Fungal Prosthetic Joint Infection in Revised Knee Arthroplasty: An Orthopaedic Surgeon’s Nightmare

Abstract

Fungal prosthetic joint infections (PJIs), despite the fact that they are rare, represent a devastating complication. Such infections in revised knee arthroplasties pose a unique surgical and medical challenge. A rare case of Candida parapsilosis PJI in revised knee arthroplasty is reported. Furthermore, a thorough review of all published fungal PJIs cases in revised knee arthroplasties is provided. A 72-year-old female with total knee replacement surgery due to osteoarthritis 10 years ago, followed by two revision surgeries six and two years ago due to aseptic loosening, presented with signs and symptoms of septic loosening of the knee components. Resection arthroplasty and cement-spacer placement was performed and periprosthetic tissue cultures yielded Candida parapsilosis. The patient was commenced on proper antifungal treatment (AFT) for six months and then the second stage of the revision surgery was performed successfully. From 2000 to 2022, a total of 46 patients with median age 69 years [interquartile range (IQR = 10)], suffering fungal PJI occurring in revised knee arthroplasty have been reported. The median time from initial arthroplasty to symptoms’ onset was 12 months (IQR = 14). Cultures of local material (52.2%) and histology (6.5%) were the reported diagnostic method, while Candida species were the most commonly isolated fungi. Regarding surgical management, two-stage revision arthroplasty (TSRA) was performed in most cases (54.3%), with median time-interval of six months (IQR = 6) between the two stages. Regarding AFT, fluconazole was the preferred antifungal compound (78.3%), followed by voriconazole and amphotericin B (19.6% each). The median duration of AFT was five months (IQR = 4.5). Infection’s outcome was successful in 38 cases (82.6%). Fungal PJIs, especially in revised knee arthroplasties, are devastating complications. A combination of AFT and TSRA seems to be the treatment of choice. TSRA in these cases poses a special challenge, since major bone defects may be present. Therapeutic procedures remain unclear, thus additional research is needed.

Prosthetic Knee Joint Infection Due to Candida lusitaniae: A Diagnostic and Therapeutic Odyssey: A Case Study

“…Fungal PJIs represent rare clinical entities, and non- albicans Candida fungal PJIs are very rarely reported [ 7 , 8 ]. Diagnostic and therapeutic methods require a multidisciplinary approach [ 11 ]. The management of these infections is demanding and challenging [ 7 , 8 , 11 ].…”

“…Diagnostic and therapeutic methods require a multidisciplinary approach [ 11 ]. The management of these infections is demanding and challenging [ 7 , 8 , 11 ].…”

“…Hematogenous spread represents the most common mechanism of Candida deep tissueinfection (67%), followed by direct inoculation (25%), and contiguous infection (9%) [ 8 , 11 , 21 ]. The most frequently reported species is Candida albicans .…”

“…Nevertheless, complications have not been completely eliminated, with periprosthetic joint infections (PJIs) being among the most challenging complications of joint replacement surgeries and accounting for 1% to 3.7% of all cases [ 6 , 7 , 8 , 9 ]. This incidence is even higher for patients who have undergone reconstruction surgery in multiple joints [ 10 , 11 ]. A plethora of pathogens may cause PJI, including, most commonly, gram-positive and gram-negative organisms and anaerobic bacteria, and more rarely, fungi [ 6 , 8 , 9 ].…”

“…Fungal PJI represents a rare infection, occurring in approximately 1% of the total number of infected joint replacement cases, with Candida albicans being the most commonly responsible fungus, followed by non- albicans Candida , including C. glabrata , C. parapsilosis , C. freyschusii , and C. lusitaniae [ 7 , 11 ]. It should be noted that there has been a reported rise in the number of deep fungal infections over the last decade, which can be mainly attributed to the elderly population, as well as the rise of immunosuppressed hosts [ 13 , 14 ].…”