SECONDARY ALIMENTARY HYPERPARATHYROIDISM and its complications – our approach

logoDepartments “Metabolic and endocrine disorders” and “Orthopedics” – veterinary clinics “Dobro Hrumvane”, Sofia, Bulgaria

The alimentary secondary hyperparathyroidism is not so rare as many specialists think. For period of only 9 months we diagnosed in our clinics 17 cases and had serious observations in other 9 cases (the owners didn’t agree to prove 100 % in Laboklin) in different stages of the problem evaluating. We present below our treatment protocol and two concrete complicated cases – both with healed patients but one not operated – and our consequences experience in cases with or without surgery.

The hyperparathyroidism is primary and secondary. The secondary could be renal – complication of chronic renal insufficiency, it is more often seen even in comparison to the primary – and alimentary: rarest but for sure not exotic. The alimentary variant is seen in young dogs and especially cats fed only or almost only with meat.  The low calcium levels and the inadequate calcium/phosphor ratio in meat starts a multi-vector pathological process evaluating for a couple of weeks to following clinical picture: unwilling for moving, lameness, stiff walking, spontaneous fractures, face edemas, easily teeth removing or teeth loosening, spontaneous neurological deficit  in different levels. The standard hematological and biochemical blood panels usually do not give any diagnose direction. It is common the right diagnose to be reached with delay because often the colleagues miss during the anamnestic phase to become well informed about the alimentary regime of the patient, X-rays are rarely made in the very beginning and usually the therapy starts with NSAIDS and general strengthening protocol.

This disease not rarely causes hind legs function insufficiency and neurological deficit, paradoxally not corresponding to and many times exceeding the found through imaging diagnostic bone (including vertebral) changes. It is not exotic OCD (even in cats) to be diagnosed later due to cartilage underlying bone and bone vessels malformation.

Most directing is the anamneses especially the alimentary regime of the young patient. Absolutely enough for 90 % sure diagnose is combination of anamneses, estimation of the bone geometry and density due to X-rays covering flat bones, spinal cord, mandibula, maxilla and blood levels of macro elements especially P. For 100 % sure diagnose we send blood hormon sample to Laboklin Germany. The differential diagnoses are not many and include some genetic or metabolic disorders.

Our newest therapeutic protocol, product of enough clinical experience and leading to fastest and completest healing includes:

  • Hospitalization of the patient in cage for maximal immobilization aiming to avoid pathological fractures and especially vertebral fractures.
  • Diet change to P-poor and Ca-rich: the variants are so many, ii is important the diet to be diverse and with enough vitamins. In most of the cases we start with renal diet combined with additional food components;
  • Calo-pet – zero P molecules and very adequate composition for this problem;
  • NEO-K9: not only because of the demonstrative bone healing stimulation but also very adequate against all cases of hyperphosphatemia – and in cases of alimentary hyperparathyroidism we have severe hyperphosphatemia as well as serious bone demineralization and decrease of their potential for resistance to physical forces and for healing;
  • Ipakitine – because of its ability to chelate and eliminate the phosphor
  • HyalOral – because of its adequate to the therapy (especially against intra-joints complications) composition and especially because of the gamma-oryzanol inside
  • NSAIDS – against pain and inflammation
  • Calciferol (Vitamin D3) in dosage 2 ng/kg/24h– please be very careful when using it because increases the resorption of calcium but also of phosphor. Should be added to the protocol only after the phosphor is already in normal blood levels or very close to them;
  • Sometimes after careful individual estimation – oral pure Ca human product for children or even injectable Ca vet product;
  • Often repeated biochemical including P and Ca blood monitoring (a big Thank you! to our trusted lab VetDiaLab for the precise and reliable work during the last 15 years), every-day neurological monitoring and checking the ability for urination, every-day check for rib and long bone fractures and regular (minimum every 8-10 days) X-ray follow-up of the geometry and healing of all fissures and fractures;
  • Therapy against the complications including the spontaneous fractures, eating difficulties because of jaw problems ets.

