Endocrine Surgery

Neuroosteoarthropathy is a rare, but devastating complication affecting patients with peripheral neuropathy. It is a progressive, destructive condition that is characterised by progressive bone and joint deterioration of the foot leading to permanent incapacity. Nowadays, diabetes mellitus is by far the most common etiology of CNO (Charcot neuro-osteoarthropathy), especially if it affects the foot or ankle.

The cause of the condition is still controversial among experts. In particular, new data have emerged on the central role of RANK/RANKL/OPG in the pathogenesis of this complication, also known as Charcot foot. No pharmacological methods of therapy have proven effective to date. Very little progress has been made in treating this condition since the days of Jean-Martin Charcot. Today, the universally accepted treatment involves completely relieving pressure from the limb using a polymer retaining bandage. The aim of this review is to analyze research into the pathogenesis of CNO and our potential to better understand the nature of this condition.

Particular attention is paid to modern concept of neuroosteopathology, according to which neuropathy is crucial to developing acute osseous pathology. Revealing new aspects of CNO pathogenesis can help extend therapeutic resources for treating this patient group.

Diabetic foot ulcer (DFU) is not only type of ulcers which can affect lower extremities of patients with diabetes mellitus (DM). The second common type is leg ulcer (LU). These ulcers may appear not only as classic ones – a result of venous diseases, but also result of some degree of leg ischemia in combination with several additional factors. Some diabetic foot outpatient clinics (DFOC) have experience with treatment of such ulcers.

Aim of our study was to analyze main characteristics of patients with diabetes and LU treated in DFOC, results of their treatment and possible reasons for treatment of this group in the DFOCs.

Object and methods

All patients with diabetes and LU of any etiology (venous, posttraumatic, mixed) treated in our DFOC from July 2007 to June 2012 were included in our study (n = 101, main group). All patients with DFU treated in the same DFOC in this time frame (n = 721) formed the control group. Follow-up data was observed from medical records or by phone calls. Follow-up time was between 6 mo and 2.5 yrs. 

Results

Most of patients with LU were females (71%) and had type 2 DM. More frequent wound infection, higher median wound surface, lower depth and very rare involvement of deep tissues (phlegmone and osteomyelitis) were characteristic for LU group. There were not significant difference (p > 0.05) between groups in terms of diabetes duration, type 2 DM treatment methods, rate of DM complications and concomitant diseases and HbA1c level. At follow-up contact time ulcers healed in 64% in LU group and 65% of DFU group (р > 0.05). More LUs stayed unhealed at this time than DFUs (13% vs 5%, р = 0.013). Minor amputations were made in 0% in LU group and in 5% in DFU group (p = 0.039), but major amputations rate was not significantly different between groups (4% vs 6%, p > 0.05). Mortality was not also significantly different between groups (p > 0.05).

Conclusions

1. Leg ulcer population of the DFOC is mainly female and has type 2 DM;
2. LUs healed during follow-up in 64% patients but stayed unhealed in 13% and leaded to major amputation in 4%;
3. Amputation prevention programs in patients with diabetes should take into account that at least 10% of major amputations in these patients are a result of LU;
4. Epidemiological studies are necessary to assess prevalence of LU and LU-related amputations in whole diabetic population;
5. Treatment of LU in patients with diabetes should be as careful as of DFU and DFOC is optimal setting for it.

Introduction

Thyroid cancer (TC) is the most often malignant tumor in childhood and made 1.5 – 3.0% of all children population or 45.3% of pediatric endocrine epithelial cancers. A lot of questions concerning to volume of thyroid surgery, postoperative radio iodine therapy (RIT) needs to be discussed.

Aim

Estimation of childhood sporadic thyroid cancer specificity and comparison of children and adolescents treatment in Saint-Petersburg Endocrine Surgery Center (Russia) and Mayo Clinic (USA).

Material and methods

During 1970 –2011 in the Saint-Petersburg Center (1 group) were operated 105 TC children and adolescent (up to 20 yeas) and in Mayo Clinic – 188 (2 group) in  1940 – 2000 period. Since of 80-s in those clinics were used the same perioperative examinations, like TSH, T4, T3 blood levels, USG, fine needles aspiration biopsy, CT and morphological examinations.

Results and discussion

Average age of the Saint-Petersburg Center and Rochester patients was the same and achieve 16.3±0.3 and 16.0±0.5, accordingly. In both groups has prevailed girls: in the 1 group they made 73.3% (M:F 1:2.7) and in the 2 – 70.7% (M:F 1:2.4). Childhood differentiated TC were associated with aggressive behavior: regional metastases were found in 53.0% and 81.4%, extrathyroid TC spreading – in 9.6 and 19.7%, distant metastases - in 9.6 and 4.8%, accordingly. In our Center (1 group) we have performed hemithyroidectomies and subtotal Thyroidectomies in 58.1% with ipsilateral central neck dissection (CND). In Mayo Clinic in all TC cases were performed thyroidectomy (TE) since 1950. TC relapses we have no   observed in 1 group and they have place in 6.9% 2 group patients, recurring lymphatic metastases – in 8.4% and 20.7%, accordingly. Radioiodine therapy (RIT) has performed in 21.1% and 25.5% operated children.

In 1 group 95 (96.0 %) of 99 operated were alive during 5 – 36 years, in the 2– only in two cases reason of death was TC, but in 14 – other malignant tumor.

Conclusion

Childhood TC is associated with more locally aggressive and more frequent distant disease than its in adult coun­terpart. Recurrence rate stend to be higher in children, but cause-specific mortality remains low. Optimal initial treatment of childhood TC should include TE and CND. RIT in child hood has in creased possibility of others malignant tumor in follow up period.