PRINCIPLE: A combination of two or more soft tissue procedures is often needed to correct specific deformities.
Plantar–Medial Plication (PMP)
1. Indications
a. In combination with a calcaneal lengthening osteotomy (CLO) (see Chapter 8) in a flatfoot (see Chapter 5)
b. In combination with a CLO (see Chapter 8) in a skewfoot (see Chapter 5)
c. In combination with a CLO (see Chapter 8) for deformity correction in certain tarsal coalitions (see Chapter 5)
d. In combination with a circumference release for resistant congenital vertical talus (see Chapter 5)
e. In combination with a circumference release for resistant congenital oblique talus (see Chapter 5)
f. In combination with the 3rd street procedure (see this chapter)
2. Technique (Figure 7-39)
a. Make a longitudinal incision along the medial border of the foot dorsal to the edge of the glabrous skin starting at a point just distal to the medial malleolus and continuing to the base of the first MT. Release the posterior tibialis from its tendon sheath.
b. Cut the posterior tibialis tendon in a Z-fashion, releasing its dorsal one-third to half from the navicular. The stump of the tendon remaining attached to the navicular contains the plantar one-half to two-thirds of the fibers.
c. Incise the TN joint capsule from dorsal-lateral to plantar-lateral around the medial side, including the spring ligament. Resect a 5- to 7-mm-wide strip of capsule from the medial and plantar aspects of this redundant tissue.
d. Perform other concurrent procedures, such as a CLO (see Chapter 8), TAL (see this chapter), TAT (see this chapter), 3rd street procedure (see this chapter)
e. Plicate the TN joint capsule plantar-medially, but not dorsally, with multiple figure-of-8 2-0 absorbable sutures
f. Advance the proximal slip of the posterior tibialis tendon approximately 5 to 7 mm through a slit in the distal stump of the tendon. Secure this Pulvertaft weave with multiple figure-of-8 2-0 absorbable sutures.
g. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable sutures
3. Pitfalls
a. Plication without complete deformity correction
b. Substitution of plantar–medial plication for osseous deformity correction in a valgus hindfoot. The default position of the hindfoot is valgus (see Basic Principle #9, Chapter 2). Therefore, except in babies with CVT and congenital oblique talus, a PMP is supplemental to a CLO in valgus hindfoot deformity correction, but not an alternative to a CLO (see Management Principle #17, Chapter 4).
4. Complications
a. None