This algorithm leads to very fast and demonstrative health status improvement. Of course it is very important to estimate carefully when the patient is ready to get out of the cage. We recommend the bone fissues to be X-ray monitored every 5-10 days and all long-bone fractures to be operated especially those near the knee joints. The reason?: the long-bone fractures caused by SAHPT heal very often with malunion which is being well tolerated by young animals but many of them suffer when achieve adult/mature age. On the other hand we recommend vertebral fractures to be operated only in case of neurological deficit or pain. In all cases of eating difficulties esofageal probe and not manual assisted eating is recommendable.

Case 1: cat Darko, SAHPT complicated with two supracondylar femural fractures, operated with delay. We added Calciferol to the therapy protocol at the 7th day when the blood phosphor decreased to normal levels. The owners asked us not to operate and to wait but as usual despide the cage rest after a couple of days the fragments geometry get worse and the healing would lead to malunion and may be to patellar luxation. The owners agreed to operate, the surgeries with implants of Mikromed were fast and simple (peri-operatively: Clavaseptin) and the case result is 100% healthy and extremely mobil cat:

pic 1 pic 2 pic 3 pic 4













Case two: cat Pisi, SAHPT complicated with fissure and fracture, not operated. The X-ray fissure (left humerus) follow up showed no need to operate and healed without problems. Unfortunately we didn’t receive permission to operate the fracture and as usual the result is serious malunion:

pic 5 pic 6


Conclusion: strict cage rest, strict food and therapeutical protocol, strict clinical and paraclinical monitoring and careful surgery estimation = successful outcome.

Tibial nerve peripheral nerve sheath tumor in dog



  1. Loncar, DVM1


    Dr Zoran Loncar

  2. Hadzic, DVM2

M.Dragomirov, DVM2

1,2 Department of Orthopedic Surgery and Neurology, Veterinary Clinic Novak, Belgrade, Serbia




An 8,5 years old miniature schnauzer dog was presented at the clinic with finding of right hind limb monoparesis and grade 1 lameness. CT diagnostic study was done but it was suggested that there was no visible lesions. MRI study shoved a lesion consistent with PNST. The dog was treated surgically and the tumor was excised completely with large margins. The dog recovered completely. The purpose of the article is to suggest that a lesion consisted with PNST distal to the stifle an elbow can be treated with large margins and very good motility of the limb afterwards. This type of pathology can be often missed with orthopedic conditions.



A 10 kg BW, 8,5 years old miniature schnauzer was presented at the clinic with owners complain of lameness on right hind limb for last five months.

At previous vet the dog was submitted to complete orthopedic, radiography and CT study with no diagnosis after the diagnostic workout. The dog was treated with 20 days of NSAID therapy (carprofen 2mg/kg BID 10 days and the dosage was reduced by half for the next 10 days). There was no improvement so the dog was treated with prednisolone for 20 days SID with again very little improvement.

The dog doesn’t have any important data in medical history.

At the presentation in our clinic:

During the walk dog showed grade one lameness.

zoran 2

CT STUDY , Fig 1 and 2

At the clinical examination the dog showed normal proprioception but reduced withdraw reflex on right hind limb.  During palpation region of gastrocnemius muscle was markedly painful. The rest of nurology and orthopedic examination was in within normal limits.

CT Study

Figure 1. and 2.

zoran 3


zoran 4


There is a focal dilation of a vascular structure, presumably a vein, caudal to the medial aspect of the right stifle. The vascular dilation/aneurism has a maximal diameter of 7.7 mm and extends over a distance of approximately 4 cm. Contrast filling of the dilated area is heterogeneous with some areas lacking contrast filling. The affected vessel is an anastomosis/branch between the caudal branches of the saphenous vein and the caudal proximal femoral vein.

