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Cotton Osteotomy in Flatfoot Reconstruction

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Cotton Osteotomy in Flatfoot Reconstruction Cotton OsteotomyYes in Flatfoot Reconstruction: a Retrospective Review of Consecutive Cases Troy Boffeli DPM, FACFAS, DPM, Katherine Schnell, DPM Regions Hospital / HealthPartners Institute for Education and Research - Saint Paul, MN STATEMENT OF PURPOSE Figure 1. Preop and Postop Meary’s Angle Measurement Table 1. Results (N=37 Feet) RESULTS The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive Thirty-two patients (37 feet) were included in the present study (10 males and 22 females). No flatfoot reconstructive procedure that is commonly performed but rarely reported which is in part Mean Age (yrs) 42 (9–77) patient was excluded and all cases were consecutive. The average age was 42 (range 9 to 77). Meary’s angle was due to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to assessed on (a) Gender (M:F) 10M:22F Fixation was used in 16/37(43%) feet. Threaded 0.062” k-wires were used in 12 cases and plate perform and is intended to correct forefoot varus deformity after rearfoot fusion or osteotomy to Preop preoperative and (b) 10 fixation was used in 4 cases. The average follow-up was 18 months (range 2.5 to 96 months). All achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical since but one patient demonstrated clinical and radiographic healing at the 10 week postoperative visit. week postoperative Laterality (R:L) 13R:24L preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or Mearys line improved in all feet, with an average change of -17.2° pre-operatively to 0.5° post- DJD of the medial column may be better treated with arthrodesis of the naviculocuneiform or first weight bearing lateral Mean Preop Meary’s Angle (°) -17.24 (-35 to -7) operatively (Table 1). Incorporation of the bone graft was seen in 36/37 feet, with no evidence of xrays. The Cotton tarsometatarsal joints. Procedure indications also include elevatus of the first ray which can be a displacement or subsidence in all 37 feet. No patients required removal of the graft or repeat primary deformity in hallux limitus or iatrogenic deformity following base wedge osteotomy for osteotomy is particularly Mean Postop Meary’s Angle (°) 0.51 (-12 to +5) surgery due to displacement of the graft (Table 2). 1/37 had a delayed union of the graft with hallux valgus. The present retrospective series highlights our experience with the use of the a continued pain 4 months after surgery. A CT confirmed no osseous bridge and a bone stimulator useful to correct Mean Change in Meary’s Angle (°) 17.76 Cotton osteotomy as an adjunctive procedure when used in flatfoot reconstructive surgery. abnormal Meary’s angle was prescribed. Two months after using the bone stimulator, pain had resolved (Figure 5). She was Follow-up Time (months) 18.12 (2.5-96) seen at 1 year post-op with no further problems of the surgical foot. There was no fixation used in Postop although correction of this case and no displacement of the graft was noted. The patient was a not a smoker and did not METHODOLOGY deformity may be limited have Vitamin D deficiency. The other post-operative complication involved 2 patients with No Fixation (# feet) 21 After institutional review board approval, we performed a retrospective analysis of consecutive in cases involving neuritis, one which resolved within 1 year after surgery and the other that did not resolve within patients treated with Cotton osteotomy as part of flatfoot reconstruction from April 2001 to instability of the medial Fixation Used (# feet) 16 (4 Plate, 12 K-wires) 4 months after surgery. Both patients with neuritis had plate fixation of the osteotomy but did not December 2015. All osteotomies were performed by one surgeon (TJB) as an adjunctive require hardware removal or revision surgery. Adjunctive procedures included gastrocnemius column joints. Adjunctive Active Smokers(# patients) 5 procedure in correction of pes valgus deformity and PTTD. Inclusion criteria included a clinic procedures also lengthening (21), STJ fusion (13), Koutsogiannis (22), Evans (12), PT tendon repair (15), FDL tendon follow-up at 10 weeks with appropriate preoperative radiographs with no joint proximal joint transfer (6), tarsal coalition resection (6), hardware removal (HWR) from previous distal bunion b contribute to correction Histroy of Chronic Pain (# patients) 3 fault or midfoot DJD or hallux valgus. Postoperative weight bearing (WB) radiographs were taken surgery (3), Kidner procedure (3), bone spur removal (6). Other various procedures that were not at 10 weeks. Patients who did not have WB radiographs at 10 weeks or were lost to follow-up of Meary’s angle. Diabetes (# patients) 1 as common included hammertoe repair, cheilectomy, 1st metatarsal phalangeal joint fusion, and prior to their 10 week post-operative appointment were excluded. Both investigators evaluated TN fusion (Table 3). postoperative radiographs to determine interval to