The Bridle procedure is a specialized surgical technique designed to treat foot drop, which is often caused by nerve injuries such as those to the peroneal nerve. It involves a series of tendon transfers and modifications to restore dorsiflexion (the ability to lift the foot) and improve foot alignment.
What is the Bridle Procedure?
The Bridle procedure is a surgical solution primarily used for individuals who suffer from foot drop, a condition that causes difficulty in lifting the foot. Foot drop can result from various conditions such as nerve injuries, cerebral palsy, or other neurological impairments. The Bridle procedure modifies a common tendon transfer, the posterior tibial tendon transfer, to help restore the foot’s function and reduce deformity.
Why is the Bridle Procedure Done?
The primary goal of this surgery is to correct foot deformities and improve the ability to walk, particularly in patients who have difficulty lifting the front of their foot (dorsiflexion) due to nerve damage. This condition is commonly seen in patients with peroneal nerve injuries, such as those caused by knee fractures or surgeries like hip or knee replacements.
In patients with this condition, walking becomes awkward and energy-draining, and in some cases, even bracing may not provide enough support. The Bridle procedure helps eliminate or reduce the need for a brace by restoring the function of the affected muscles and tendons.
The History of the Bridle Procedure
The technique behind the Bridle procedure was first developed as part of a long-standing effort to correct foot deformities caused by nerve damage. While variations of the procedure have been in use for many years, the Bridle modification specifically combines tendon transfers and adjustments to provide a more balanced outcome, especially in cases with complex deformities.
Dr. Daniel Riordan and Dr. Paul Brand are credited with its development, although its roots trace back to earlier methods of tendon transfer for conditions like leprosy and cerebral palsy, where patients suffered from severe deformities in the feet.
How the Bridle Procedure Works
The procedure involves transferring tendons from different parts of the leg and foot to restore balance and function. Specifically:
The posterior tibial tendon, which usually helps turn the foot inward, is relocated to the top of the foot.
Additional tendons from the peroneus longus and tibialis anterior are also used in a process called a “tri-tendon anastomosis.” This technique ensures that the forces from the transferred tendons are balanced, preventing further deformities like inward or outward bending of the foot.
These tendon transfers are carefully placed to improve both the dorsiflexion (lifting the foot) and the alignment of the foot and ankle, which can be deformed due to nerve injury.
Types of Deformities Treated
The Bridle procedure is designed to treat multiple types of foot deformities:
Equinus Deformity – where the foot is permanently pointed downward (as in tiptoe walking).
Equinovarus Deformity – where the foot is pointed downward and turned inward.
Drop-Foot – a condition where the front of the foot cannot be raised due to weakness or paralysis in the foot’s muscles.
Patients with these deformities often have difficulty walking and may use a brace to help them lift their foot while walking. The Bridle procedure aims to reduce or eliminate the need for such braces by improving muscle function and foot positioning.
Advantages of the Bridle Procedure
One of the major advantages of the Bridle procedure is that it can treat both uniplanar (one-direction) and multiplanar deformities, where the foot and ankle are out of alignment in more than one direction. The procedure also helps those suffering from drop-foot related to peroneal nerve injuries or neurological conditions like cerebral palsy and Charcot-Marie-Tooth disease.
Additionally, the modification in the Bridle technique, such as securing the transferred tendons to the bone (instead of relying on tendon-to-tendon transfers), provides a more stable and long-lasting result.
Challenges and Risks
Although the Bridle procedure can provide significant improvements, it is not without its risks. The surgery is technically demanding, requiring multiple incisions and careful tendon adjustments. Potential risks include:
Injury to the nerves – particularly the superficial peroneal nerve, which runs near the site of the surgery.
Postoperative deformities – sometimes, patients may develop issues like a “calcaneus deformity,” where the foot is too rigid and cannot move properly.
Weakness in the transferred muscles – even after the surgery, some weakness in the foot’s muscles may remain, affecting balance and gait.
Postoperative Care and Recovery
After surgery, patients are placed in a soft dressing or cast for several weeks. Physical therapy plays an essential role in rehabilitation, helping patients re-educate their foot muscles to function correctly. The recovery time can be lengthy, typically requiring up to 6 months before full weight-bearing activities can be resumed, with continued use of a brace until strength improves.