MRI study:

Figure 3. T1+contrast: On the right limb at the level of tibial nerve there is a lesion with heterogeneous contrast intake in long contact with blood vessel. The lesion is 3 cm long in diameter.

Figure 4. T1+contrast: Lesion at the level of tibial nerve in close contact with saphenous vein and the caudal proximal femoral vein. Heterogeneous contrast intake.


zoran 1

Figure 5. Surgical field

The surgical approach was made from medial side at the level of proximal part of gastrocnemius muscle. The careful identification of blood supplies and nerve structure was needed. The healthy proximal and distal part of the nerve was identified and the excision with 3 cm margins has been done.

The dog was treated post operatively with antibiotics for 7 days (cephalexin 15mg/kg BID), fentanyl patch for 3 days, carprofen 2 mg/kg BID for 7 days, gabapentin since 3th day 20 days 10mg/kg TID.

Neurological exam has been done after 1,3,6 and 12 months. The only abnormal finding 6 and 12 months post op was longer ground phase during walk and reduced withdraw reflex.




Tibial nerve is in charged for the motor function of caudal aspect of tibia and fibula. Deficit in function shows clinical signs that look similar to orthopedic conditions. Ground phase is longer, calcaneus drops distally more than in contralateral limb. Sometimes we can see plantigrade stance. Orthopedic conditions similar to these in term of signs are pathology of Achill’s tendon and tarsus and metatarsus.

PNST if at the distal part of peripheral nerves can be treated with good outcome. The reasons are fewer functions that lead in less of dysfunction of the limb, and good surgical margins.  If PNST is localized at plexus or nerve root, 78% of dogs are going to be euthanized. The prognosis depends on localization and histopathology grading.




This article shows how close sometimes can be neurology and orthopedic clinical findings. Even if advanced imaging is available the cruciate information is localization of the lesion during the clinical examination. Further a right interpretation of images is necessary to define the lesion. PNST is an important differential diagnosis in investigation of distal extremities dysfunctions.


TTA cases , Dr Goran Tomisic from Belgrade, Serbia

big dog 3

Neapolitan mastiff

big dog 1

Neapolitan mastiff

In our experience most of the patients with TTA surgery are large breed dogs between 25-45kg. We heve  had experienced to work with gient dog (70kg  Neapolitan mastiff)big dog 2 and very small dog (6kg Poodle). 12966364_10209325595520597_1193906793_nFurthermore, the expectations before surgery were that the bigger dog will be a problem for setting the implants, but after both surgeries we were surprised how difficult was to set all implants into the smaller dog. Making the plane of  TTA surgery for small dog our biggest concern before the surgery of poodle was how we would cut the bone, but that part was easiest of the surgery.12966314_10209325898568173_2006959456_n12935231_10209325902128262_1630163835_n Placing the cage and screws was the real challenge. 12939598_10209325908008409_1471598489_n12966391_10209325905128337_1038654349_nThe toughest job was insert the fork into the TTA plate that took most of  the time of surgery. Overall, TTA would be the first chouse for ACL rupture in dogs.

Double plated TPLO in oversized dogs



Dr. Tsvetan Ivanov

Dr. Tsvetan Ivanov, “Dobro hrumvane!” veterinary clinics, Sofia, Bulgaria


The most common cause of rear limb lameness in the dog is rupture of the cranial (anterior) cruciate ligament. This derangement results in degenerative changes (osteoarthritis) in the stifle (knee) joint, including cartilage damage, osteophyte (bone spur) production, and meniscal injury. The Tibial Plateau Leveling Osteotomy (TPLO) has proven effective in returning these deranged stifles to full function.

Developed by Dr. Barclay Slocum, TPLO was a radical procedure for addressing canine ACL injuries. Now in existence for over 20 years, the surgery has proven itself, time and time again, to be an extremely effective long term solution for addressing cruciate ligament injury in dogs.

