How is the Bridle procedure performed in the treatment of foot drop?

Updated: Mar 23, 2020
  • Author: James W Pritchett, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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A popular approach to tendon-to-bone attachment is the Bridle procedure, a modification of the Riordan technique described by Rodriguez. [26] This procedure involves insertion of the PTT into the second cuneiform bone, combined with anastomosis of the PTT transfer to the anterior tibial tendon (ATT) and a rerouted peroneus longus tendon in front of the lateral malleolus to balance the foot in dorsiflexion.

The Bridle procedure makes use of five incisions (see the first image below). The PTT insertion is secured through incision 1 on the medial foot. Incision 2 is used to retrieve the end of the PTT proximal to the tarsal canal into the posterior compartment of the leg (see the second image below).

Incisions for Bridle procedure. Incisions for Bridle procedure.
Posterior leg with retrieved posterior tibial tend Posterior leg with retrieved posterior tibial tendon above ankle. Window in interosseous membrane is labeled with X.

Incision 3, on the anterior leg proximal to the ankle, provides wide exposure of the interosseous membrane. The PTT is pulled through the interosseous membrane and a longitudinally split ATT, then into the anterior compartment between the tibia and the ATT. The PTT is anastomosed to the ATT with the foot in full dorsiflexion (see the image below).

Posterior tibial tendon (C) is pulled through slit Posterior tibial tendon (C) is pulled through slit in anterior tibial tendon (A) and inserted into second cuneiform. Posterior tibial tendon is anastomosed to anterior tibial tendon and distal stump of peroneus longus (B) that has been rerouted anterior to lateral malleolus.

Incision 4, posterior to the lateral malleolus, accesses the peroneus longus and brevis tendons proximal to the lateral retinaculum. The peroneus longus is transected about 5 cm proximal to the tip of the lateral malleolus. The distal transected end of the peroneus longus is retrieved into the foot distal to the superior and inferior peroneal retinaculum, then transposed via a direct subcutaneous tunnel that is anterior to the lateral malleolus. The proximal end of the transected peroneus longus is anastomosed to the peroneus brevis tendon.

Incision 5 accesses the distal stump of the PTT as it is brought to the dorsum of the foot via a subcutaneous tunnel. Here, the tendon is secured to the second cuneiform bone while full dorsiflexion of the foot is maintained. Ideally, if the tendon has sufficient length, it should be anastomosed to itself through a tunnel in the second cuneiform bone. If this is not feasible, the tendon may be secured to the bone with sutures or tunneled through and secured with a button.

In a study comparing 19 patients with foot drop who underwent the Bridle procedure with 10 matched control subjects, Johnson et al found that although the procedure did not restore foot and ankle strength and balance to normal, it was successful in that patients with a functional posterior tibial muscle had significantly better outcomes and were able to discontinue using an AFO. [27] All of the Bridle-procedure patients had good-to-excellent outcomes and stated that they would undergo the operation again.

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