Endoprosthesis Replacement Research Articles

Oncological and functional results after surgical treatment of bone metastases at the proximal femur

BackgroundMetastatic lesions to the proximal femur occur frequently (about 10% of patients with cancer) and require surgical treatment. There are many surgical methods of treatment, however, use of the tumor modular endoprostheses seems to be particularly promising. The aim of study was to evaluate oncological and functional results of treatment in patients with proximal femur metastases. Oncological results were evaluated considering the survival of patients and the number of local recurrences. Functional results were assessed as pain intensity in VAS score and performance in Karnofsky and MSTS score.MethodsBetween 2010 and 2016, 122 patients with metastatic tumour to the proximal femur were treated in our hospital. Majority of the patients were women − 77 patients. The mean age was 67 years for women and 72 years for men. Pathological fracture was diagnosed in 98 cases. Metastatic bone tumors commonly develop from breast cancer – 48 and myeloma – 24. One hundred one patients underwent tumor resection and in 21 cases metastatic tumors was not resected. In 75 patients wide tumour resection and modular endoprosthetic replacement were prefomed. Twenty-one patients underwent standard or long stem hip endoprosthetic replacement. Intramedullary gamma nails were implanted in 20 cases and DHS plate in 6 cases. In 92 cases 3-4 weeks after surgery patients undergo external beam radiotherapy (8Gy).Functional results were assessed as pain intensity in VAS score and performance in Karnofsky and MSTS score. Oncological results were evaluated considering the survival of patients and the number of local recurrences.ResultsThe mean follow-up of patients was 27 months (min 4, max 51). Forty-five patients died before last visit in hospital. The mean survival after modular endoprosthetic replacement was 860 days and after bone fixations 360 days. We noticed 9 cases of local recurrences or progressions, 6 in patients who had no radiotherapy. Three patients after modular endoprosthesis replacement and 6 after bone fixations.After surgery, all patients experienced improvement in the comfort of life resulting from reduction in pain. Mean VAS score before modular endoprosthetic replacement was 6.8 and after 3.4; before standard prothesoplasty 4.9 and after 2.8; and before and after bone fixation 6.9 -5.1. Mean MSTS score was respectively 6.4-19.8; 8.8-22.4 and 10.8-18.2.In 6 patients after modular endoprosthesis replacement, delayed wound healing were observed. Infectious complications were not observed after fixation with nails and plates. In 3 cases, the fixation was failed. The systemic complications affected 12 patients.ConclusionsResults of surgical treatment for metastases to the proximal femur are particularly good in patients after standard or modular endoprostheses replacement. The author considers this treatment method to be optimal in patients with good prognosis.

Clinical-Statistical Analysis of Repeated Surgical Interventions after Endoprostheticing of a Tazeded Joint

Unfortunately, one cannot entirely avoid surgical intervention after hip joint prosthesis. That’s why the authors analyzed the current situation in the area of hip joint endoprosthesis replacement based on the materials of two large clinics. The authors analyzed the case stories of over 200 patients, out of them after reendoprosthesis replacement–740 persons. Reendoprosthesis replacement makes up to 5,2% from the primary ones. It’s found out that among re-operated patients women are predominant (60-65%), their average age is higher than the age of re-operated men. Early check-up operations were carried out on the average in 2,6 years (in men) and 1,9 years (in women) after the first one. The analysis demonstrated significant differences of indications to check-up operations depending on the terms after initial hip joint endoprosthesis replacement (HJ EPR). Temporary distribution of HJ reEPR was found out. Clear temporary distribution of HJ reEPR on the curve with two spikes–at 2,2 years and 12 years was found out. Infection and endoprosthesis component dislocation or both of them are generally the most frequent cause of early check-up operation. Late interventions are often carried out due to wear, damage of element construction or their loosening, which demonstrates as aseptic instability.

