ankles), stage IV (6 ankles), with a mean observation period of 8.9 (range: 3?13) months. Clinical evaluations were made before and 3 months after wearing the orthosis. The ankle/hindfoot scale of the Japanese Society for Surgery of the Foot (JSSF) Standard Rating System and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) subscale of the Japanese Orthopaedic Association/Japanese Society for Surgery of the Foot, respectively, were used for making evaluations. Scores were compared using a paired t-test. Results: JSSF scores improved from 55.1 points at baseline to 71.4 points after wearing the HFG (p < 0.001). According to the SAFE-Q subscales, changes after wearing the HFG were as follows: 28.9 to 61.9 points for items related to pain (p < 0.001), 36.9 to 53.7 points for those related to physical function and daily life (p = 0.001), 31.3 to 58.9 points for those related to social functions (p = 0.002), and from 31.3 to 65.0 points for those related to overall perception of health (p < 0.001); items related to shoes showed no substantial change (from 52.1 to 53.6 points). Conclusion: Our results revealed that wearing the HFG improved pain in patients with severe ankle osteoarthritis. Retained flexibility in the ankle range of motion was believed to be the factor underlying improvements in physical function and daily life, social functions, and overall perception of health. HFG is a potential option for conservative therapy in patients who cannot obtain sufficient pain control during the preoperative waiting period or in those who do not wish to undergo surgery.

This study aimed to compare the foot muscle morphology and foot posture between healthy adults and lifesavers in sandy beach sports. The participants included 15 lifesaver athletes and 15 healthy adults. Using a non-contact three-dimensional foot measurement device, the foot length, width, and arch height of the right foot were measured while standing and sitting without back support, and the transverse arch length ratio and arch height index were subsequently calculated. Muscle cross-sectional area was measured using an ultrasound imaging device. Muscle cross-sectional areas, arch height, foot width, arch height index, and transverse arch length ratio were larger in the lifesaver than in the healthy adult group. Lifesavers had higher arches and more developed intrinsic and extrinsic muscles than healthy adults. Performing physical activity while barefoot on sandy beaches may effectively develop the foot intrinsic and extrinsic muscles and raise the arch. [ABSTRACT FROM AUTHOR]

Category: Arthroscopy Introduction/Purpose: Open surgery of the sole of the foot requires an extensive amount of soft tissue to be dissected. In recent years, various types of endoscopic surgery for the sole of the foot have been reported, making it possible to dynamically evaluate and treat plantar lesions with a small skin incision and minimal dissection. However, there have also been reports of complications involving plantar nerve injury. A good knowledge of the plantar nerve anatomy is crucial for safe endoscopic surgery of the sole. We aimed to anatomically dissect the soles of cadaveric feet to investigate the safe zones for plantar portals. Methods: We studied 36 feet of 24 cadavers. The soft tissue of the sole was dissected, and the relationships between the plantar nerve and flexor digitorum longus tendon, flexor hallucis longus tendon and peroneus longus tendon were studied. The plantar nerve course was digitally imaged and uploaded into Image J software to determine the nerve position. The back of the calcaneus, the medial side of the base of M (Metatarsal) 1, the medial side of the head of M1, the lateral side of the head of M5, and the proximal tip of M5 were plotted and defined as A, B, C, D, and E respectively on Image J. The nerve courses were plotted on AB, BE, and CD, and the percentage at which they were positioned on the line segment was calculated. Next, the bifurcation positions of each nerve were plotted and measured to the defined line segments. Results: No major differences were noted in the course of the medial plantar nerve and lateral plantar nerve. The medial plantar nerve and lateral plantar nerve ran between B and E, at 32.4% ± 4% and 61.2%± 5.1% respectively from B. No plantar arteries were found to run between the medial plantar nerve and lateral plantar nerve on BE. Taking mean and standard deviation values into account, no neurovascular structure existed from 36.4% to 56.1% along a line between the medial aspect of the base of M1 to the proximal tip of M5. The flexor digitorum longus tendon and peroneus longus tendon passed through the deep layer of this region. Conclusion: We believe this region to be a safe zone for creating plantar endoscopic portal. The plantar central portal can be created at the center of the sole. An approach from the plantar central portal to the flexor digitorum longus tendon, flexor hallucis longus tendon, and peroneus longus tendon with the plantar lateral portal, posteromedial portal, and toe portal allows for a greater range of vision and treatment options and may further advance endoscopic surgery of the sole.

