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.
How Common It Is and Who Gets It? (Epidemiology)
Foot drop is commonly caused by nerve injuries, including those to the peroneal nerve, and is often seen in patients with conditions like cerebral palsy, Charcot-Marie-Tooth disease, or as a result of trauma or surgeries like knee or hip replacements.
Why It Happens – Causes (Etiology and Pathophysiology)
Foot drop occurs when there is damage to the muscles responsible for lifting the foot, often due to nerve injuries. The Bridle procedure addresses deformities caused by conditions such as:
- Peroneal nerve injury (due to trauma or surgery).
- Cerebral palsy.
- Neurological impairments affecting foot movement.
How the Body Part Normally Works? (Relevant Anatomy)
The muscles responsible for lifting the foot are located in the lower leg and include the tibialis anterior, peroneus longus, and posterior tibial tendon. When these muscles or their associated nerves are damaged, foot drop occurs, making it difficult to lift the front of the foot while walking.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of foot drop include:
- Difficulty lifting the foot while walking.
- Weakness or paralysis in the muscles that raise the foot.
- The need for a brace to help lift the foot while walking.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis involves:
- Physical examination to assess foot movement and gait.
- Electromyography (EMG) to test nerve function.
- MRI or X-rays to rule out other causes of foot deformities and to assess the extent of nerve injury.
Classification
The Bridle procedure is used to treat various types of foot deformities, including:
- Equinus Deformity: Foot pointed downward (tiptoe walking).
- Equinovarus Deformity: Foot pointed downward and inward.
- Drop-Foot: Difficulty lifting the foot due to nerve weakness.
Other Problems That Can Feel Similar (Differential Diagnosis)
Other conditions that can present with symptoms similar to foot drop include:
- Osteoarthritis affecting the joints.
- Charcot-Marie-Tooth disease, which can also lead to muscle weakness in the foot.
- Peroneal neuropathy not involving foot deformities.
Treatment Options
Non-Surgical Care
- Bracing to assist with lifting the foot.
- Physical therapy to improve strength and function.
- Orthotics to help with foot positioning.
Surgical Care
- The Bridle procedure, which involves tendon transfers to restore dorsiflexion and improve foot alignment.
Recovery and What to Expect After Treatment
Recovery from the Bridle procedure can take 3 to 6 months. Initially, patients will need to wear a soft dressing or cast for several weeks and will gradually begin physical therapy to help regain muscle function.
Possible Risks or Side Effects (Complications)
Possible risks include:
- Nerve injury (particularly to the superficial peroneal nerve).
- Postoperative deformities such as calcaneus deformity (rigid foot).
- Weakness in transferred muscles, affecting gait and balance.
Long-Term Outlook (Prognosis)
The Bridle procedure is highly effective for improving foot function and walking ability. Most patients experience a reduction or elimination of the need for a brace, although full restoration of muscle strength and joint motion may not occur.
Out-of-Pocket Costs
Medicare
CPT Code 27691 – Bridle Procedure: $175.25
Medicare Part B covers 80% of the approved cost for this procedure once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover this remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans work alongside Medicare to fill the coverage gap.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining coinsurance or deductibles, which generally range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your bridle procedure is required due to a work-related injury, Workers’ Compensation will cover all medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved treatments.
No-Fault Insurance
If your injury and bridle procedure are related to an automobile accident, No-Fault Insurance will typically cover the full cost of your treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your policy.
Example
Ryan Brooks required the bridle procedure (CPT 27691) to address a severe ankle injury. His estimated Medicare out-of-pocket cost was $175.25. Since Ryan had supplemental insurance through AARP Medigap, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the surgery.
Frequently Asked Questions (FAQ)
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.
Summary and Takeaway
The Bridle procedure is a valuable option for treating foot drop caused by nerve injuries or neurological conditions. It provides significant improvements in walking ability and eliminates the need for braces, although it does not fully restore normal strength in the foot.
Clinical Insight & Recent Findings
A 2024 review in Orthopedic Reviews highlights that the Bridle procedure is one of the key surgical options for treating foot drop, especially when the cause is peroneal nerve palsy. The surgery combines tendon transfers of the tibialis posterior, peroneus longus, and tibialis anterior in a “tri-tendon” connection, aiming to restore balance in both upward motion and side-to-side alignment of the foot.
Clinical outcomes show most patients can dorsiflex past neutral and no longer need a brace, with high satisfaction rates even though strength and function may not return fully to normal.
The review emphasizes that while tendon transfers like the Bridle provide excellent results for flexible foot drop, rigid deformities may still require fusion procedures.(“Study on surgical options for foot drop, including the Bridle procedure – see PubMed.”)
Who Performs This Treatment? (Specialists and Team Involved)
The Bridle procedure is performed by orthopedic surgeons specializing in foot and ankle surgery. The surgical team may also include physical therapists and neurologists to assess pre- and post-operative function.
When to See a Specialist?
If you experience difficulty lifting the front of your foot (foot drop), it’s important to see an orthopedic surgeon or a specialist in neurological disorders to evaluate if surgical intervention is necessary.
When to Go to the Emergency Room?
Seek emergency care if you experience:
- Severe pain at the surgery site.
- Infection symptoms such as fever, redness, or swelling.
- Severe weakness in the foot or leg after surgery.
What Recovery Really Looks Like?
Recovery involves wearing a cast or walking boot for several weeks, followed by physical therapy to restore function. Patients typically return to normal activities within 3 to 6 months, but high-impact activities should be avoided until full healing.
What Happens If You Ignore It?
If foot drop is not addressed, it can lead to chronic walking difficulties, dependence on braces, and long-term muscle weakness, which could impair daily activities.
How to Prevent It?
Prevention includes:
- Proper management of conditions that can lead to foot drop, such as nerve injuries.
- Strengthening exercises for the foot and ankle muscles to prevent weakness.
- Early intervention with physical therapy if nerve damage is suspected.
Nutrition and Bone or Joint Health
Adequate calcium, vitamin D, and protein intake is essential for maintaining healthy bones and joints, which can support the recovery process after foot surgery.
Activity and Lifestyle Modifications
Post-surgery, patients should avoid high-impact activities until the foot heals. Gradually resuming physical activities, with the help of physical therapy, will restore strength and flexibility.
Dr. Mo Athar