Диагностически значимые отличия асептической и септической нестабильности компонентов эндопротеза при артропластике крупных суставов

The purpose of the work is to analyze the results of laboratory, microbiological and instrumental studies to search for screening criteria for the difference between aseptic and septic instability of endoprosthesis components after knee and hip joint arthroplasty. The materials contained 146 cases of revision arthroplasty of the knee and hip joints, performed under the conditions of Federal State Budgetary Institution Federal Center of Traumatology, Orthopedics and endoprosthesis replacement of Ministry of Health of the Russian Federation (Cheboksary) for a 3-year period, including cases of aseptic instability - 69, septic instability - 77. By methods for laboratory diagnosis were used to evaluate the blood levels of leukocytes, stab neutrophils, ESR, C - reactive protein (CRP), presepsin, procalcitonin, D-dimer, interleukin-6. Using ultrasound (ultrasonic) examination of the periprosthetic zone, the presence of fluid, granulation tissue in the joint cavity, altered lymph nodes was determined. Before the operation, the level of cytosis and cellular composition were determined in the synovial fluid; tissue bioptates, removed components of implants (after ULTRASONIC treatment) with sowing on the microflora were studied intraoperatively. Intraoperative tissue biopsies were used to make smears-prints on the glass, with gram staining, estimating the number of leukocytes and neutrophils in the field of vision. Results. Determination of indicators of ESR, presepsin and interleukin-6, the level of which goes beyond the generally recognized normal values in the presence of infection, can be recommended as a screening test in the diagnosis of the infectious nature of instability of the components of the endoprosthesis of large joints. The second stage of differential diagnosis of septic and aseptic instability can be the detection of lymphadenopathy. The third (final) stage of determining the infectious nature of instability is an invasive technique to determine the level of cytosis with the calculation of neutrophils in the synovial fluid.

OSTEOPETROSIS AND ENDOPROSTHETICS - CLINICAL OBSERVATIONS

Aim - to evaluate the efficacy of treatment of secondary arthrosis of the coxofemoral joints associated with osteopetrosis using arthroplasty. Materials and methods - clinical observation of two cases of treatment of patients with autosomal dominant form of osteopetrosis who underwent total hip arthroplasty at the Federal State Budgetary Institution Federal Center of Traumatology, Orthopaedics and Endoprosthesis replacement (Cheboksary). Results. We obtained positive results and patient’s satisfaction with the function of prosthetic joints with a follow-up period of 3.5 years. This method of treatment showed its efficacy during the specified follow-up period. Arthroplasty provides relief from pain, improved quality of life and increased mobility of the joint for patients with coxarthrosis associated with osteopetrosis.

ANALYSIS OF NONSURGICAL POSTOPERATIVE VENTRAL HERNIA PREDICTORS

Aim. The aim of this study was to detect the predictors of the postoperative herniation in midline laparotomy as the most frequent type of approach in urgent surgery. The study included retro-and-prospective analysis of 398 case histories. Analysis was performed according to 45 signs. Materials and methods. The following parameters were taken into account: Kettle index, anterior abdominal wall status, presence of the signs of undifferentiated connective tissue dysplasia, hard physical labour, use of bandage in the postoperative period as well as blood erythrocyte and hemoglobin indices, bilirubin and creatinine levels. Separately, the following parameters were assessed: presence of aponeurosis defects (physically and by US data) and presence of hernia outpouching. Results. According to the obtained data, the indications to preventive endoprosthetic replacement of the anterior abdominal wall were formed. Conclusions. Combination of some factors, not connected with surgical treatment, raises the risk for herniation, being the indication to preventive endoprosthesis replacement of the abdominal wall.