Outcome and Effectiveness
Overall, the Bridle procedure has shown to be highly effective in improving foot function and allowing patients to stop using a brace for everyday activities. However, outcomes can vary depending on factors such as the severity of the initial injury, the patient’s overall health, and the specific etiology of the foot drop. According to a clinical study, while strength and balance improvements are seen, the procedure does not fully restore normal function in terms of muscle strength and joint range of motion.
Conlusion
The Bridle procedure is a valuable surgical option for patients suffering from foot drop caused by peroneal nerve injury or other neurological conditions. While it may not fully restore normal strength, it significantly improves the quality of life by allowing patients to walk without braces and engage in daily activities. This procedure has proven effective for various foot deformities and is particularly beneficial for individuals who have functional tibialis posterior muscles. However, it requires careful consideration of the patient’s specific needs and potential risks associated with the surgery.
Do you have more questions?
Q. What is the Bridle Procedure?
A. The Bridle procedure is a surgical technique designed to treat foot drop by performing tendon transfers to restore dorsiflexion and improve foot alignment, commonly used for conditions caused by peroneal nerve injury.
Q. Why is the Bridle Procedure done?
A. It is performed to correct foot deformities and restore the ability to lift the front of the foot (dorsiflexion), especially in cases of nerve damage, such as peroneal nerve injury, cerebral palsy, or other neurological impairments.
Q. What conditions does the Bridle Procedure treat?
A. The Bridle procedure treats foot deformities like equinus deformity (tiptoe walking), equinovarus deformity (foot pointing downward and inward), and drop-foot caused by nerve injuries or neurological disorders.
Q. How does the Bridle Procedure work?
A. The procedure involves transferring tendons, such as the posterior tibial tendon, to help restore foot movement and balance. It uses a tri-tendon anastomosis to ensure balanced forces, improving dorsiflexion and realigning the foot.
Q. What are the advantages of the Bridle Procedure?
A. The procedure provides a more balanced and stable result, especially for patients with multiplanar deformities, and it allows many to walk without braces, improving overall foot function and quality of life.
Q. What are the risks associated with the Bridle Procedure?
A. Risks include nerve injury, postoperative deformities like calcaneus deformity, weakness in the transferred muscles, and complications like infection or difficulty with tendon healing.
Q. What is the recovery process after the Bridle Procedure?
A. After surgery, patients typically wear a soft dressing or cast for several weeks, followed by physical therapy to restore foot muscle function. Full recovery can take up to 6 months, and patients may need to use a brace during rehabilitation.
Q. How effective is the Bridle Procedure?
A. The procedure is effective in improving foot function and enabling patients to stop using a brace for daily activities. While muscle strength and joint range of motion may not fully return to normal, most patients see significant improvements in balance and walking ability.
Q. How long does the Bridle Procedure take?
A. The Bridle procedure typically takes about 2 to 3 hours, depending on the complexity of the deformity and whether additional procedures are required.
Q. Can the Bridle Procedure be performed on both feet at the same time?
A. While it is technically possible, it is generally recommended to perform the procedure on one foot at a time to allow for proper healing and reduce the risk of complications.
Q. Will I experience any pain after the Bridle Procedure?
A. Some discomfort and swelling are common immediately after the surgery, but these can be managed with prescribed pain medications. Pain usually decreases as the foot heals.
Q. Will I need to wear a cast after the Bridle Procedure?
A. Yes, you will likely need to wear a cast or a walking boot for several weeks following surgery to protect the foot while it heals and to ensure the tendons remain in their new positions.
Q. Can I return to normal activities after the Bridle Procedure?
A. Most patients can return to normal activities within 3 to 6 months, but high-impact activities should be avoided until the foot has fully healed and strength is restored.
Q. Are there any alternative treatments to the Bridle Procedure?
A. Alternative treatments include bracing, physical therapy, or other tendon transfer surgeries depending on the specific foot deformity and underlying cause, such as the posterior tibial tendon transfer or the tendon transfer procedures for foot drop.
Q. How successful is the Bridle Procedure in treating foot deformities?
A. The Bridle procedure is highly successful in restoring foot function and improving gait for many patients, with most achieving significant improvement in foot alignment and stability, leading to better walking without the need for braces.
Q. Can the Bridle Procedure be combined with other surgeries?
A. Yes, the Bridle procedure is sometimes combined with other foot surgeries, such as those for tendon releases, joint fusions, or corrections of other deformities, to provide a comprehensive solution for complex foot conditions.
Dr. Mo Athar
