Abstract
Purpose
Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA).
Methods
Nine patients who were diagnosed and treated for chronic fungal PJIs after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, amphotericin-impregnated cement spacer was inserted for all patients. Systemic antifungal medication was used during the interval between two stage operations. Patients were followed up for more than 2 years after exchange arthroplasty and their medical records were reviewed.
Results
The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, 5 to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by preoperative joint aspiration culture in 6 cases. For the other 3 cases, it was confirmed by open debridement tissue culture. All infections were caused by Candida parapsilosis except for one case which was caused by Candida pelliculosa. The average number of operations before exchange arthroplasty to solve the infection was 2.7 times (range, 1 to 5 times). Average duration of antifungal agent use confirmed by sensitivity test was 7 months (range, 4 to 15 months). Mean interval between two stage operation was 6 months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months).
Conclusions
Due to its ill-defined symptoms and inconclusive blood test, fungal PJI after TKA is difficult to diagnose and has a prolonged clinical course. Two-stage exchange arthroplasty with antifungal-impregnated cement spacer is a very effective strategy with excellent outcome.
