Evora® chromium-cobalt dual mobility socket: results at a minimum 10 years' follow-up.

INTRODUCTION: The Evora chromium-cobalt alloy dual mobility socket claims to display a large articulation tribology different from that of stainless steel models, limiting the risk of intraprosthetic dislocation and wear. The present study reports a minimum of 10years' follow-up in a multicenter prospective series of 200 sockets previously reported on at 5years. HYPOTHESIS: The use of chromium-cobalt in dual mobility sockets provides a low rate of failure at 10years, especially as regards to osteolysis and intraprosthetic dislocation. MATERIALS AND METHODS: Two hundred hydroxyapatite-coated molded chromium-cobalt sockets without titanium interface were implanted without cement in 194 patients with a mean age of 70 years (range, 32-91 years). Clinical results were assessed on Postel Merle d'Aubigné and Harris scores, plain radiographs and survival analysis. RESULTS: At a mean 11 years' follow-up (10-13 years), 56 patients had died and 31 were lost to follow-up. Four underwent surgical revision (3 femoral components, and 1 socket for migration at 9 years with complete disappearance of the hydroxyapatite). A total of 109 implants were analyzable in 107 patients with a mean age of 81 years (55-93 years). At follow-up, the mean Harris score was 90 (75-96) and the PMA score 16.3 (14-18). There were no cases of loosening (except for the case reoperated on at 9 years) and no acetabular radiolucency or cysts. There were 2 cases of non-evolutive femoral radiolucency and 10 of femoral granuloma, involving head size > 22 mm (P<0.0001) and a cemented titanium stem (P=0.004) as risk factors. There were no dislocations in the large or small articulation. Ten-year survival was 99% (95% CI: 97.3%-100%) with socket revision as censorship criterion. DISCUSSION: The absence of dislocation in both small and large articulations confirmed the efficacy of the dual mobility concept and suggested an advantage for chromium-cobalt sockets in reducing the rate of intraprosthetic dislocation and preventing blockage of the large articulation by a better performance in the friction couple. Granulomas were associated with wear in cemented titanium stems and with heads greater than 22 mm in diameter. Ten-year survival was 99% (censorship criterion: revision for socket failure); there was, however, one case of socket loosening with disappearance of the hydroxyapatite, indicating that surveillance should be continued in this cohort.

A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions.

BACKGROUND: Drug patch tests (PTs) can reproduce delayed hypersensitivity to drugs and entail a moderate re-exposure of patients to offending drugs. OBJECTIVES: To determine the value of PTs for identifying the responsible drug in severe cutaneous adverse drug reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). METHODS: In a multicentre study, PTs were conducted on patients referred for DRESS, AGEP or SJS/TEN within 1 year of their SCAR. All drugs administered in the 2 months prior to and the week following the onset of the SCAR were tested. RESULTS: Among the 134 patients included (48 male, 86 female; mean age 51·7 years), positive drug PTs were obtained for 24 different drugs. These included positive tests for 64% (46/72) of patients with DRESS, 58% (26/45) of those with AGEP and 24% (4/17) of those with SJS/TEN, with only one relapse of AGEP. The value of PTs depended on the type of drug and the type of SCAR (e.g. carbamazepine was positive in 11/13 DRESS cases but none of the five SJS/TEN cases). PTs were frequently positive for beta lactams (22 cases), pristinamycin (11 cases) and in DRESS with pump proton inhibitors (five cases), but were usually negative for allopurinol and salazopyrin. Of 18 patients with DRESS, eight had virus reactivation and positive PTs. In DRESS, multiple drug reactivity was frequent (18% of cases), with patients remaining sensitized many years later. CONCLUSIONS: PTs are useful and safe for identifying agents inducing SCAR.

[Management of drug reaction with eosinophilia and systemic symptoms (DRESS)]. / Prise en charge du drug reaction with eosinophilia and systemic symptoms (DRESS).

OBJECTIVE: The management of drug-induced hypersensitivity syndrome or drug reaction with eosinophilia and systemic symptoms (DRESS) is not codified. Demonstration of the reactivation of Herpesviruses illustrates the specific pathophysiology of this syndrome. Proposals for the management of DRESS were elaborated by the cutaneous adverse drug reaction working group of the French Society of Dermatology to help with its management. METHODS: From a review of literature and the experience of the members of this group, consensual proposals were written about diagnostic criteria, tests, treatment options, and follow-up. These proposals will need to be validated in prospective studies. RESULTS: A decisional tree of treatment options is proposed, based on the severity of visceral manifestations. The importance of a rapid withdrawal of the culprit drug and of a long-term follow-up is underlined. Treatment will be adapted to the clinicobiological status (topical corticosteroid, systemic corticosteroid, intravenous gammaglobulins, antivirals).