Category: Midfoot/Forefoot Introduction/Purpose: We report the middle-term outcomes after performing Lisfranc ligament anatomical reconstruction surgery (LARS), using an optimal route of reconstruction based on anatomical measurements of and biomechanical experiments with cadavers. Methods: Subjects included 20 patients (8 female and 12 male, mean age: 35.5 years, mean follow-up period: 35 months) who were diagnosed with Lisfranc joint injury and underwent surgical treatment from 2012 to 2015. Acute case were fourteen cases, chronic cases were 6 cases. The optimal anatomical route of reconstruction was calculated from anatomical measurements obtained from 78 legs of cadavers. The Myerson’s classification and the Kaar’s classification based on stress X-rays were used to classify the injuries at the time of their occurrence. Furthermore, the Japanese Society for Surgery of the Foot (JSSF) Midfoot scale and Stein’s radiographic assessment were used for clinical evaluation postoperatively. Results: According to the Myerson’s classification, Type B1 was one case, Type B2 was 15 cases, Type C1 and Type C2 were each 2 cases. According to the Kaar’s classification, 17 patients had transverse-type injuries and 3 patients had longitudinal-type injury. Partial weight bearing was encouraged within 6 week and return to exercise within 12 weeks. Average JSSF scores at final follow-up were 93.8 points in both examples (85-100) respectively. Joint congruities on X ray were appropriate in most cases but admitted a little diastasis by one case of chronic and one acute case. Conclusion: LARS achieves both static and dynamic stability, does not require removal of the internal fixation material, and enables all patients to support a full load 8 weeks postoperatively. LARS is beneficial for maintaining anatomical reduction, preserving the joint, and shortening the post-therapy period. Our newly developed ligament reconstruction is not only able to acute injuries but also to the chronic injuries.

Category: Ankle Arthritis Introduction/Purpose: MRI is gaining attention as a tool for examining the severity of osteoarthritis (OA) over X-ray findings. However, there are few reports on the relationship between MRI and X-ray findings in ankle joints. We assessed the combination of ankle joint alignment and MRI to find the factor to predict MRI findings from X-ray findings in OA. Methods: Of the 341 patients who had a diagnosis of ankle OA in our hospital from May 2009 to August 2015, we assessed 46 feet of 45 patients who underwent MRI. We determined ankle joint alignment by measuring tibial anterior surface (TAS) angle, and tibial lateral surface (TLS) angle on X-ray, and determined the areas of Bone Marrow Edema (BME) appearing on STIR, by partitioning 22 areas for talocrural, tarocalcaneal, Chopart joint. In the statistics analysis, we divided into two groups with and without BME, and we compared TAS angle and TLS angle. Moreover, for predicting the occurrence of BME, we divided the disease group into 2 groups, training set and validation set. We then verified the validity of the results by measuring cut-off value of TAS angle and TLS angle from ROC curve, an area which had statistically significant difference. Results: TAS angles or TLS angles were significantly lower in the group which showed BME at the anterior medial part of the tibia canopy and medial malleolus joint surface. From the ROC curve of the training set, the cut-off value (TAS angle of 82 degrees or less and TLS angle of 76 degrees or less) was obtained. Applying the obtained cut-off value to the validation set, it was possible to predict the occurrence of BME on the medial malleolus joint surface (sensitivity 71%, specificity 67%). Conclusion: Association with BME and clinical symptoms as well as disease prognosis has been reported in the OA area, so predicting the appearance of BME can be a useful index for prescribing a treatment plan. It was suggested that the appearance of BME could be predicted from X-ray findings because it was related to ankle alignment and MRI. It is possible that these findings could be used as a new diagnostic tool to estimate disease severity in the future.

