ACL Tear Bulldogs French Bulldogs
ACL Tear Bulldogs French Bulldogs (Anterior Cruciate Ligament)
ACL Tear Bulldogs French Bulldogs is the most common orthopedic injury I see in my bulldog practice. The English Bulldog, French Bulldog puppy, and American Bulldog knees are stabilized by four primary ligaments: the medial and lateral collateral ligaments, the anterior cruciate ligament (ACL), and the posterior cruciate ligament ( PCL).
ACL Tear in Bulldogs French Bulldogs TRIPPLE FUNCTION:
The function of the ACL in bulldog is threefold:
- TIBIAL THRUST: The first and most significant function is to prevent the forward thrust of the tibia
- INTERNAL ROTATION: Second, the ACL limits internal rotation of the tibia.
- HYPER EXTENSION: Finally, the anterior cruciate ligament in bulldogs also prevents the hyper-extension of the knee joint (stifle).
*Note: ACL (anterior cruciate ligament) is a human anatomical term, while CrCL (Cranial Cruciate Ligament) is the dog equivalent. In this article, I will use the terms interchangeably
ACL tear in Bulldog and French Bulldog puppies can happen as early as 6 months of age.
ACL tear in Bulldogs French Bulldogs CAR ANALOGY:
While canine and human knee anatomies are very similar, our bio-mechanics differ greatly. Start by looking at the differences in posture: we stand heels on the ground and our knees are essentially straight during weight-bearing. Contrast that with your bulldog, who stand hocks/ankle elevated, with their knees bent during weight-bearing. The significance of this difference is that there are different force vectors in the canine knee than in the human knee.
In a normal bulldog knee, this shearing force is counteracted by the large muscles of the leg, notably the quadriceps group and hamstrings. However, in situations where the leg muscles are unable to resist this shear, all that is left as the last line of defense, Mother Nature’s “emergency brake” if you will, the ACL.
LOADED KNEE: In contrast to us humans, your bulldog puppy is born with a knee that has a slight degree of flexion, this flexed knee position is normal to a four-legged pet. Because of this anatomical bending, and natural sloped knee, your bulldog puppy ACL is always load, meaning it always has tension/stress on it. To demonstrate the knee bio-mechanics, think of two parked cars one on a flat street and the other on a steep slope :
- “CAR MODEL: BULLDOG” that car model representing your bulldog puppy knee at rest is parked facing uphill with the brakes and hand-cable (the “car ACL” loaded ) stretched to the limit as it holds against the downhill roll representing a normal healthy at rest bulldog knee.
- “CAR MODEL: HUMAN: The second car model represents your knee which at rest is like a car parked on a flat road with the brake cable under no tension (the “car ACL” unloaded) representing a normal healthy at rest human knee.
ACL tear in Bulldogs French Bulldogs HUMAN VS DOG:
HUMANS / TRAUMATIC / ACUTE: Humans have a relatively level tibial plateau: about a four-degree (4) tibial plateau angle (TPA) thus almost all human ACL tears are traumatic and due to an acute athletic injury.
BULLDOGS / STRESS /CHRONIC: in contrast to human’s 4 degrees TPA, bulldogs TPA’s are 25 to 30. Therefore tears are typically due to chronic biomechanical stress caused by the downward sloping of the tibial plateau. It is why bulldogs and bulldog puppies with untreated ACL tears usually do poorly in comparison with humans.
TIBIAL THRUST: Because your bulldog knee tibial plateau is naturally sloped, there is a force that transmits a forward motion to the tibia. This force is called ‘Cranial Tibial Thrust’, (better known as “draw” even though they are not exactly the same) and is one in which the anterior cruciate ligament is countering by preventing this natural forward motion of the tibia and backward motion of the femur.
ACL Tear Bulldogs French Bulldogs PRESENTATION:
PAIN & LIMP:
- TIBIAL RUB: Pain is inflicted when your bulldog femur rubs the tibia as it slides backward.
