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What's New in the Literature?

Recently, I watched an online class hosted by Malcolm Gladwell, the journalist and author. While lecturing on how to find ideas of topics to write about, he used the metaphor of a library. When one goes to a library, looking for a particular book, it is common to examine the books adjacent to that one particular book, and as you explore further down the row, you’ll find tangentially related topics that might be interesting and often end up expanding one’s knowledge. This metaphor spoke to me, especially as someone who used libraries when young (there was no Internet when I was a youth). What better way to expand my knowledge and find interesting, otherwise unknown articles than to do the same but in an online format?

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I decided to try out this method of browsing for interesting research studies using Google. No, I didn’t use the regular Google; I’d have to fire myself as a college professor if that’s where I received my information! 

Instead, I used Google Scholar – an excellent adjunct to Pub Med – and limited my search by date (“Since 2021”) and relevance (“most relevant”). I searched “hallux valgus”, “hammertoe”, and “flatfoot pes planus”. I picked the 10 most recent articles and looked for trends regarding what has been studied most recently. My real purpose for doing this was not to analyze recent journal articles in the manner of a journal club, but rather to peruse available articles in a way that exposed me to new information that I might not otherwise have experienced. 

Ok, let’s get to it. 

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Hallux Valgus

When I searched “hallux valgus” I found 6 articles pertaining to surgery (5 of which researched aspects of percutaneous or minimal incision procedures1,2,3,4,5,6), a review about weightbearing CT imaging for HAV7, two cohort studies examining social factors (progression of the deformity in those with advanced age, poor health, foot pain, and prior use of constrictive shoes8 as well as a decreased quality of life in women with HAV9). One of the 10 articles was about orthotics (a systematic review and meta-analysis10 that found orthoses with a toe separator improved symptoms but not the first intermetatarsal angle, which makes sense since there’s no proof orthoses change hallux valgus kinetics or kinematics).

Comments: There’s a lot more surgical research than non, and the vast majority is about minimally invasive procedures (definitely in vogue at the moment). Perhaps not surprisingly, the level of research was low: no higher than a level 3 (six studies were level 3, one was a 4, and two were 5). 

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With this search, the trends were a little more of a mixed bag, but some interesting trends were noted. First, there was only one paper specifically about a surgical procedure11, while there were two papers related to implants for hammertoe correction.12,13 Interestingly, there were three biomechanical studies14,15,16, though two of them12,13 were basically the same paper by the same author published in two different journals. Two of the ten were reviews about hammertoes17,18. Finally, there was one study 19 about imaging (for plantar plate pathology rather than strictly for hammertoes alone – but that’s ok; the pathology goes hand in hand) and one proposing a new classification system to guide treatment.20

Comments: It’s interesting that implants were part of these papers, indicating where the surgical side currently sits. It’s not new procedures or MIS that dominates surgery for hammertoes but rather the implants available. It’s also telling that biomechanics, classification, and imaging methods were present, indicating the challenges in diagnosis and understanding the pathomechanics of this deformity. Our understanding of hammertoes is not quite as developed as hallux valgus.

Flatfoot/Pes Planus

I used both search terms simultaneously for this one at first and found a larger distribution of epidemiologic studies (four, in fact), two nonsurgical papers, and three papers on subtalar arthroereisis procedures. When I removed “pes planus” from the search, it completely changed the types of studies found. I’ll discuss these below. This points to the importance of search terms with “pes planus” not leading to surgical topics as much as “flatfoot.”

This is emphasized by the fact that no less than 5 of the studies under the “flatfoot” search term were surgical (3 about the outcomes of surgical procedures21,22,25, 2 arthroereisis outcomes23,24, and 1 about the effect of flatfoot reconstruction on hallux valgus25 – I just had to download this one since it discusses the frontal plane bunion question as well as if we should fix the flatfoot during bunionectomies). Biomechanics-oriented studies (4 of them26,27,28,29) made up the lion share of the rest with 1 study oriented on epidemiology.30

Comments: As before, the overall level of evidence for these flatfoot research studies was low, and it was not surprising to see an absence of randomized controlled trials. These are simply not possible with surgical and biomechanics research. This is a disorder that, although we continue to learn and study about its pathomechanics, we have reached a point where surgical correction is highly common. 