Results of the Evora dual-mobility socket after a minimum follow-up of five years.

PURPOSE OF THE STUDY: Dislocation is a well-known complication of total hip arthroplasty. The risk can be reduced to one or two cases per thousand using a dual-mobility cup. The survival rate achieved with the Bousquet implant is 95% at 10 years. The complications with this implant are early mobilization and inguinal pain. An overly-large cup and insufficient primary and secondary fixation can be implicated. The design of the original implant was later modified to limit these early complications. The purpose of this study was to check the validity of these design changes. PATIENTS AND METHODS: The chromium-cobalt moulded cementless cup was used. The outer surface of this cup presents large geometric striations and is coated with hydroxyapatite. The cup has the shape of a 180 degrees half sphere and a posterior wall prolongation measuring 6.5mm. Three mechanisms were used for the primary fixation: an asymmetrical growth ring, four anchorage stems and a superior screw. Two hundred cementless cups were implanted in 194 patients. The femoral piece was a Charnley stainless-steel implant (n=139), a titanium SEM implant (n=59) or another implant (n=12). Cement was used for femoral fixation in 193 implantations. The series included 97 women and 103 men with osteoarthritis (n=180), necrosis (n=16) and surgery for fracture and primary arthroplasty (n=9). The Harris and Postel-Merle-d'Aubigné scores were noted. Eight radiographic criteria were analyzed to assess the position of the cup and the radiological course of the interface. RESULTS: The mean follow-up was six years and the minimum was five years. The mean age at surgery was 70 years (range, 32 to 91). At last follow-up, 17 patients had died, eight were lost to follow-up and five were bedridden. Three patients underwent revision surgery. Thus, this analysis included 170 prostheses followed for more than five years (mean, six years; range, five to seven years). The Harris score improved from 48 to 92 and the Postel-Merle-d'Aubigné score from 2/5/4 to 5.8/5.9/5.5 (range, 4 to 6/5 to 6/1 to 6). None of the patients complained of anterior pain during active hip flexion in supine position (related to ilio-psoas irritation). Cup inclination was 46 degrees on average (range, 62 to 22 degrees ). Medialization, lateralization or ascension greater than 10mm from the center of rotation was not observed on the postoperative films. At the last follow-up, no measurable mobilization or migration could be identified on plain X-rays. Radiolucent lines, condensations and bony defects around the cup, when visible postoperatively, were not found on the last follow-up X-rays. There were two cemented femoral pieces that developed a radiolucent line in the nonspecific metaphyseal area. There were no cases of granuloma and no cam effect. Three patients underwent revision for femoral loosening, fracture of the femur below the prosthesis and hematogenous infection. There were no cases of dislocation. DISCUSSION: Changing the design of the implant to modify its volume, material and primary fixation has eliminated the early mobilizations and inguinal pain described for the original Bousquet cup. These options have not had any deleterious effect on prosthesis stability. The question of long-term wear remains an important problem and requires optimization: a neck as thin as possible, optimized surfacing, elimination of laser marks, extraction leads and head skirts.

[Sweet's syndrome and phenylbutazone-induced sialadenitis]. / Syndrome de Sweet et sialadénite à la phénylbutazone.

BACKGROUND: Phenylbutazone frequently induces a range of potentially dangerous adverse reactions. We report a case of Sweet's syndrome with sialadenitis induced by phenylbutazone. CASE-REPORT: A 54-year-old woman presented lumbar pains treated with phenylbutazone for three days. Six days later, she exhibited inflammation of the submaxillary and parotid salivary glands, followed by an erythematous, oedematous, pustular and febrile eruption, with failure of antibiotic therapy. Laboratory data showed leukocytosis and neutrophilia, anaemia, an elevated platelet count and liver dysfunction. The infectious and autoimmune tests were negative. The skin biopsy confirmed Sweet's syndrome. Clinical and biological abnormalities resolved on administration of systemic steroids. DISCUSSION: Phenylbutazone-induced sialadenitis is rare and presents unrecognized adverse effects that may be associated with a systemic reaction. In the present case report, Sweet's syndrome met the criteria for drug-induced Sweet's syndrome. There appears to have been a systemic reaction caused by a hypersensitivity mechanism, in the same way as sialadenitis.

