Foot reconstruction surgery encompasses various specialized techniques designed to correct structural deformities and restore proper foot function. The Cotton osteotomy is an established procedure primarily targeting adult acquired flatfoot deformity, also known as pes planus. This technique is often one component of a broader reconstructive plan aimed at rebuilding the foot’s architecture. It is performed when non-surgical treatments, such as custom orthotics, have failed to adequately address the misalignment and resulting pain.
Defining the Procedure and Its Purpose
The Cotton osteotomy is a specific type of bone cut that addresses the collapse of the medial column of the foot, the inner side responsible for maintaining the arch. The anatomical target is the medial cuneiform, one of the small bones located in the midfoot. In a severely flat foot, this bone often becomes positioned incorrectly, contributing to a fallen arch and causing the front of the foot to angle upward (forefoot varus). The procedure is technically known as a dorsal opening wedge osteotomy of the medial cuneiform. The surgeon makes a precise cut through the top (dorsal) aspect of the bone, leaving the bottom layer intact. Opening this cut creates a wedge-shaped gap. The goal of the surgery is structural realignment, specifically to increase the height of the medial longitudinal arch. Inserting a wedge into this gap forces the medial cuneiform bone to rotate downward (plantarflexion). This movement brings the first metatarsal bone down to a more natural, weight-bearing position, which elevates the arch and corrects the deformity.
The Surgical Process
The Cotton osteotomy is typically performed under general anesthesia or a regional nerve block. The procedure is often combined with other reconstructive steps, such as calcaneal osteotomies or tendon transfers, to achieve comprehensive correction of the flatfoot deformity. The surgeon begins by making an incision over the medial cuneiform bone, avoiding damage to nearby nerves and tendons. Once exposed, a precise cut is executed across the bone’s dorsal aspect, leaving the plantar cortex intact to act as a hinge. Specialized surgical instruments are then used to gently open the wedge-shaped space. The size of this gap is determined intraoperatively based on the desired degree of arch correction.
A wedge-shaped graft material is then inserted into the newly created space to hold the correction in place. This wedge can be a bone graft (autograft or allograft) or a synthetic or metallic spacer. The graft is secured using specialized fixation hardware, such as small plates, screws, or staples, ensuring the bone remains stable while it heals and fuses. After confirming the new alignment, the surgical site is irrigated, and the incision is closed in layers. The foot is then immobilized in a protective splint or cast to begin the healing process.
Recovery Timeline and Expectations
The initial phase of recovery focuses on protecting the surgical site and allowing the bone graft to integrate, or fuse, with the medial cuneiform. Patients are required to remain non-weight-bearing on the operated foot for six to eight weeks. During this time, a cast or specialized boot is worn to maintain immobilization and prevent stress on the surgical repair. Post-surgical expectations include swelling and stiffness, which can persist for several months. Keeping the foot elevated above the heart during the initial weeks is recommended to manage swelling and promote healing. Pain medication will be prescribed to manage discomfort in the immediate post-operative period.
After the initial non-weight-bearing period, and once X-rays confirm sufficient bone healing, the patient transitions to partial weight-bearing. This phase typically involves the use of a walking boot and crutches or a cane for support. Physical therapy becomes a component of recovery at this stage, focusing on regaining range of motion, strength, and a normal walking pattern. The overall time required for a full return to daily activities and unrestricted walking ranges from four to six months. The long-term goal of the Cotton osteotomy is a stable, pain-free foot with a restored medial arch, improving the mechanics of walking and standing.