Category: Ankle Arthritis Introduction/Purpose: Takakura-Tanaka classification is effective as an X-ray evaluation method for determining the severity of and treatment strategy for ankle osteoarthritis (OA). Concerning OA, MRI is gaining attention as a tool for examining the condition of the articular cartilage over X-ray findings. However, there are few reports on the relationship between MRI and X- ray findings in ankle joints. We assessed MRI findings of ankle OA at each stage of Takakura-Tanaka classification to investigate the effects of bone and articular cartilage. Methods: We studied the localization of Bone Marrow Edema (BME) partitioned articular surface by MRI in 22 regions at the talocrural, talocalcaneal, talonavicular, and calcaneocuboid joints of 46 feet of 45 patients who had a diagnosis of ankle OA in our hospital. Furthermore, we compared the radiological findings with the localization of BME. Results: By MRI, the area where BME was seen is located in the anterior medial part of the talocrural joint. Pointedly, 60% of BME was confirmed on the tibial side of the talocrural joint. In addition, as the Takakura-Tanaka classification advanced, the identification of BME tended to increase on the anterior of the talus and the medial malleolus articular surface. Conclusion: We found on MRI that the localization of BME was identified by Takakura-Tanaka classification in osteoarthritis of the foot. On the other hand, there are some cases of OA without BME that were identified by X-ray in this study. In the future, there is a possibility that the severity of OA can be classified into more inclusive classifications by MRI. We intend to combine the severity of ankle OA with MRI findings and Takakura-Tanaka classification together.

Category: Bunion Introduction/Purpose: Surgery for hallux valgus (HV) includes a variety of techniques based on the osteotomy site. We use the modified Mann technique in cases with deformity ranging from 30° to 40° and the modified Lapidus procedure in HV cases with deformity of over 40° or with metatarsalgia. Methods: Here we report our investigation of the appropriateness of the modified Mann technique and the modified Lapidus procedure based on a comparison of postoperative outcomes. In total, 73 feet of 58 cases who underwent surgery for HV with subsequent follow-up observation for at least 1 year were included in the study. The modified Mann technique was performed on 31 feet of 26 cases (M Group), and the modified Lapidus procedure was performed on 42 feet of 32 cases (L Group). Six cases in the M Group and 39 cases in the L Group also underwent concurrent surgery for metatarsalgia. The outcome measures were changes in the HV angle, the angle between the M1M2, the Japanese Society for Surgery of the Foot (JSSF) hallux scale, complications, and HV recurrence. These outcome measures were compared using the unpaired t-test on standing anteroposterior X-ray of the feet. Results: In the M Group, comparison of pre- and postoperative radiological changes indicated that the HV angle improved from 38.2° to 11.4°, M1M2 angle improved from 14.5° to 5.0° respectively. JSSF hallux score improved from 53.3 to 89.6. Postoperative hallux varus was confirmed in four cases, Osteoarthrosis of the MTP joint in six, and HV recurrence in two. In the L Group, comparison of pre- and postoperative radiological changes indicated that the HV angle improved from 46.0° to 16.9°, M1M2 angle improved from 15.2° to 6.6°respectivelty. JSSF hallux score improved from 47.8 to 94.7. Postoperative hallux varus was confirmed in two cases, Osteoarthrosis of the MTP in four, and HV recurrence in four. In both groups, only preoperative HV angle exhibited significant differences (p < 0.0001). Conclusion: Surgical technique was selected based on HV severity and metatarsalgia whether were present; however, both groups showed satisfactory results. In cases of severe HV or in cases accompanied by metatarsalgia, we performed the modified Lapidus procedure that reduced pronation and valgus of first metatarsal. The X-ray and clinical findings of the present study showed that the results of the L Group were not inferior when compared to those of the M Group. Surgical technique should be selected based on both HV severity and lessor toe symptoms.