[Results of the Evora dual mobility socket: five years follow-up]. / Résultat à cinq ans de la cupule à double mobilité Evora.

PURPOSE OF THE STUDY: Dislocation is a well-known complication of total hip arthroplasty. The risk can be reduced to one or two cases per thousand using a double mobility cup. The survival rate achieved with the Bousquet implant is 95% at 10 years. The complications with this implant are early mobilization and inguinal pain. An overly large cup and insufficient primary and secondary fixation can be implicated. The design of the original implant was later modified to limit these early complications. The purpose of this work was to check the validity of the changes made. PATIENTS AND METHODS: The chromium-cobalt moulded cup was used. The outer surface of this cup presents large geometric striations and is coated with hydroxyapatite. The cup has the shape of a half sphere of 180 degrees and a posterior wall prolongation measuring 6.5mm. Three mechanisms were used for the primary fixation: an asymmetrical growth ring, four anchorage stems, and a superior screw. Two hundred cups were implanted in 194 patients. The femoral piece was a Charnley stainless steel implant (n=139), a titanium SEM implant (n=59) or another implant (n=12). Cement was used for 193 implantations. The series included 97 women and 103 men with osteoarthritis (n=180), necrosis (n=16), surgery for fracture and primary arthroplasty (n=9). The Harris and Postel-Merle-d'Aubigné scores were noted. Eight radiographic criteria were analyzed to assess the position of the cup and the radiological course of the interface. RESULTS: Mean time to surgery was six years. Mean age at surgery was 70 years (range: 32-91) and varied depending on the operators from 67 to 73 years. At last follow-up: 17 patients had died, eight were lost to follow-up and five were bedridden. Three patients underwent revision surgery. Thus, this analysis included 170 prostheses followed for more than five years (mean: six years, range: 5-7 years). The Harris score improved from 48 to 92 and the Postel-Merle-d'Aubigné score from 2/5/4 to 5.8/5.9/5.5 (range: 4-6/5-6/1-6). None of the patients complained of anterior pain during hip flexion against resistance. Cup inclination was 46 degrees on average (range: 62-22 degrees ). Medialization, lateralization or ascension greater than 10mm of the centre of rotation was not observed on the postoperative films. At last follow-up, no measurable mobilization or migration could be identified on plain X-rays. Lucent lines, condensations and bony defects around the cup, when visible postoperatively, were not found on the last follow-up X-rays. There were two cemented femoral pieces, which developed a lucent line in the nonspecific metaphyseal area. There were no cases of granuloma and no cam effect. Three patients underwent revision for femoral loosening, fracture of the femur below the prosthesis, and hematogenous infection. There were no cases of dislocation. DISCUSSION: Changing the design of the implant to modify its volume, material and primary fixation has eliminated the early mobilizations and inguinal pain described for the original Bousquet cup. These options have not had any deleterious effect on prosthesis stability. The question of long-term wear remains an important problem and requires optimization: a neck as thin as possible, optimized surfacing, elimination of laser marks, extraction leads, head skirts.

Omenn syndrome: a rare case of neonatal erythroderma.

Omenn syndrome is a severe combined immunodeficiency characterized by erythroderma, hepatosplenomegaly, lymphadenopathy and failure to thrive, with activated oligoclonal T lymphocytes and an absence of circulating B cells.A 3 day-old boy presented with a congenital erythroderma. Investigations revealed a marked neutropenia and lymphopenia and the absence of a thymus. Genetic studies showed RAG 1 mutations. He was successfully treated with an HLA identical bone marrow transplantation. Omenn syndrome is a rare severe combined immunodeficiency. Most cases are due to mutations in the RAG genes with autosomal recessive transmission. Our observation is original because of an incomplete clinical presentation. During the course of the disease, the child had no failure to thrive, no organomegaly and no recurrent infection. Immunodeficiency must be excluded in every case of neonatal erythroderma and an immunological assessment should be performed without delay.

[Contact allergy to antiseptics: 75 cases analyzed by the dermato-allergovigilance network (Revidal)]. / Allergie de contact aux antiseptiques: 75 cas analysés par le réseau Revidal de dermato-allergovigilance.