Part of the positive indications for TPLO are:

  • Bodyweight:

TPLO is most frequently performed in medium to giant breeds. Greater bodyweight is a positive indicator for selection of TPLO as a treatment option. The procedure can be performed and on small dogs and even cats, but then should be make exact discretion the potential benefits and complications.

  • Age:

Cruciate ligament degeneration is seen increasingly in young large breeds, in some cases within their first year.

Minimising osteoarthritis in the long term is a priority for these young dogs. Many surgeons believe that this leads to the TPLO being the technique of choice, although long term comparative studies continue to investigate this. These cases frequently show bilateral degeneration, and partial cruciate ruptures are common.

The procedure is good option for dogs over 6 months of age, with progression of ossification of proximal tibial growth plates.

  • Partial ligament rupture.

Cases of partial ligament rupture show a very rapid iprovement following TPLO. Importantly, they typically do not progress to complete ligament failure as TPLO acts to neutralise the forces on the cranial cruciate ligament.

TPLO is widely accepted to give the best functional outcome, in the short to medium term, and has enabled working/performance animals to return to high functional standards.

  • Excessively sloping tibial plateau:

Average plateau angles range from 22°-26°, but angles from 15° are still remain a TPLO candidate with good post-operative outcome. However, in cases with an increased tibial plateau angle, TPLO has proved particularly beneficial.

Case studies have advocated TPLO as the technique of choice for even small breeds with excessive tibial plateau slopes. In some of those cases the amount of angular correction required leads to a Wedge resection technique being favoured over the Slocum(curved-cut) TPLO.

  • Cranially translocated tibial crest.

Occasionally the stifle will rest with the tibia cranially translocated following cruciate rupture the tibial crest is  palpated cranially, the patella tendon is less distinct, and the first movement during cranial drawer is backwards, often associated with a dramatic degree of movement. In some authors experience these cases may return to cranial translocation with significant recurrence of lameness weeks after extracapsular lateral fabella suture placement. In those cases, in a limited number of procedures, TPLO have shown better outcomes.

Overall, the good TPLO candidate is medium to large breed dog, from 6 months and plus, active, with need of full functional restoration of the limb.

The Case:


This is the case of Hades. He is oversized cane corso, 6 years old, bodyweight is 78 kg and he suffers from hip arthrosis of the right hip in result of hip dysplasia and chondroma of right carpal bones. He came with lameness on the right rear limb from few weeks, which is worsening. He had and positive “sit and drawer tests.

This is video of his walk:

The diagnosis was cranial cruciate ligament rupture.65 6My favorite procedure is TPLO, but definitely no one can be sure that, the standard procedure can give good outcome with this size dog. Furthermore, the dog have and two other problems on the right side. We were afraid from implant failure so we decided to make insurance. Instead only the TPLO plate we placed and second DCP 3.5 mm plate. The original idea was to use 3.5 screws for the 2-nd plate, but because of the risk from caudal cortex fracture the most distal three screws was 2.7 mm




0 post op DP

Immediately postoperator

0 post op LL

Immediately postoperator

Those are intraoperative pictures and the immediately post-op pictures:








Video 14 day after the surgery:


X-ray pictures 45 days after the surgery:

45 dni post op - LL

45 days post op – LL

45 dni post op

45 days post operator

And this is the final result – 6 months after the surgery:

240 days post op

240 days post op




The TPLO remains one of the best surgically ways to manage CrCrLR even in oversized dogs, even with concomitant diseases of the locomotor system.

The most important thing is every surgeon to make optimal assessment of the patient’s status and to remember that every case is specific.