Система анестезиологического обеспечения при протезировании крупных суставов

The operation of total endoprosthesis replacement of large joints is associated with several anesthetic problems. Solving these problems ensures the safety of these highly traumatic operations and requires the solution of the following anesthetic tasks in the perioperative period: high degree of antinociceptive protection of patients with effective relaxation of the surgical intervention area; prevention of fatty hyperglobulinemia; decrease in the volume of perioperative hemorrhage and prophylaxis of thrombogenic complications. We developed our own program of anesthetic maintenance at major joints replacement. The components of the program are: the type of anesthesia - spinal anesthesia preservation of spontaneous respiration; our method of fat globulinemia prevention, based on maintaining the functional stability of the hepatocyte; our own method of replacement of peri-operative blood loss, based on the additional principle of normalization of the oncotic blood pressure. Before the operation, patients receive a solution of tranexamic acid at a dose of 10 mg/kg of body mass to inhibit proteolysis (blood preservation technology). This method provides a dry operating field, reducing intraoperative hemorrhage. In the early postoperative period (5 hours after the surgery), under the control of whole blood clotting time, patients receive low molecular weight heparin Clexane at a therapeutic dosage of 1 mg/kg of body weight. This provides effective prevention of thrombogenic complications. The application of the developed technique shows its high clinical effectiveness. Over the past 5 years, 5,800 operations for large joint prosthetics have been performed, including 3,200 total hip replacement operations, 2,600 total knee replacement operations. There were no complications with a fatal outcome, in 5 cases fatty hyperglobulinemia was noted, which was stopped by the own method of treatment. There are no thrombogenic complications.

Treatment of osteosarcoma around the knee in skeletally immature patients.

Limb sparing surgery in growing young patients with malignant tumors is difficult as invasion of the physis by the tumor or surgical resection through the metaphysis may cause significant limb discrepancy following surgery. At present, hinged tumor prosthesis or biological reconstructions are the main methods following tumor resection in these patients. The aim of the present study was to assess different procedures for the treatment of osteosarcoma around knee joints in immature patients. A retrospective study of 56 patients (<15 years old, open physis) who had been treated for osteosarcoma around the knee joint between January 2007 and December 2015 was performed. Clinical data collected included patient demographics (age at diagnosis, sex and date of diagnosis), tumor characteristics [location, Enneking stage and subtype on magnetic resonance imaging (MRI)], treatment (response to neoadjuvant chemotherapy and type of primary surgery) and clinical outcomes (limb function, discrepancy and overall survival). The median age at the time of diagnosis was 12.14 years (range, 3–15 years). There were 32 male patients (57.1%). A total of 41 (82%) tumors were located at the distal femur, and 15 (18%) at the proximal tibia. A total of 49 (87.5%) patients were diagnosed with stage IIB tumors, and 7 (12.5%) had stage III, according to the Enneking stage classification. Different surgical methods, including amputation, rotation-plasty, endoprosthesis and biological instructions (e.g., allograft) were performed according to MRI type classification. During follow-up, 21 patients (37.5%) succumbed to disease. The Musculoskeletal Tumor Society score ranged from excellent to fair functional result. Recurrence (2 cases, 16.67%) and infection (2, cases, 16.67%) were the main complications following endoprosthesis replacement, while delayed union (12 cases, 57.14%) and fracture (3 cases, 14.29%) were the main causes for biological reconstructions. Limb-length discrepancy ranged from 0–10 cm in limb-saving surgery. The overall survival rate was 57.66% with different cohorts in Enneking stages IIB and III, with or without involvement of the physis and different cycles of chemotherapy. Results of the present study indicated that different limb saving surgeries, including epiphysis/physis preservation with biological construction in patients with MRI types I to III and endoprosthetic/osteoarticular reconstruction in patients with MRI types IV and V, are useful in the management of osteosarcoma in growing young patients with proper surgery indications, and knee joint function was maintained with acceptable complications including limb discrepancy, delayed union, infection, recurrence and fracture.