- MENISCUS INJURY: Pain is compounded if a meniscus injury occurred. The meniscus is a cushion between the two bones that acts as a shock absorber that could suffer injury generated by the sliding femoral bone. Once again, imagine your “BULLDOG CAR” facing uphill but this time, add a wooden block as safety behind the back wheel of the car. Now, imagine that the cable-brake (“your bulldog puppy ACL”) suddenly snaps, placing all the car’s weight on that safety wooden block (“your bulldog puppy menisci”), you can see how that can inflict injury usually in a form of a tear to the medial (inner) menisci.
Meniscal tear is often accompanied by a “click” that can be heard when your bulldog walks.
50% of bulldogdogs with ACL injuries, will present with an injured menisci cartilage.
LIMP: ACL tears usually present with a limp while raptures compounded by menisci tear will toe touch or will not bear any weight on that injured leg
Dr. Kraemer’s V4B ACL Tear Bulldogs French Bulldogs PREVENTIVE & MAINTENACE:
WEIGHT CONTROL: Keep your bulldog puppy in shape, keep him/her toned and keep him/her lean. Inactive bulldog will have weaker muscular support and poorer muscle function critical to help and “protect” the ACL. Bulldog obesity also increases the weight load on the knee, thus intensifying the ACL daily wear and tear.
SUPPLEMENTS: In addition to weight control I also recommend that you keep your bulldog and French Bulldog puppies on joint and pain control supplements like:
- Dr. Kraemer’s V4B Bully Total Joint for Advance Formula to help heal and replace the joint periarticular cartilage
- Dr. Kraemer’s V4B Bully Comfort Aid Formula to help manage pain and discomfort
- Dr. Kraemer’s V4B Bulldog Fish Oil Joint-Immune- Skin. to help reduce inflammation
RX: for pain and inflammation such as NSAID’s (non-steroidal anti-inflammatories) and analgesics
Dr. Kraemer’s V4B ACL Tear Bulldogs French Bulldogs RULE OF THUMB:
When the Anterior Cruciate Ligament tears or ruptures surgical repair is recommended and performed by a skilled, experienced surgeon. Nevertheless, much of the successful outcome depends on owner compliance.
ACL Tear in Bulldogs French Bulldogs TREATMENT /SURGICAL REPAIR:
Bulldog and French Bulldog ACL tear surgery goals are to stabilize the knee joint and do so early to minimize DJD ( Degenerative Joint Disease, Bulldog Arthritis,). A variety of repair methods have been used and they can be divided into static repairs, which attempt to replace the function of your bulldog ACL, and dynamic repairs, which alter the knee biomechanics to absolve the need for a functioning ACL.
STATIC REPAIR: Static repairs include intracapsular grafting techniques, extracapsular lateral suture techniques, tight rope, and fibular head advancement.
DYNAMIC REPAIR: Dynamic repairs involve neutralization of cranial tibial thrust (or cranial drawer) as the primary goal. The two current dynamic repair techniques addressing the underlying biomechanical instability in a canine ACL tear are the tibial plateau leveling osteotomy (TPLO) and the tibial tuberosity advancement (TTA).
The TPLO which changes the angle of the tibial plateau has been popular for over a decade and is considered the gold standard for bulldogs. The TTA is a technique that changes the relationship of the patellar tendon and tibial plateau angle via an osteotomy (bone cut)
SURGERY REPAIR SURGEON TIP: When it comes to choosing TPLO vs. TTA, many of you are confused. First, you should know that not just any veterinarian can perform either of these procedures. In order to truly master these surgical techniques, extensive training is required. Second, within the veterinary profession, even to date, there is still constant debate about which surgical procedure is the best overall. One veterinary surgeon may say one thing and another may have a completely different opinion. Naturally, when a surgeon is heavily invested in one technique, he or she is likely to favor it over the other, thus in his or her mind, it is the “superior method” despite the obvious bias.
In general, all things being equal, in the right hands, they are both excellent surgical choices. The surgeon’s skill and experience in executing their chosen technique to perfection are what counts the most.
TPLO (Tibia Plato Leveling Osteotomy) is my preferred surgical choice for ACL tears in bulldogs and is considered the gold standard by most orthopedic surgeons.
