Cotton Osteotomy

Ryan Pfannenstein, DPM, AACFAS

Dept. of Foot and Ankle Surgery
HealthPartners Medical Group / Regions Hospital
Chief of Professional Services-HealthPartners Riverside Clinic
Externship Director-Regions Hospital Reconstructive Foot and Ankle Surgical
Residency Program
Definition
• Opening dorsally-
based wedge
osteotomy of the
medial cuneiform
– Lengthens the medial
column
– Plantarflexes the 1st
ray
 Opening Dorsal Wedge Osteotomy
of Medial Cuneiform
• Indications
– Pes plano valgus
foot structure
• Medial column
procedure (usually
adjunct)
– Especially if no
particular joint as
apex
» No plantar
gapping
• Hallux limitus with
metatarsus primus
elevatus
Opening Dorsal Wedge Osteotomy
of Medial Cuneiform
• Technique
– Planning
• Fluoro-localize first met
cuneiform, med cuneiform, n-c
joints
– Mark out with skin lines
– Anatomic structures
• EHL, Tib Ant, saph vein and
nerve, DP
 Opening Dorsal Wedge Osteotomy
of Medial Cuneiform
• Technique
– Incision
• At least the entire med
cuneiform
• Just medial to EHL
– Dissection
• Skin and sub q
• EHL sheath – retract EHL lat,
retract tib ant
• Incise to bone entire dorsal med
cuneiform, can do a medial T
• Elevate periosteum, may need
to partially section
intercuneiform ligaments
Osteotomy
– Parallel to 1st met-cuneiform
joint
– Middle of the medial
cuneiform
– Sagittal saw
Osteotomy
– Osteotome plantar
cortex
• Green stick or at min
leave plantar
periosteum intact
– Pry open with
osteotome or lamina
spreader
 Bone Graft
• Cadaver iliac crest tricortical
– Try to select widest piece from bone bank
• Usually 7 mm wedge
• Draw out on graft (use one end to save in
case it breaks, falls, does not fit)
• Back table cut out
– With sagittal saw (? Irrigation)
Bone Graft
 Bone Graft
• Slip in behind
osteotome
• Bone tamp until flush
– Could remove the little
prominence (low
strength)
 Fixation
• Not necessary
• Could use a staple, spanning plate, screw
– If concerned at crushing graft or loss of
reduction
– Layered closure, repair EHL sheath
• Postop
– 6 weeks strict NWB
– 4 weeks graduated WB with crutches / walker
in air cast
Fixation
 Advantages
• Easy dissection
• Quick Procedure
• Decreased chance of non-union vs. fusion
• Better clinical correction of the arch
– Treat the patient not the x-ray
• Apex of deformity
– Especially if there is a generalized midfoot
collapse
 Complications
• Graft resorption
• Incomplete osteotomy – fx of plantar
cuneiform
– Leave saw blade in and fluoro
• Cutting through plantarly leading to
gapping and instability
Complications
Thank You