Surgical Correction of Dysplastic Coxarthrosis and Endoprosthesis Replacement by TiNi-based Implants

Dysplastic coxarthrosis is predominating among children orthopedic cases and its surgical correction continues to be an urgent issue. Despite the application of advanced therapies and medical treatment, such patients constitute a significant percentage of the total patient number, i. e. from 19 to 35%. In this article a detailed literature review of surgical correction methods for missing acetabular roof by applying different implants has been described. The authors have proposed applying titanium nickelide materials in surgical correction method, as such materials possess the following properties: high corrosion stability, full compatibility with the body tissues, as well as, high porosity to provide radial border structure regeneration of the acetabular roof, which in its turn, improves the support ability of extermity. In the event of coxarthrosis progression iliac segment is reserved for the replacement.

Removal of Temporomandibular Joint Bone Ankylosis by Shape Memory Materials

A special attention has been attracted by the method of endoprosthesis replacement of temporomandibular joint. This research is devoted to an increase of surgical treatment efficiency of temporomandibular joint bone ankylosis using porous titanium nickel endoprosthesises. The analysis of distant results of application of porous nickelid titanium endoprosthesises for replacement of mandibular condylar processes in patients with temporomandibular ankylosis affects, according to anatomical specifics of affected organ, allows to make conclusion on possibility of complete restoration of lost anatomical and functional specifics of dentomaxilla apparatus. Through correspondence of hysteresis behavior of lost organ and recipient tissues to hysteresis behavior of whole complex system of endoprosthesis, the connecting tissues from implant surrounding areas grow through porous structure of implant not causing any aggressive reactions from organism side.

THE TACTIC OF CEMENTLESS TOTAL ENDOPROSTHESIS REPLACEMENT OF HIP JOINT IN PATIENTS WITH INHERENT HIP DISLOCATION

Introduction. The total endoprosthesis replacement is a main method of treatment of congenital dislocation of hip. However, significant disorders of joint, resistant muscular contractures create technical complications under operation and force to apply various surgical tactics. Methods. The analysis was implemented concerning results of Crowe total endoprosthesis replacement in 69 patients with one-sided high hip dislocation type IV operated on the basis of traumatological orthopedic department of Saratovskii research institute of traumatology and orthopedics during 2010-2015. The treatment of patients was implemented using original genuine technique including total endoprosthesis replacement of hip joint combined with double V-subtrochanteric osteotomy. Results. The pathological types of implantation in operated hip joint are absent. On the whole, one can notice amelioration of bio-mechanical indices: cycle of step, period of double support, coefficient of rhythm. Among systemic complications of total endoprosthesis replacement one is to mark out phlebothrombosis established in 3 patients (7.1%) that was conditioned by sedentary state of patients. Among specific complications one stated dislocation related to inobservance of restrictive orthopedic regimen in 1 (2.4%) patient. None case of instability of prosthesis and difference in length of extremities in average periods of observation more than on 0.5 cm was established. This is a proof of effectiveness of developed technique of correcting V-subtrochanteric osteotomy. Therefore, the proposed technique of femoral bone osteotomy permitted to ameliorate the results of treatment and to diminish number of complications. The applied technique permits to obtain satisfactory clinical and technical results of surgical treatment of patients with high hip joint dislocation. The osteotomy permitted to eliminate difference in length of bones of patients and at that to ameliorate conditions for union of distal and proximal fragments of femur bone at the expense of larger surface of their contact.

Paraprosthetic Complications After Endoprosthesis Replacement of Pelvis Joint with Implants

PurposeThe purpose of the paper is shaping of ideas about possible ways of decreasing complications of the analyzed types of operations and identification of opportunities of the impact on the socio-economic environment among the Afro-American population of USA. The paper demonstrates that the issue of coxofemoral prosthesis is not only a purely medical but also a social problem. In particular, availability of timely aid, as well as insurance in the form of surgery, refer to relevance of the range of problems. MethodologyThe experimental method was used in the study. Patients were implanted different types of endoprostheses. 90 patients were implanted customized endoprostheses, 27 patients were implanted foreign module endoprostheses. The research subject is prediction of complications after endoprosthesis replacement surgeries depending on methods, types and forms. ResultsAs a result, we can see that available health insurance is more acceptable understanding of the need for endoprosthesis replacement. Post-operative care issues fall into the range of social policy problems. A comparative aspect of a country with general insurance and differentiated coverage among the Afro-America population appears innovative. ConclusionsIn the context of the current situation it can be concluded that surgery is the last stage for already established support system of the population. For this reason, it's worth mentioning that state bodies of the U.S. should put a greater emphasis on the health care of the Afro-American population.

