Medial Cuneiform Osteotomy for PTTD: Bone Surgery Explained

Medial cuneiform osteotomy—also known as Cotton osteotomy—is a specialized bone procedure used to correct flatfoot deformity in PTTD patients. While less common than tendon procedures, it plays a crucial role in comprehensive surgical reconstruction.

What Is Medial Cuneiform Osteotomy?

This procedure involves cutting the medial cuneiform bone (the bone located at the highest point of your arch) and inserting a small bone graft to gradually elevate the arch. Named after Dr. Henry Cotton, who first described it in the 1930s, it’s sometimes simply called a “Cotton osteotomy.”

The goal is to:

  • Raise and support the collapsed arch
  • Improve foot alignment
  • Reduce stress on the posterior tibial tendon
  • Create a more stable foot foundation

How It Helps PTTD

When the arch collapses in PTTD, the medial cuneiform osteotomy addresses the problem mechanically:

  1. The bone cut creates a space
  2. A bone graft (often from the patient or donor) is inserted
  3. This gently pushes the front of the foot upward
  4. The arch is restored to a more normal height

By supporting the arch surgically, the posterior tibial tendon gets a chance to heal and function more effectively.

When It’s Performed

Medial cuneiform osteotomy is typically done:

  • In Stage II PTTD when the deformity is flexible
  • In combination with tendon transfer procedures
  • When the arch needs structural support beyond what tendons can provide
  • As part of a comprehensive flatfoot reconstruction

It’s rarely performed alone—usually part of a surgical package that addresses multiple aspects of the deformity.

Combined Procedures

This osteotomy is almost always combined with other surgeries:

  • Tendon transfer: FDL tendon transfer to replace posterior tibial tendon
  • Calcaneal osteotomy: A separate bone cut to shift the heel bone
  • Ligament repair: Addressing lax spring ligament

These combined procedures create comprehensive correction of all components of the flatfoot deformity.

Recovery Timeline

Weeks 1-6: Non-weight-bearing in cast or splint

Weeks 6-10: Transition to boot, begin gentle weight-bearing

Weeks 10-14: Physical therapy, progressive weight-bearing

Months 3-6: Return to supportive shoes, strengthening

Months 6-12: Full recovery, bone healing completes

What to Expect

The medial cuneiform osteotomy is a well-established procedure with good outcomes:

  • The bone graft integrates over several months
  • Most patients achieve lasting arch support
  • Combined with tendon surgery, it provides comprehensive correction
  • Hardware (screws) is sometimes used and may later be removed

While more invasive than tendon procedures alone, it offers structural correction that can halt PTTD progression and eliminate pain for appropriate candidates.