Surgical Anatomy of the Medial Cuneiform (Cotton) Osteotomy.

Thumbnail Image



Journal Title

Journal ISSN

Volume Title

Repository Usage Stats


Citation Stats



The Cotton osteotomy, or dorsal-opening wedge osteotomy of the medial cuneiform (MC), is used to address medial column alignment to restore the static-triangle of support. There are many described techniques regarding the incision and osteotomy. Successful completion of the osteotomy requires knowledge of the anatomy, particularly the location of the medial dorsal cutaneous nerve (MDCN). This study describes the relationship between MDCN, tibialis anterior, extensor-hallucis-longus tendon, and ligamentous attachments to the MC. A technique to determine a safe location for the osteotomy is also described.


Twelve fresh-frozen adult foot specimens were used for this study (7 male and 5 female). The MDCN and its branches were dissected and its relationship with the MC was documented. Osteotomy tilt angle and relationship to structures around the MC were measured.


MDCN traveled medially and distally over the dorsum of the MC, and a small branch to the MC was observed. The tilt angle was 80.1 ±1.4 degrees. There was no significant difference between the distance from the distal-articular surface to the midline of the cuneiform and to the interosseous ligament (P = .69), or between the distance from the distal-articular surface to the second tarsometatarsal joint and to the origin of the Lisfranc ligament (P = .12).


The dorsal-medial-oblique incision effectively protected MDCN and the MC. We believe the osteotomy should be performed in the safe zone to maintain the stability of the opening wedge.

Clinical relevance

The dorsal-medial-oblique incision could reduce the risk of injury to the MDCN and the tibialis-anterior tendon.





Published Version (Please cite this version)


Publication Info

Wei, Baofu, Brian C Lau and Annunziato Amendola (2019). Surgical Anatomy of the Medial Cuneiform (Cotton) Osteotomy. Foot & ankle orthopaedics, 4(4). p. 2473011419885344. 10.1177/2473011419885344 Retrieved from

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Brian Chei-Fai Lau

Assistant Professor of Orthopaedic Surgery

Annunziato Amendola

Virginia Flowers Baker Distinguished Professor of Orthopaedic Surgery

Chief of Sports Medicine

Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.