The Diagnosis of Breast Cancer after Augmentation Mammoplasty (Case Report)

The number of women resorting to endoprosthesis replacement of breast is growing from year to year. To date, the most popular and safe method of correcting the shape and size of the breast is augmentation mammoplasty with silicone gel prostheses. Unfortunately, the diagnosis of breast cancer in patients who have had recourse to the augmentation mammoplasty at preclinical stages, is difficult. Most often this is due to the fact that the patient does not undergo preventive examinations. This research exemplifies a comprehensive procedure facilitating diagnostication of a breast cancer in a patient previously subjected to augmentation mammoplasty. A physical examination, a digital and an ultrasound mammography reveals a BI-RADS 5 nodal formation in the patient’s right breast. An ultrasound-guided biopsy of the newly formed tissue over the breast implant is morphologically cross-checked. The diagnosis of breast cancer is thus confirmed histologically.

Morphofunctional changes of Jurkat T lymphoblasts upon short-term contact with a relief calcium phosphate surface

Human leukemic T lymphoblastoid cells (hereinafter, Jurkat T cells) have been used to model the morphofunctional reaction of T lymphocytes to 24-h in vitro contact with relief (roughness index Ra = 2.2–2.7 μm) pure titanium substrates (12 × 12 × 1 mm3) covered by a calcium phosphate (CP) bilateral coating prepared by the microarc method. Jurkat T cells placed in plastic multiwall plates (2D control of culture growth), as well as cells in contact for 24 h with oxide (TiO2) microarc coating on pure titanium substrate (3D control), served as comparison tests. From 27 to 98% of immortalized cells in the 2D control culture had the CD3+CD4+CD71+CD45RA+ immunophenotype and secreted IL-2, IL-4, IL-8, IL-10, and TNFα, but not IL-1b and IL-6. Other markers of cell activation, differentiation, maturation, and death (CD8, CD16, CD56, CD25, and CD95) were found in 0–2.5% of cells. IL-8 release elevated by the microtextured CP surface by 183 and 160% relative to 2D- and 3D-control cultures, respectively. The CD4/CD8 ratio dropped to 9: 1 (13: 1 and 82: 1 in 2D and 3D controls, respectively) due to CD4+ cell depletion and an increase in CD8+ cell number. The total cell number (TCN) in Jurkat T cell culture after 24-h contact with CP coating was decreased to 88% compared to 2D control (p < 0.04), which indicated cell division suppression. A drop in total cell number was accompanied with accelerated IL-8 secretion (r = −0.97, p < 0.00009). Low concentrations of IL-8 (pg/mL) induced apoptosis (r = 0.94, p < 0.0001). These results show that CP, rather than TiO2, coating is a preferential surface material for endoprosthesis replacement and fracture osteosynthesis in patients suffering from hematological and bone malignancies.

ИННОВАЦИОННЫЕ РАЗРАБОТКИ ДЛЯ ДИАГНОСТИКИ И ЛЕЧЕНИЯ ПОВРЕЖДЕНИЙ И ПОРАЖЕНИЙ ОПОРНО-ДВИГАТЕЛЬНОГО АППАРАТА В ИНЦХТ (К 70-ЛЕТНЕМУ ЮБИЛЕЮ НИИТО)

