This narrative review covers two medial column procedures used as adjuncts in adult acquired flatfoot reconstruction. It addresses how to choose between the Cotton plantarflexion medial cuneiform osteotomy and first TMT arthrodesis based on first TMT joint stability and arthritic status. Technique, indications, contraindications, and outcomes evidence for each procedure are summarized.
Correcting hindfoot valgus and forefoot abduction in AAFD reconstruction is not enough — the first ray can remain elevated, leaving the patient without a functional plantar tripod and with lateral border overload.
When you have fixed the hindfoot and forefoot abduction but the first ray is still up, evaluate the first TMT joint before closing: stable and non-arthritic means add a Cotton osteotomy (5–8 mm wedge maximum); hypermobile, painful, or arthritic means fuse it. Both procedures are performed as the final step in reconstruction, after all hindfoot work is secured, so you are assessing the true residual deformity.
The Cotton osteotomy heals reliably (0% nonunion in two published series) and preserves first TMT joint motion. But it has hard limits. Exceeding the 5–8 mm wedge or ignoring TMT instability leads to recurrence, and that is the most common error with this procedure.
The original Lapidus arthrodesis described fusion of both the first and second TMT joints for hallux valgus; the modern application fuses only the first TMT joint and has been expanded to correct medial column deformity in AAFD. A conceptual evolution worth knowing for boards.
This narrative review covers two medial column procedures used as adjuncts in adult acquired flatfoot reconstruction. It addresses how to choose between the Cotton plantarflexion medial cuneiform osteotomy and first TMT arthrodesis based on first TMT joint stability and arthritic status. Technique, indications, contraindications, and outcomes evidence for each procedure are summarized.
Correcting hindfoot valgus and forefoot abduction in AAFD reconstruction is not enough — the first ray can remain elevated, leaving the patient without a functional plantar tripod and with lateral border overload.
When you have fixed the hindfoot and forefoot abduction but the first ray is still up, evaluate the first TMT joint before closing: stable and non-arthritic means add a Cotton osteotomy (5–8 mm wedge maximum); hypermobile, painful, or arthritic means fuse it. Both procedures are performed as the final step in reconstruction, after all hindfoot work is secured, so you are assessing the true residual deformity.
The Cotton osteotomy heals reliably (0% nonunion in two published series) and preserves first TMT joint motion. But it has hard limits. Exceeding the 5–8 mm wedge or ignoring TMT instability leads to recurrence, and that is the most common error with this procedure.
The original Lapidus arthrodesis described fusion of both the first and second TMT joints for hallux valgus; the modern application fuses only the first TMT joint and has been expanded to correct medial column deformity in AAFD. A conceptual evolution worth knowing for boards.