TTA surgery for Cranial Cruciate ligament rupture

Vet Tommy



Belgrade, Serbia

Surgery specialist DVM Goran Tomišić



TTA surgery for Cranial Cruciate ligament rupture



TTA surgery for Cranial Cruciate ligament rupture

Medical history


TTA surgery for Cranial Cruciate ligament rupture


TTA surgery for Cranial Cruciate ligament rupture


TTA surgery for Cranial Cruciate ligament rupture


TTA surgery for Cranial Cruciate ligament rupture


TTA surgery for Cranial Cruciate ligament rupture


TTA surgery for Cranial Cruciate ligament rupture


TTA surgery for Cranial Cruciate ligament rupture

Dog , Golden Retriever 4 year old,  29 kg weight, was presented to the clinic with chronic pain and lameness in his left hind limb. Beside that the dog was perfectly healthy.  During the orthopedic examination in sedation, there are persistent sign of drawers  which is the most important sing of Cranial Cruciate  Rupture. On  X- ray  was no osteoarthritis founded. During the preparation for the surgery, measures of the knee were taken from the same  X-ray. Measuring for this procedure must be precise and it’s done with help of special equipment.



Surgical treatment


During the surgery dog was placed in left lateral position, and approach on the knee was from medial side. After exposing the tibial  bone markers were placed  into the tibial crista. Afterwards,  precise cut was performed with special saw to cut of the tibial crista, on that  site the titanium plate was placed with fork. Next step during the surgery is placing a cage into the space between tibial crista and other part of tibial bone  screwing  it with screws. When everything was stabile it was irrigated and closed.


Postoperative treatment

User comments

TTA surgery for Cranial Cruciate ligament rupture


The dog that we operated was necessary to be under restriction  as much as possible minimum two weeks. After only 24h dog was touching ground with operated leg, but he was on restricted walks for two weeks because of his temperament. There was no postoperative complications, one month later  dog was using his leg practically normal, but he was still under the supervision  of the owner.


Traumatic cranial cruciate ligament rupture combined with either medial or lateral collateral ligament rupture in two dogs. Surgical stabilisation of the stifle joint using tibial tuberosity advancement and collateral ligament prosthesis


Dr Svetoslav Hristov

Dr Svetoslav Hristov

United  Veterinary Clinic in Varna, Bulgaria

Multiple ligament knee injury is rare in dogs but more common in cats. Cranial cruciate ligament rupture in dogs is considered to be mainly degenerative in origin rather than primary traumatic which is opposite compared to humans. In the followed two cases there were no signs of preexisting degenerative changes in the stifle joint and they were considered as primary traumatic. In dogs statistically injury to the medial collateral ligament is more common than an injury to the lateral one. Only third degree and some second degree collateral ligament injury leads to stifle joint instability and requires surgery.

Anatomical notes

The main ligamentous support in the stifle joint is provided by four femorotibial ligaments – two cruciate ligaments and two collateral ligaments.


fig 1

unnamed (3)

fig 2

The lateral collateral ligament in the stifle joint has an insertion points on the lateral.
The cranial cruciate ligament mainly prevents from cranial tibial translation with respect to the femur , hyperextension and excessive internal rotation in the stifle joint
epicondyle of the femur and the proximal part of the fibula with some fibbers also attaching on the lateral tibial condyle (fig.1) . The medial collateral ligament has proximal insertion point on the medial epicondyle of the femur and broad distal insertion point on the caudomedial aspect of the proximal tibia (fig.2) . Some part of the ligament also blends with the joint capsule and has an attachment to the periphery of the medial meniscus. To summarise, the lateral collateral ligament is more loosed, superficially positioned and is taut only in the knee in extension. With the stifle joint in flexion the lateral collateral ligament relaxes which allows axial internal rotation inside the joint which is known as “screw home mechanism”. With the knee in extension, both collateral ligaments are taut preventing from excessive internal or external rotation.

The cranial cruciate ligament mainly prevents from cranial tibial translation with respect to the femur , hyperextension and excessive internal rotation in the stifle joint.