radiographic incorporation of the allograft, Vitamin D Deficiency (# patients) 2 which was defined as bridging of the interface between the graft and native bone by bone callus Figure 2. Surgical Technique Pearls for Cotton Osteotomy or trabeculae at 3 out of 4 cortices and obliteration of the graft interface as previously described ANALYSIS AND DISCUSSION (1). Graft displacement and subsidence were also evaluated. Meary’s angle was also measured on Table 2. Complications The Cotton Osteotomy is a common and well-accepted adjunctive procedure for correction of preoperative and 10 week postoperative digital lateral WB radiographs (Figure 1). Clinical healing flatfoot deformity with or without posterior tibial tendon dysfunction. In his original article, was determined by absence of pain at the surgical site with palpation and weightbearing. Other Postoperative 0 Cotton stated that “the operation is simple, not painful, and… in the short review of cases done data collected included age, gender, tobacco use at the time of procedure, and chronic medical Infection since I have devised this operation, there has been no trouble in any” (4). The procedure is comorbidities including diabetes, Vitamin D deficiency, and chronic pain. Type of fixation and generally thought to be safe and effective. adjunctive procedures were recorded. Complications including need for revision surgery, non- Hardware Removal 0 A search of medical literature identified few reports of outcomes regarding the Cotton osteotomy. union or delayed union, and neuritis or nerve symptoms related to the Cotton osteotomy were d In a review of 16 patients, Hirose and Johnson used a 4.0 or 3.5 screw to fixate the cotton also assessed. Graft Subsidence 0 osteotomy when performed in conjunction with adjunctive flatfoot procedures. They found a union rate of 100% which is greater than the 77% reported for midfoot arthrodesis and concluded Nonunion 0 SURGICAL TECHNIQUE that an advantage over fusion is more predictable union and preservation of first ray mobility (5). a b c e Luts and Myerson reported on 101 medial cuneiform osteotomies performed in conjunction with Malunion 0 A consistent surgical technique was used in all cases regarding medial cuneiform osteotomy and comprehensive flatfoot reconstruction procedures. They did not report nonunions which supports bone grafting although use and type of fixation was variable. Surgery was performed with the Delayed Union 1 No fixation used, resolved with the theory that the Cotton osteotomy heals predictably (8). Our union rate was very similar, with a patient in the supine position under general anesthesia with a popliteal block. A thigh tourniquet 2 months of bone stimulation delayed union noted in one patient at four months that resolved with the use of a bone stimulator is preferable due to adjunctive procedures. The medial dorsal cutaneous nerve (MDCN), extensor after two months. This patient did not have internal fixation of the graft but there was no shift of hallucis longus (EHL), and tibialis anterior (TA) tendon were marked out pre-operatively and a Plate fixation both cases, Sensory neuritis 2 the osteotomy. This patient was assessed for bone healing risk factors and did not have vitamin D longitudinal dorsal incision was made medial to the EHL tendon which was centered over the 1/2 was resolved at 1 year postop deficiency, or history of tobacco use. medial cuneiform (Figure 2a). The MDCN was carefully freed and protected as needed and the 0/2 required hardware removal incision was carried down to bone. The periosteum was reflected along the dorsal and medial Hirose and Johnson reported one postoperative complication in which a painful screw had to be removed due to screw head prominence. (Hirose & Johnson). We report an incidence of 0/16 for aspect of the medial cuneiform using a periosteal elevator. Care was taken to preserve the g h f ligaments. An osteotomy guide wire was placed centrally within the cuneiform along the lateral hardware removals when using k-wire or plate fixation. Although previous studies did not cortex from dorsal to plantar. The pin was placed parallel to the first TMT joint from dorsal to compare fixation to no fixation groups, there appears to be no difference in union rate between (a) The traditional Cotton incision (dashed line) is centered dorsally over the Figure 5. Delayed Union Case those that used fixation and those that did not. In our study, union rates and complication profiles planar rather than perpendicular to the weight bearing surface which was confirmed on lateral imaging. The osteotomy was made from dorsal to plantar using an oscillating saw. The plantar medial cuneiform. (b,c) Distraction assists with graft placement. (d,e) Tricortical between the groups with fixation (16/37) and without fixation (21/37) were similar. 2/16 patients cortex was preserved to serve as a hinge along with the plantar soft tissues. An osteotome was iliac crest allograft was used in all patients undergoing Cotton osteotomy.
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