Osteotomies in Flatfoot Surgery: A Narrative Review and Practical Framework

Background: Progressive Collapsing Foot Deformity (PCFD)—historically termed adult-acquired flatfoot deformity or posterior tibial tendon dysfunction—is a three-dimensional disorder of the hindfoot, midfoot, medial column, and, in advanced cases, the ankle. Joint-preserving reconstruction depends on matching each procedure to the dominant mechanical component of the deformity. Objective: This narrative review describes four osteotomies used in adult PCFD reconstruction—lateral calcaneal lengthening osteotomy (LCLOT), medial-sliding calcaneal osteotomy (MSCO), Cotton osteotomy, and medial-closing-wedge supramalleolar tibial osteotomy (MC-SMOT)—and proposes a deformity-oriented framework for procedure selection rather than a hierarchy of competing techniques. Methods: A structured narrative review of PubMed/MEDLINE and the Cochrane Library was performed through July 2026 and updated in September 2026. Study selection was performed by two authors and key studies were graded using the Oxford Centre for Evidence-Based Medicine 2011 levels. Results: Each osteotomy addresses a different component of PCFD. Among the osteotomies reviewed, the LCLOT has the broadest potential for multiplanar correction, particularly with forefoot abduction and talonavicular uncoverage, although clinical superiority has not been demonstrated. The MSCO targets valgus-dominant hindfoot malalignment. The Cotton osteotomy is an adjunctive procedure for residual forefoot varus or first-ray elevation with stable medial column joints. The MC-SMOT is reserved for selected supramalleolar valgus malalignment; evidence specific to PCFD is limited and largely extrapolated. The clinical evidence is predominantly level 4, and most deformities require combining osteotomies with soft-tissue reconstruction. Conclusions: Osteotomy selection should be driven by deformity morphology, flexibility, joint preservation, and soft-tissue competence. The proposed stepwise framework is intended to structure planning; its effect on planning consistency has not been validated. Prospective comparative studies using standardized classifications and patient-reported outcomes are needed.