Dr. Kraemer’s V4B ACL Tear Bulldogs French Bulldogs TIPS & WARNINGS:
ACL Tear Bulldog and French Bulldog Tip #1 STEM CELL THERAPY & CRYOBANING: In Dr. K’raemer’s offers a state-of-the-art therapeutic treatment called stem cell therapy. When combined with surgery the cost is dramatically reduced. In addition, other joints and medical conditions can be treated simultaneously. Last, as an additional benefit we almost always also cryobank some pet stem cells for future medical and surgical needs.
I am often asked if stem cell therapy is a good noninvasive alternative to ACL tear surgery repair. In general, my answer is “NO” because the treatment does not fix the biomechanical problems. Nevertheless, on many occasions, I recommended and performed stem cell therapy in combination with surgery to improve healing, range of motion, and osteoarthritis, as well as to try and save the opposite side from tearing (it is my experience that about 50% of bully’s will have the other knee torn within one year.). In addition, we almost always also cryobank some of our client pet’s stem cells for future medical and surgical needs. Last, most of the better pet insurance companies now cover stem cell therapy for pets.
It is my experience that about 50% of bulldogs will have the other knee torn within one year.
There are exceptions to the rule, and on special occasions, I have treated dogs with ACL tears non-surgically with stem cell therapy alone. Sometimes owners refuse surgery due to the dog’s advanced age, the risk of prolonged anesthesia, cost, the long post-op confinement, and the long road to recovery (3-4 months). Other cases where we will consider substituting stem cell therapy for surgery is for dogs suffering from multiple orthopedic problems in addition to the ACL tear, such as elbow dyspepsia, bad hip, bad arthritic hocks (Tarsal or Ankle Joint, etc.), especially in mid-age and older dogs. In those cases, surgical repair of only one problem might not make sense. In contrast to surgery, Stem Cell Therapy can provide pain relief for multiple injuries at once, with minimal anesthesia and minimal post-surgery down time all at a relatively low cost. Plus the stem cells can be cryobank for additional future treatments
ACL Tear in Bulldog and French Bulldog Tip #2 PRP: Most of my pets, dog, and cats, orthopedic surgical cases also receive PRP (Platelet Rich Plasma) during surgery via direct injection to their joins. When it is done in conjunction with a surgical procedure the cost is minimal and the benefits are widely known both (for pets and humans)
Tip #3 PAIN & LAMENESS: Pain and lameness with bulldog ACL injury are due to the instability of the stifle joint and the inflammation. The stretching of the joint capsule initiates a cascade of events, including cartilage degradation, and degenerative joint disease which all contribute to the pain and lameness.
Tip #4 MENISCUS: Often your bulldog pain is exacerbated when the medial meniscus becomes crushed under the medial femoral condyle when the tibia is drawn forward and the femur slides backward during cranial tibial thrust.
Tip #5 POSITIVE SEAT TEST: Bulldogs and other dogs with a CrCL injury and a subtle lameness may exhibit a shortened stride and a somewhat extended stifle. The normal limb will appear to land harder on the ground. Pay attention to how the dog seats. The dog may seat with the leg extended and out to the side. This is known as the “positive seat test”.
Tip #6 INNER ROTATION: In addition to the forward thrust, your bulldog ACL also prevents inner rotation of the tibia which might be the reason why ACL tears are so common in bulldogs and bulldog puppies. Bulldogs have an excessive weight load resting on the inner part of the tibia due to the unsully combination of a relatively heavyweight and large body, short axial bones, and broad angulated stance.
Tip #7 TIBIAL LOAD: Almost all bulldogs have some degree of hip dyspepsia and/or Medial Patella Luxation. Those two orthopedic conditions will affect your bulldog quadriceps, gastroc (calf), and hamstrings muscles, shorting and contracting them, which further contribute to that inner tibial load.
Tip #8 TIBIAL NOTCH: It is my conclusion that the bulldog’s knee’s tibial femoral space is different than other breeds. This finding has been confirmed with my orthopedic surgeon, Dr. Paul Cechner, Diplomate A.C.V.S. who has been operating on a dog’s knees for over 40 years and on my bulldog patient’s knees for a decade. We HAVE observed a narrowing in the bulldog’s tibial femoral space (notch) in the inner part of the joint at the ACL attachment, which leaves very little wiggle room for the ligament and might add additional wear and tear and the greater possibility for rupture or partial tears.