AIM: To determine the clinical features of contact dermatitis caused by antiseptics and to ascertain whether the substance responsible is the antiseptic itself or the excipients. PATIENTS AND METHODS: A multicenter, retrospective study based on analysis of all cases reported over a 2-year period to the Dermato-Allergology Vigilance network known as Revidal. Each dossier contained details of the clinical characteristics of lesions, the incriminated antiseptic, the mode of exposure and the results of patch tests done with the antiseptic in question. RESULTS: 75 patients (mean age: 44 years) were sensitized to chlorhexidine (14 cases), hexamidine (20 cases), povidone iodine (14 cases), mercuric antiseptics (3 cases), triclocarban (Septivon, 17 cases), hexamidine-chlorhexidine-chlorocresol (Cytéal, 4 cases), or chlorhexidine surfactant (Hibiscrub), cetrimide or chlorhexidine digluconate (Diaseptyl) (1 case each). Exposure was therapy-related (68 cases), work-related (6 cases; 5 in health workers and 1 in a cattle farmer due to povidone-iodine) or related to cosmetics (1 case, hexamidine). The clinical features consisted mainly of localized contact dermatitis, although generalized eczema occurred in 9 cases due to hexamidine contact. Sensitization was due to the antiseptic itself (53 cases) or to the excipients alone (22 cases), particularly in the 17 cases caused by Septivon. In 27/75 cases (35%), patients exhibited polysensitization to antiseptics belonging to different chemical classes or to other topical drugs. CONCLUSION: Sensitization to antiseptics is probably not rare, with various sources of exposure being present in everyday life. Patch tests are essential for diagnosis in order to distinguish between antiseptic-related and excipient-related sensitization and to screen for polysensitization to topical drugs.

Spectrum of cross-photosensitization in 18 consecutive patients with contact photoallergy to ketoprofen: associated photoallergies to non-benzophenone-containing molecules.

Contact photoallergy to ketoprofen gels has been widely reported, and cross-sensitivity reactions with other compounds, such as tiaprofenic acid, fenofibrate and benzophenones, are well known. However, positive photopatch tests to other different non-benzophenone-related compounds have recently been observed. We report the results of photopatch testing in patients with contact photoallergy to ketoprofen and discuss the spectrum of cross-sensitization to ketoprofen. 18 consecutive patients with a history of photocontact dermatitis from ketoprofen were investigated. Patch and photopatch tests were performed. As expected, we observed positive photopatch tests to Ketum* gel and ketoprofen 2.5% in petrolatum in all patients (100%). However, it was remarkable to note positive photopatch tests to other unexpected and non-relevant allergens, including fentichlor (67%), tetrachlorosalicylanilide (28%), triclosan (17%), tribromsalan (11%) and bithionol (11%), with no clinical relevance. Interestingly, these agents belong to the family of halogenated salicylanilides and related compounds, which have been forbidden in Europe since the 1970s. Our results raise the question of hyper-photosusceptibility to non-relevant allergens induced by photosensitivity to ketoprofen. The mechanism may involve the high photoreactivity induced by the association of a benzene ring with an oxygen group.

An epidemic of allergic contact dermatitis due to epilating products.

Over a period of 19 months, 33 cases of acute allergic contact dermatitis from Veet epilating waxes and/or the accompanying tissue (Reckitt Benckiser, Massy, France) were observed in France and Belgium. The lesions started on the legs and spread to other parts of the body, especially the face, and were sometimes so severe that hospitalization and/or systemic corticosteroids were required. Primary sensitization occurred as early as after the first application in several patients. Patch tests were performed in 26 of the patients and produced strong positive reactions to the tissue (25 times) and/or the wax (13 times). The allergenic culprits in the wax were modified-colophonium derivatives (colophonium in the standard series testing negatively in all except 4 patients), while methoxy PEG-22/dodecyl glycol copolymer and to a lesser degree lauryl alcohol turned out to be the main causal allergens in the tissue.

[Photocontact dermatitis due to ketoprofen and photosensitization to tetrachlorosalicylanide and to Fenticlor(R)]. / Photoallergie au kétoprofène et photosensibilisations au tétrachlorosalicylanide et au Fenticlor(R).

BACKGROUND: Photoallergy to ketoprofen and cross reactivity of ketoprofen with diphenylketones are well known; here are some cases of photoreaction to ketoprofen and unusual substances. PATIENTS AND METHODS: Eleven photoallergic to ketoprofen patients were photo patch tested with Ketum(R), ketoprofen, oxybenzone, tiaprofenic acid, fenofibrate, and also chlorphenesin, sunscreen series, and photobiologists series (without lichen mix and benzocaine). We performed tests at day 0, we irradiated them with UVA at day 2, and control series remained closed. We performed readings at day 3 and 4 according to ICDRG's recommendations. RESULTS: Nine tested patients had positive reactions to the irradiated tests with no expected allergens: fenticlor (9 cases), halogenated salicylanilides (4 cases), dibenzoylmethane (3 cases) and cinnamate (1 case). DISCUSSION: The mechanism of these unusual photosensitizations is discussed. These cases show that it is important to test sunscreen series and photobiologists series in patients photoallergic to ketoprofen.