The article summarizes experience and achievements of Irkutsk Scientific Research Institute of Traumatology and Orthopedics (now – Irkutsk Scientific Center of Surgery and Traumatology) over a 70-year period. The development of new methods of diagnostics and treatment and organization of health care for patients with traumatological and orthopedic pathology are highly influenced by the Institute. The team of Irkutsk Scientific Center of Surgery and Trau-matology developed a new promising direction of combined tension-band osteosynthesis, substantiated organ-sparing endoprosthesis replacement, created new technologies of treatment of chronic osteomyelitis, developed concept of treat-ment of spinal trauma and spinal cord injuries, determined regularities of cross-system organization of physiological functions at the musculoskeletal system pathology, created original technologies and instruments for the treatment of musculoskeletal system traumas and disorders.Innovations created in ISCST include 330 patents. Irkutsk Scientific Center of Surgery and Traumatology was awarded Governor’s Award in Science and Technics for the development and introduction in clinical medicine of new diagnostic and treatment methods and of candidate medicines in 2012 and 2013.

EXPERIENCE OF TREATMENT OF INFECTIOUS COMPLICATIONS AFTER PRIMARY HIP JOINT ENDOPROSTHESIS REPLACEMENT

Aim. The aim of the study was to analyze the results of treatment of infectious complications after primary hip joint endoprosthesis replacement. Materials and methods. The results of treatment conducted in 735 patients after primary hip joint endoprosthesis replacement were analyzed. Clinical, roentgenological, laboratory and bacteriological methods of study were used. Results. Development of paraprosthetic infection is a severe complication after primary hip joint endoprosthesis replacement. Complications connected with paraprosthetic infection were found in 8 (1 %) patients. The early postoperative infectious complications developed in the terms up to 4 weeks - in 3 patients, from 4 weeks to 6 months - in 2 patients. The late postoperative infectious complications (more than 1 year) were stated in 3 patients. In 6 patients the infectious agent was revealed - it was St. Aureus ; in 1 patient it was Ps. Aeruginosa ; in 1 patient infectious agent was not identified. Three patients with developing paraprosthetic infection in the early postoperative period (up to 4 weeks) underwent debridment (sanation) of the joint using washing system and antibacterial therapy course. Conclusions. 1. The paraprosthetic infection development rate in primary hip joint endoprosthesis replacement is 1 %. 2. Efficiency of surgical treatment of paraprosthetic infection is determined by the quality of joint debridment performed, irrespective of the terms of development of this infection.

CLASSIFICATION AND ALGORITHM FOR DIAGNOSIS AND TREATMENT OF HIP PROSTHETIC JOINT INFECTION

Prosthetic joint infection (PJI) is the second common reason for revision surgery of the hip joint prosthesis. The rate of hip PJI is about 1% after primary surgery and it goes up to 4% or higher after revision surgery. In most cases, the main cause of this complication is an intraoperative bacterial contamination, rarer is a haematogenic one. An up-to-date diagnostic approach and clearly defined treatment strategy are required for the successful therapy of PJI. Based on the analysis of the scientific literature and own experience, an algorithm for diagnosis and treatment of this complication is proposed. A thoroughly obtained case history plays a predominant role in the diagnosis of PJI. Lack of the increased serum C-reactive protein cannot be considered as an exclusion criterion because in some cases, especially chronic infection, it can be within the normal range. Bacteriology lab tests of periprosthetic tissue biopsies and synovial fluid is the gold standard for the diagnosis. Novel methods such as ultrasound debridement of the removed prosthetic components have allowed to substantially increase the diagnostic sensitivity of bacteriology tests. This led to the discovery of PJI in some cases which before that were regarded as aseptic loosening. Visualization methods including MRI and scintigraphy play only a secondary role. The authors propose the classification of PJI for further determination of the treatment strategy which takes into account parameters such as biofilm maturity, prosthesis stability, the type of pathogen and soft tissue state for the decision on the treatment strategy. While desire to retain the implant is only justified in case of the immature biofilm, in most cases the infection can be cured only after the replacement of endoprosthesis. According to the proposed algorithm, patients undergo one- or two-stage procedure with a short or long interval. Antibiotics that are active against biofilm pathogens play an important role in the efficacy of the therapy. Selection of these antibiotics should be based on the results of bacteriology tests, preferably in collaboration with specialists in infectious diseases and microbiology.