Tip #9 MEDIAL BUTTRESS: Some bulldogs form a bump on the inner aspect of their knee, which is a fibrotic response to stifle instability.
Tip #10 RADIOGRAPHS: Radiographs are very helpful in diagnosing bulldogs ACL tears and rupture. In some instances, the radiograph will actually catch the joint in this slipped/draw position. Other common radiographic findings are joint effusion (fluid) and evidence of osteoarthritis.
Tip #11 ACL RAPTURE: In my practice, the most common presentation of an ACL injury is a dog that has a history of acute onset hind limb lameness with some improvement while on pain management medication and rest, followed by recent worsening of the lameness. These dogs may have had a partial tear that improved with rest, and then went on to re-injure or fully rupture.
Tip #12 HYPEREXTENSION: Most bulldogs experiencing an ACL rupture or partial tear are painful when the tibial thrust maneuver is preformed and/or the stifle is placed in hyperextension.
ACL Tear Bulldogs French Bulldogs Tip #13 TPLO: I rarely recommend static repairs that attempt to replace the function of the ACL but fail to address the biomechanical problems.
TPLO repair (Tibial Plato Leveling Osteotomy) is our preferred surgical repair method.
The philosophy behind TPLO surgery is to completely change the dynamics of the dog’s knee so that the torn ligament becomes irrelevant to the knee stability. The TPLO completely alters the dynamics of the knee by neutralizing the effect of the forward tibial thrust. Once the tibia is cut and rotated the femur can no longer slide backward and the knee is immediately stabilized. Menisci injuries in bulldogs are also corrected during the surgery.
ACL Injury in Bulldog and French Bulldog Tip #14 SURGEON: When choosing between TPLO and TTA depends on the degree of the tibial sloop, tibial plateau, the health of the patella and patella ligament. The dog’s general anatomy, degree of osteoarthritis, and age should all be taken into account. But most importantly is the surgeon’s experience with the elected procedure.
Tip #15 COST: The cost of TPLO surgery in dogs varies depending on the region and who is performing the surgery.
Tip #16 STRESS INJURY: A bulldog puppy suffering from an ACL injury might have just a subtle limp that turned into a sudden acute non-weight bearing lameness. However, unlike humans, the injury is rarely of a purely traumatic etiology.
Tip #17 PARTIAL TEAR: Partial ACL tear in bulldog puppies is not uncommon. In some cases, a complete tear of only one portion of the ligament may occur. Due to the degenerative nature of most ACL ruptures, a significant proportion of bulldogs will proceed to a full tear.
Tip #18 LASER THERAPY: All my orthopedic surgeries including Bulldog ACL tears are treated post-op with class 4 cold laser therapy to reduce pain and enhance healing.
Tip #19 tPEMT: All our bulldog ACL surgeries and other orthopedic surgeries are sent home post-op with pain management medication (NASID and other Analgesics). In many cases, we also send our post-op surgical cases such as Bulldog TPLO for ACL tear with PEMT loop, a nonpharmacological safe device that enhances healing, reduced inflammation, and improves pain control.
ACL Tear Bulldogs French Bulldogs WARNINGS
ACL Tear Bulldogs French Bulldogs Warning #1 BULLY OSTEOARTHRITIS: When left untreated, ACL injuries in dogs almost always lead to progressive osteoarthritis, a lifelong, debilitating, chronic painful condition. Frequently, untreated ACL injuries will also lead to uneven weight bearing, forcing overcompensation of other legs and joints, with the contralateral knee enduring most of the extra load, thus increasing the chances of additional injuries and an ACL tear on the opposite knee.
Warning #2 BRACES: Bulldog and French bulldog stifle anatomy and biomechanics differ from humans, misunderstanding has resulted in many misconceptions by the pet-owning public. Non-surgical treatments are usually unsuccessful in bulldogs ACL tears due to chronic biomechanical stress.
Your bulldog puppy tibial plateau slope and joint biomechanics is why braces are relatively ineffective.
Warning #3 TPLO: The bulldog puppy tibial slope and resulting sliding action are why most orthopedic veterinary surgeons have abandoned old-style static replacement procedures in favor of dynamic ones like TPLO and TTA.