Effect of light on hypericins contents in fresh flowering top parts and in an extract of St. John's Wort (Hypericum perforatum).

St. John's Wort is a medicinal plant increasingly used for its antidepressive activity. Hypericins are considered as one of the compounds contributing to the activity of the extract. These naphthodianthrones exist in various forms in Hyperici herba. Protopseudohypericin and protohypericin (protopigments) are converted into pseudohypericin and hypericin (pigments) under the action of light. The aim of this work is to study the influence of light on the phototransformation of protopigments into pigments. Two experiments were carried out. The studies were performed on one hand, on plant material in order to know the proportion of these substances in various plant parts and the possibility of transforming the protopigments into pigments under the action of sunlight; on the other hand, in the extract to determine the optimal wavelength allowing this transformation. Three parts of the fresh plant (buds, flowers, leaves) were treated with sunlight on three levels of exposure. Liquid extracts were exposed to various types of light with wavelengths ranging between 480 and 660 nm by means of diodes. The flowering tops of St. John's Wort contain a share of approximately 30% hypericins in the form of protopseudohypericin and protohypericin: buds (48%), flowers (30%), leaves (17%). After an exposure of fresh buds to sunlight for 16 hours the share of protopigments was then 32%. In the extract, the transformation of the protopigments is total and requires less energy than in the plant material. The optimal wavelength for the transformation of the protopigments in the extract is around 515 nm (green), close to the optimum absorption level of protopigments.

Improved procedure for the quality control of Hypericum perforatum L.

A new, fast and reliable procedure for the quantification of the major compounds of Hypericum perforatum L. has been developed. Four naphthodianthrones (protopseudohypericin, pseudohypericin, protohypericin, hypericin) and two phloroglucinols (hyperforin, adhyperforin) were assayed by HPLC using a short (17 min) linear gradient, with hypericin and hyperforin as external standards. Extraction of dried plant material with methanol in the dark at room temperature for 2 h led to a complete recovery of phloroglucinols but only a partial recovery of the naphthodianthrone derivatives. Treatment of plant material with water:ethanol (40:60, v/v) in a water bath shaker at 80 degrees C led to the total extraction of hypericins, but a 10% loss of total hyperforins was also observed. The two extraction methods, applied successively to the same sample, allowed the complete extraction of all compounds of interest. A 5 min exposure of the crude extract of H. perforatum to sunlight (1 E/m2) induced a 96% loss of hyperforins, whereas the dry plant material lost only 20% of hyperforins after 2 h exposure to sunlight (24 E/m2).

[A new allergen dibromodicyanobutane. Report of a study in 310 patients January-December 1994]. / Un nouvel allergène: le dibromodicyanobutane. Compte rendu d'une étude portant sur 310 malades de janvier a décembre 1994.

INTRODUCTION: Methylisothiazolinone chloride (Kathon CG) and its derivatives, used as preservatives in cosmetics, have been shown to be allergenic when used in humans although preliminary studies in Guinea pigs failed to reveal any sensitization. Dibromodicyanobutane, associated with phenoxyethanol in Euxyl K400, has been proposed to replace the isothiazolinone derivatives in cosmetics. Preliminary study has shown that these thiazolinone derivatives are not allergenic in Euxyl K400. The similarity of these situations led us to hypothesize that dibromodicyanobutane could become allergenic. METHODS: We tested 0.1 p. 100 dibromodicyanobutane in vaseline in the additional battery of the ICDRG battery in patients with contact eczema. Among the 310 patients tested, 1.94 p. 100 had a positive test for this allergen (during this same period, 1.29 p. 100 of the patients were positive for isothiazolinones). Three patients were hospitalized because of generalized eczema and 1 patient had changed occupation with no effect because the crems containing the allergen had not been avoided. CONCLUSION: Dibromodicyanobutane is a new allergen. Numerous cases of allergy have developed as use of the product becomes more widespread. The consequences of this sensitization may have an economic impact. Animal experimentation has been unable to predict this allergenic effect. Cosmetic products must be precisely labeled with a single international term for each specific molecule and the name of the preservative added to the active substance.