Background: Understanding the plantar nerve anatomy is crucial for safe endoscopic surgery of the sole. We aimed to anatomically dissect the lateral aspect and soles of cadaveric feet to investigate the safety of peroneus longus tendoscopy with a plantar lateral portal and the safe zones for plantar portals. Methods: We studied 36 feet of 24 cadavers (mean age, 86.5 years). A cannula for 2.7-mm scope was inserted from the plantar lateral portal to the peroneus longus tendon, and the positional relationship between the cannula and sural nerve was observed. Then, the soft tissue of the sole was dissected, and the relationships between the plantar nerve and flexor digitorum longus tendon and flexor hallucis longus tendon was observed. The plantar nerve course was digitally imaged and uploaded into Image J software to determine nerve position. We further observed the positional relationship between the cannula and plantar nerve. Result: The mean minimum distance between the cannula and sural nerve was 13.8 mm, and the closest distance was 4.2 mm, allowing for the relatively safe creation of a plantar lateral portal. The use of the plantar lateral portal and evaluation of the peroneal tendon was safe with respect to the lateral plantar nerve as the nerve was in a different tissue layer of the foot. Dissection of the plantar foot demonstrated a relatively safe zone, 36.4% to 56% along a line between the medial aspect of the base of the first metatarsal bone to the proximal tip of the fifth metatarsal. This region may allow for a plantar endoscopic portal; however an anatomic variation may result in the plantar nerve being within this zone. The flexor digitorum longus tendon and peroneus longus tendon passed through the deep layer of the relatively safe zone. Conclusion: Peroneus longus tendoscopy was relatively safe to perform from a plantar lateral portal. No neurovascular structure exists on the slightly medial aspect of the central region of the sole, potentially allowing for a relatively safe creation of plantar central portal. An approach from the plantar central portal to the flexor digitorum longus tendon, flexor hallucis longus tendon, and peroneus longus tendon allows for a greater range of vision and treatment options as compared with conventional approaches. The combination of the plantar central portal with portals such as the plantar lateral portal may further the development of endoscopic surgery of the sole. Clinical Relevance: We found the anatomic characteristics of a relatively safe zone for the plantar portal for plantar lateral portal. [ABSTRACT FROM AUTHOR]

Activities on sandy soil are known to contribute to improved leg strength and balance. Lifesavers (LSs) have shown that sandy soil activity promotes intrinsic foot muscle development and improves balance. LS improves leg strength and balance through activities on sandy soil. However, the effect of foot muscle development on the actual muscle activity of LS remains unclear. We aimed to evaluate the effect of foot muscle development on muscle activity in lifeguards on a sandy beach compared with the corresponding in healthy participants. Fifteen LSs and 15 healthy adults underwent a Y-balance test to assess dynamic balance and surface electromyography to measure muscle activity. The LSs exhibited a significantly higher percentage of maximum voluntary contraction values in the tibialis anterior muscle in all directions than the healthy adults. The LSs showed increased peroneus longus and abductor hallucis muscle activity in the posterolateral and posteromedial directions, suggesting their involvement in contralateral postural control during dynamic balance. These findings suggest that engaging in barefoot activities on sandy soil enhances foot muscle activity and improves dynamic balance in LSs., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics Review Committee of Waseda University issued approval 2023-370. Written informed consent was obtained from the participants, who were informed in advance. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Suzuki et al.)

Objectives: We report the long-term outcome of joint-preserving surgery by combining metatarsal osteotomies for shortening for forefoot deformity in patients with rheumatoid arthritis (RA)., Methods: Forty-three patients (57 feet) aged 41.7-70.8 years (mean, 57.7 years) underwent a combination of first tarsometatarsal fusion and distal realignment (modified Lapidus procedure), shortening oblique osteotomies of the bases of metatarsals 2-4, and fifth ray osteotomy (modified Coughlin procedure). Patients were followed up for 64-108 months (mean, 76.6 months)., Results: Average postoperative Foot Function Index scores for pain, disability, and activity were 10.3, 19.9, and 16.2, respectively. Average Japanese Society for Surgery of the Foot RA foot and ankle score improved significantly from 52.1 points preoperatively to 90.3 points postoperatively. Postoperatively, 41% of patients reported some forefoot stiffness, but showed no disability. Residual deformity and callosity were absent in all patients. Average hallux valgus and intermetatarsal angles decreased postoperatively from 48.5° to 8.6° and from 15.2° to 4.6°, respectively. Nonunion in two metatarsals, hardware breakage in three, and mild infection in one were identified during follow-up., Conclusions: With good perioperative medical management of RA, surgical repositioning of the metatarsophalangeal joints by proximal metatarsal shortening and consequent relaxing of the surrounding soft tissue shows successful long-term results.

This study analyzed imaging, arthroscopic findings, and treatment responses for peroneal spastic flatfoot (PSFF) caused by talocalcaneal impingement at the accessory anterolateral talar facet (AALTF) (accessory talar facet impingement) in 13 adolescents without histories of trauma and tarsal coalition. The AALTF was determined with computed tomography and MRI. Focal abutting bone marrow edema (FABME) on MRI around the AALTF was confirmed. In seven patients who underwent AALTF resection, subtalar arthroscopy was performed. All experienced alleviation PSFF after treatment; reduction in FABME was observed. AALTF resection alone is beneficial for PSFF caused by accessory talar facet impingement when peroneal spasms are restored by an injection of local anesthesia.