Again, this is in sharp contrast to human orthopedics where replacement with a biological graft is the standard.
Warning #4 LIMP: Bulldog CrCL injury should be suspected and ruled out in any case of hind-limb lameness. Affected dogs may have a variety of presentations, probably due to the multifactorial nature of the disease. Your bulldog puppy may be non-weight bearing, partially-weight bearing, or occasionally non-ambulatory with this injury.
Warning#5: Some dogs present with a mild, chronic lameness and may have only a partial CrCL rupture, with minimal effusion and no osteoarthritis visible on radiographs. These dogs may have no cranial drawer sign but will exhibit discomfort and pain when the tibial trust maneuver is performed due to the crashing of the inner menisci when the stifle is placed in hyperextension.
Warning#6 OTHER PROBLEMS: Less commonly, some bulldogs may present acutely non-ambulatory, or with difficulty rising, or with shifting leg lameness. They are often diagnosed erroneously as a neurological case (disc disease, bulldog malformation, etc). To make things more challenging, these patients sometimes have concurrent hip dysplasia, DJD, and lumbosacral disease.
A proper orthopedic and neurological exam can differentiate a CrCL tear from bulldog back disease
Warning# 7 RADIOGRAPHS: both your French Bulldog legs should be examined and radiographed. Very often the opposite side is also injured due to overcompensation. I usually start my physical exam with the “good” leg to allow your bully to relax and get an idea of what baseline responses are. I begin by flexing and extending the joint to assess the range of motion, crepitus, or clicking noise, then I check for a tibial thrust and draw. Some bulldog ACL injury may have a diminished range of motion due to fibrosis, pain, or effusion. Crepitus can be consistent with degenerative joint disease (osteoarthritis).
A palpable or audible click may indicate a meniscal tear.
Warning #8 DRAW SIGN: If no drawer is palpated in your bulldog, but CrCL injury is still suspected, the cranial drawer should be re-evaluated under sedation because they are resisting palpation with their leg muscles, or/and they have significant fibrosis which has stabilized the stifle. Lack of drawer sign in your bulldog knee can also be due to a partial ligament tear and the remaining intact ligament resisting gross displacement.
Warning #9 MPL: many bulldogs have MPL (medial/inner patella laxation) prior, or in addition to ACL injuries. These two conditions can be interwoven since many patients with an MPL have medial rotation of the tibial crest, which puts continuous tension on the ACL. This is thought to predispose the tearing of the ACL.
In addition, chronic osteoarthritis, present in the stifles of bulldog puppies with MPL will initiate an enzymatic environment that can lead to degradation of the ACL.
Last, rupture of the ACL tends to make the degree of patellar luxation worse, because a restraint on the inward rotation of the tibia has been lost and because of the cranial displacement of the tibia during weight-bearing moves the insertion of the patellar tendon, thus “lifting” the patella out of the trochlear groove and facilitating luxation.
Warning #10 X-RAY: Even in cases that a clear diagnosis of your bulldog CrCL rupture is made in the exam room, radiographic examination of the joints and hips is required. Radiographs are used to rule out concurrent diseases and secondary signs of CrCL rupture, primarily joint effusion with fat pad displacement, and evidence of degenerative joint disease (DJD). The degree of DJD may be an indicator of prognosis, as dogs with minor degenerative changes probably have a better prognosis for long-term function than do those with advanced osteoarthritis. Last, in cases without positive cranial drawer or trust, these give support to the diagnosis
Warning #11 ACUTE BILATERAL ACL: Acute bilateral ACL ruptures (i.e. both ACL tear at once) are rare but when present erroneously diagnosed as a neurological condition, such as degenerative myelopathy or herniation of an intervertebral disc. A bulldog with acute bilateral ACL rapture will have great difficulty rising and may appear to have hind limb paresis.
ACL Tear in Bulldog and French Bulldog Warning #12 STEROIDS: I don’t recommend treating bulldog ACL injuries with long-term cortisone (prednisone) due to the steroid effects on cartilage and healing as well as other adverse effects it’s known for.
“An Ounce of PREVENTION is Worth a Pound of CURE”