Minimally invasive technologies in the treatment of closed fractures of the intercondylar elevation of the knee: a clinical case

Тhis article presents a clinical case of the surgical treatment of a fracture in the intercondylar eminences of the knee joint in a 7-year-old child. Closed fractures of the intercondylar exaltation are mainly a characteristic of childhood. This type of damage occurs by dysfunction of the knee resulting from instability. Because the fracture of the intercondylar eminences of the knee joint in children is similar to the damage of the anterior cruciate ligament in adults, the current course of knee surgery is a minimally invasive technique. These include fixation of the intercondylar exaltation using video stroboscopy as well as the assistance of various implants (e.g., screw, wire, and Dacron). In the children's Department of Traumatology and Orthopedics of the Federal Center of Traumatology, Orthopedics and Endoprosthesis Replacement in Barnaul, various surgeries are performed, including arthroscopy of the right knee joint, intercondylar exaltation reposition, and fixation of the intercondylar exaltation latch Lupine (De PuyMitek).

A TWO-YEAR FOLLOW-UP OF A FEMALE PATIENT WITH RECURRENT PULMONARY THROMBOEMBOLISM AFTER SUCCESSFUL COMBINED TREATMENT

Objective: to describe a clinical case of recurrent pulmonary thromboembolism (PTE) with developed chronic thromboembolic pulmonary hypertension (CTEPH) and successful stenting of the pulmonary artery branch after ineffective thrombolysis. Patient Ch. born in 1978 was admitted to a cardiology unit with suspected PTE. The patient complained of obvious resting dyspnea increasing with minimal physical exercise. Blood test revealed leukocytosis, D-dimer just above the normal value. Electrocardiography showed sinus rhythm, right axis deviation, and complete right bundle-branch block. EchoCG indicated right hearth dilatation with an increase in systolic pressure gradient across the tricuspid valve up to 60 mm Hg. Lower extremity venous duplex scanning revealed a muscle vein dilated up to 14 mm with echogenic parietal deposits in the muscle thickness at the middle third of the right leg; compression was virtually complete; the valves were incompetent and a muscle vein irregularly dilated up to 7 mm in the middle third of the left leg; the walls were uneven; compression was complete. Angiopulmonography detected occlusion of the lower and middle lobe branches of the right pulmonary artery and the lower lobe branch of the left pulmonary artery. Results. It was decided to perform local thrombolysis in terms of the patient»s young age, obvious clinical symptoms (New-York Heart Association Functional Class (FC) III–IV dyspnea) and the data of earlier studies on the benefit from thrombolysis in intermediate-risk persons and a council of a vascular surgeon, a cardiologist, and an X-ray endovascular diagnosis and treatment physician, and an invasive specialist. The patient underwent local thrombolysis with purolase 6,000,000 IU. Control angiopulmonography revealed no positive changes in the branches of the pulmonary artery. Because of ineffective thrombolysis and the persistence of significant pulmonary hypertension and FC III–IV dyspnea, the patient underwent conduction recanalization of the area of left lower lobe pulmonary artery occlusion, percutaneous transluminal balloon angioplasty, and endoprosthesis replacement with an 8.0–29-mm holometallic peripheral stent. Control angiopulmonography showed that the arterial lumen was completely restored and blood flow was not distally embolized. Conclusion. This clinical case is an example of the delayed diagnosis of recurrent PTE, which was a reason for ineffective thrombolytic therapy that had been performed 11 days after the onset of an episode. In this situation, percutaneous transluminal balloon angioplasty and pulmonary artery branch stenting can improve the status of a patient and reduce the risk of CTEPH in the future. In spite of its apparent ease, angioplasty can cause problems: impossibility and hazard of enhanced contrasting of the pulmonary artery; extensive injury of its branches; arterial cicatricial process associated with multiple episodes of PTE. After angioplasty, patients may develop reperfusion pulmonary edema, the causes of which are fully unclear. However, the successful intervention makes it possible to lower pulmonary artery pressure, pulmonary vascular resistance, and blood NT-proBNP levels and to increase exercise tolerance. At the present time, a number of centers are performing such procedures in patients with CTEPH. This requires 2–3 balloon inflations per session. Holometallic stent placement can decrease the number of necessary inflations and reinterventions in the future. This clinical case demonstrates that pulmonary artery stenting is successful in the patient with recurrent PTE after ineffective thrombolysis.