18 months male Drahthaar, weighting 32 kg with unknown trauma during hunting. Dog was presented a few hours after the trauma fully non weight bearing with the left hind limb. During physical examination an obvious cranial to caudal instability (positive drawer test) and lateral collateral instability (positive varus test) were detected. Medial to lateral and posterior to anterior radiographs were taken. There were no signs of preexisting degenerative joint disease. The dog was scheduled next day for a surgical stabilisation of the lateral collateral ligament, exploratory arthrotomy and tibial tuberosity advancement for the failed cranial cruciate ligament. After lateral parapatellar approach, the cranial cruciate ligament rupture was confirmed and the remnants were removed. No other intraarticular structures were visibly injured. By retracting the biceps muscle caudally, a mid substance tear of  the lateral collateral ligament was discovered. Both parts of the ligament were sutured using a locking-loop suture pattern (Kesler type). For additional stability, the suture was protected by figure-eight 80# leader nylon positioned at the collate.
Tibial tuberosity advancement we performed as a second stage of the surgery after medial approach to the proximal tibia. Based on the preoperative measurements using the common tangent method a 12 mm cage was used for the tibial crest advancement
ral ligament attachments. The prosthetic ligament were fixed to the femoral condyle using a bone anchor and passed through a bone tunnel in the fibular head. Both ends of the new ligament were tightened using a dedicated spreadand crimped by  with the joint in extension.unnamedunnamed (1)unnamed (2)



Dog #2


A female mixed breed dog, 4 years old, 12 kg was presented not able to walk after car accident. Fracture of the left humerus was suspected and confirmed by a radiography. Rupture of the urinary bladder was suspected during an abdominal ultrasound and confirmed by a contrast bladder radiographic study. On physical examination a cranial drawer and positive valgus test were noticed on the right knee. Rupture of the medial collateral ligament was confirmed also by stress anterior posterior radiography. On the medial lateral radiograph there were no signs of previous degenerative changes in the stifle joint.

Tie-in external skeletal fixator was used for stabilisation of the midshaft humerus fracture during the first surgery performed together with a laparotomy for suturing of the ruptured urinary bladder. A second surgery was performed for the stifle joint consisting of medial collateral ligament repair and tibial tuberosity transposition. After medial approach to the stifle joint and the proximal tibia, medial arthrotomy confirmed cranial cruciate ligament rupture. No other intraarticular structures were visibly injured. Retracting the caudal part of the sartorius muscle revealed a rupture of the medial collateral ligament close to its insertion on the medial tibial condyle. Because the tear was so severe, a primary reposition of the ligaments was not possible. 40# leader nylon in figure of eight suture was anchored at the medial collateral ligament attachments around two 2.7mm cortical screws and metal washers to prevent suture slippag Tibial tuberosity advancement was performed as a second stage during the surgery. Based on the preoperative measurements using the common tangent method a 7.5 mm cage was used for the tibial crest advancement.

Early postoperative period in both dogs passed without complications. About 10 days after surgery dog #2 was diagnosed also with grade II medial patella luxation in the operated knee and another surgery was performed next. Only this dog was followed for a few monunnamed (4)unnamed (1)unnamedths after surgery when the external fixator from the humerus was removed. The dog recovered to a fully weight bearing with his right hind limb.


Failure of both the cranial cruciate and the collateral ligament support will result in pain, rapid osteoarthritis progression  and impaired limb function.

The complexity of multiple ligament injury makes the palpation of the joint a bit confusing and could leads to mistakes in diagnosis of cranial vs caudal cruciate ligament rupture. Also because of the possibility of another damaged intra articular structures, an arthrotomy always has to be performed. Collateral ligament injury was first addressed in both cases followed by tibial tuberosity advancement for the failed cranial cruciate ligament. Tibial tuberosity advancement is one of the so called geometry modified procedures in cranial cruciate ligament rupture treatment and seems to be a better choice in cases when also a medial collateral ligament is ruptured. In such a cases positioning of implants (like TPLO plate) on the proximomedial aspect of the tibia will be challenging.




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