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Overall Conclusions

Now, perhaps the most significant conclusion to draw here is a caution not to read too much into these “trends.” I sampled very small numbers of studies, and these are not necessarily indicative of current research. Additionally, there’s a bias toward the most recent studies, since I deliberately limited my search to 2021. Maybe 2020 had a larger number of biomechanics studies for flatfoot, for example. With this said, my goal of “shopping around” and quickly looking for interesting studies that I might not have found with a more focused search was quite fruitful. Try this yourself with a topic of interest. Who knows what new research about diabetic limb salvage, PAD, neuromas, or other topics you’ll find when you try it!


  1. Biz C, Crimì A, Fantoni I, Tagliapietra J, Ruggieri P. Functional and radiographic outcomes of minimally invasive intramedullary nail device (MIIND) for moderate to severe hallux valgus. Foot Ankle Int. 2021 Apr;42(4):409-424.

  2. Hernández-Castillejo LE, Álvarez-Bueno C, Garrido-Miguel M, Torres-Costoso A, Reina-Gutiérrez S, Martínez-Vizcaíno V. The effect of hallux valgus open and percutaneous surgery on AOFAS scale: a systematic review and meta-analysis. Quality of Life Research. 2021 Jan 2;30(4):957-966.

  3. Migliorini F, Eschweiler J, Tingart M, Maffulli N. Revision surgeries for failed hallux valgus correction: A systematic review. Surgeon. 2021 Jan 7.

  4. Aiyer A, Massel DH, Siddiqui N, Acevedo JI. Biomechanical comparison of 2 common techniques of minimally invasive hallux valgus correction. Foot Ankle Int. 2021 Mar;42(3):373-380.

  5. Trnka HJ. Percutaneous, MIS and open hallux valgus surgery. EFORT Open Reviews. 2021 Jun;6(6):432-438.

  6. Lewis TL, Ray R, Robinson P, Dearden PM, Goff TJ, Watt C, Lam P. Percutaneous Chevron and Akin (PECA) Osteotomies for Severe Hallux Valgus Deformity With Mean 3-Year Follow-up. Foot Ankle Int. June 11, 2021.

  7. Mahmoud K, Metikala S, Mehta SD, Fryhofer GW, Farber DC, Prat D. The role of weightbearing computed tomography scan in hallux valgus. Foot Ankle Int. 2021 Mar;42(3):287-293.

  8. Menz HB, Marshall M, Thomas MJ, Rathod‐Mistry T, Peat GM, Roddy E. Incidence and Progression of Hallux Valgus: a Prospective Cohort Study. Arthritis Care & Research. 15 Jul 2021.

  9. Lewis TL, Ray R, Gordon DJ. The impact of hallux valgus on function and quality of life in females. Foot Ankle Surg. 2021 Jul 26.

  10. Kwan MY, Yick KL, Yip J, Tse CY. Hallux valgus orthosis characteristics and effectiveness: a systematic review with meta-analysis. BMJ Open. 2021 Aug 18;11(8):e047273.

  11. Bastías GF, Sage K, Orapin J, Schon L. Diaphyseal Proximal Phalangeal Shortening Osteotomy for Correction of Hammertoe Deformity: Operative Technique and Radiological Outcomes. Foot Ankle Spec. 2021 Jun 18.

  12. Štalc J, Cicchinelli LD, Miller S, Richter M. Fiber-reinforced fixation implant for proximal interphalangeal joint arthrodesis shows implant bio-integration at 1-year follow-up. Foot Ankle Surg. 2021 Jul 3.

  13. Ehredt Jr DJ, Kawalec JS, Zulauf EE, Wetzel B, min Kim H. Relative Strengths of Intramedullary K-Wire Techniques for Digital Deformities. J Foot Ankle Surg. 2021 Apr 20.