Our experience with Russian voice prostheses long used in patents after laryngectomy with tracheoesophageal shunting and endoprosthesis replacement

Despite broad current diagnostic capabilities, most (60–70 %) patients with larynx cancer seek medical advice only when they have stages III and IV. Until the present time, laryngectomy has remained the most common treatment option for cancer of the larynx and laryngopharynx. Tracheoesophageal shunting with endoprosthesis replacement is one of the most important surgical vocal rehabilitation techniques after laryngectomy. According to different authors» data, the mean lifetime of voice prostheses is 6–12 months. The long-term use of voice prostheses in patients after laryngectomy with tracheoesophageal shunting with endoprosthesis replacement was the object of our investigation. Patient G., aged 34 years was admitted to the Department of Head and Neck Tumors, Oncology Clinical Dispensary (OCD) One, Moscow Healthcare Department, with a diagnosis of larynx cancer spreading to lymph nodes (LN) (T3N1M0) in the left neck on September 16, 2010. Surgery involving laryngectomy with tracheoesophageal shunting and implantation of a Russian voice prosthesis, as well as radical fascial excision of LN and fat in the neck on the left side were performed on September 21, 2010. During the 4-year use of the voice prosthesis, his voice was sonorous and good. The voice prosthesis was removed in November 2014. Antifungal therapy was used; a new voice prosthesis was implanted. His speech was fluent and his voice was sonorous and good. Patient M., aged 54 years was admitted to the Department of Head and Neck Tumors, OCD One, Moscow Healthcare Department, with a clinical diagnosis of laryngopharynx cancer (T4N1M0) and an aftereffect of gamma-therapy with a summary focal dose of 42 Gy on November 18, 2003. Surgery involving laryngectomy with laryngopharyngeal resection, tracheoesophageal shunting, and endoprosthesis replacement with implantation of a Russian voice prosthesis, as well as radical fascial excision of LN and fat in the neck on the right side were performed on November 25, 2003. The voce prosthesis was removed in December 2014. Antifungal therapy was performed. A new Russian prosthesis was implanted in the tracheoesophageal shunt. His voice was sonorous and good.

First experience of application of modular endoprosthesis for treatment of bone sarcomas in the Federal Research Center of Pediatric Hematology, Oncology, and Immunology named after Dmitriy Rogachev

At present, endoprosthesis of bones and joints with the use of modular oncology prosthesis is the most common method of organ-preserving treatment. Since the moment of opening of the FCRC of PHOI named after Dmitriy Rogachev, over 20 surgical operations for endoprosthesis replacement have been performed in the department of surgery of children and adolescents. MSTS (Musculoskeletal Tumor Society Score) international scale was used for assessment of the functional result after the surgical therapy. The worst result in accordance with the scale comprised 50 %, the best result comprised 93 %. The average index was 76 %. The possibility of the intra-operational varying of the replacement volume of the postresection defect is a good feature of modular endoprosthesis that saves the surgeon from possible errors of the pre-operational planning and unpleasant findings in the course of the operation. This simplified performance of endoprosthesis replacement in conditions of a small medical center with little clinical experience in this field, particularly in the course of performance of operations for children. Endoprosthesis secures good onclological and functional results as well as favors the most adequate social adaptation of a child.