  14. Moayedi M, Arshi AR, Salehi M, Akrami M, Naemi R. Associations between changes in load-bearing pattern, deformity, and internal stresses at the foot with hammer toe during walking; a finite element approach. Computers in Biology and Medicine. 22 Jun 2021, 135;104598.

  15. Moayedi M, Salehi M, Arshi AR, Akrami M, Naemi R. A Finite Element Analysis of foot with hammer toe deformity during walking. 28 July 2021.

  16. Hellgren E, Breiner M. A pilot study on plantar pressure differences at the interface between the metatarsal pad and foot plantar surface: Comparing groups of claw toe, hammer toe and/or hallux valgus toe deformity.

  17. Goransson M, Constant D. Hammertoe. StatPearls [Internet]. Updated 2021 Jul 25.

  18. Thomson, AB (2021). The Wild West of Forefoot Surgery.

  19. Cherevtsov VN, Blazhenko AN, Bogdanov SB, Ketov MS. Objectification of indications for surgical restoration of the plantar plate in the treatment of multiplanar static foot deformities accompanied by hammertoe deformity of the lesser toes using ultrasound. Genij Ortopedii. 2021 Apr 20;27(2):214-219.

  20. Weyandt Z, Capuzzi M, McGlone W, Bernatsky A, Ford T. Lesser toe deformity classification: A simplified approach with treatment influence. Foot (Edinb). 2021 May 4;48;101819.

  21. Tejero S, Carranza-Pérez-Tinao A, Zambrano-Jiménez MD, Prada-Chamorro E, Fernández-Torres JJ, Carranza-Bencano A. Minimally invasive technique for stage III adult-acquired flatfoot deformity: a mid-to long-term retrospective study. International Orthopaedics. 2021 Jan;45(1):217-223.

  22. Raikin SM, Rogero RG, Raikin J, Corr DO, Tsai J. Outcomes of 2B Adult Acquired Flatfoot Deformity Correction in Patients With and Without Spring Ligament Tear. Foot Ankle Int. 2021 Jul 22:107.

  23. Mattesi L, Ancelin D, Severyns MP. Is subtalar arthroereisis a good procedure in adult-acquired flatfoot? A systematic review of the literature. Orthop Traumatol Surg Res. 2021 Jun 30;103002.

  24. Mazzotti A, Di Martino A, Geraci G, Casadei C, Panciera A, Giannini S, Faldini C. Long-term results of subtalar arthroereisis for the treatment of symptomatic flexible flatfoot in children: an average fifteen year follow-up study. Int Orthop. 2021 Mar;45(3):657-664.

  25. Wang CS, Tzeng YH, Yang TC, Lin CC, Chang MC, Chiang CC. First-Ray Radiographic Changes After Flexible Adult Acquired Flatfoot Deformity Correction. Foot Ankle Int. 2021 Aug 5;10711007211034516.

  26. Ortolani M, Leardini A, Pavani C, Scicolone S, Girolami M, Bevoni R, Lullini G, Durante S, Berti L, Belvedere C. Angular and linear measurements of adult flexible flatfoot via weight-bearing CT scans and 3D bone reconstruction tools. Sci Rep. 2021 Aug 9;11(1):1-3.

  27. Phan CB, Lee KM, Kwon SS, Koo S. Kinematic instability in the joints of flatfoot subjects during walking: A biplanar fluoroscopic study. J Biomech. 2021 Aug 10;127:110681.

  28. Zhang YJ, Guo Y, Long X, Du JY, Liu T, Lin XJ. Analysis of the main soft tissue stress associated with flexible flatfoot deformity: a finite element study. Biomech Model Mechanobiol. 2021 Jul 30:1-9.

  29. Hu CW, Dabnichki P, Baca A, Nguyen CT, Pang TY. Preventive strategy of flatfoot deformity using fully automated procedure. Med Eng Phys. 2021 Sep;95:15-24.

  30. Shin BJ, Lee KM, Chung CY, Sung KH, Chun DI, Hong CH, Kim JB, Kwon SW, Kim WJ, Song MG, Yoon SJ. Analysis of factors influencing improvement of idiopathic flatfoot. Medicine. 2021 Aug 13;100(32):e26894.
Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor

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