Three-stage revision arthroplasty for the treatment of fungal periprosthetic joint infection: outcome analysis of a novel treatment algorithm: a prospective study

• Main Authors: Hinnerk Baecker, Sven Frieler, Jan Geßmann, Stephan Pauly, Thomas A. Schildhauer, Yannik Hanusrichter
• Format: Article
• Language: English
• Published: The British Editorial Society of Bone & Joint Surgery 2021-08-01
• Series: Bone & Joint Open
• Subjects: prosthetic joint infection; total hip arthroplasty; total knee arthroplasty; revision arthroplasty; fungal infection; fungal prosthetic joint infection; infection treatment; fpji; pji; revision joint arthroplasty; periprosthetic joint infections (pji); infections; fungal infections; knee arthrodesis; charlson comorbidity index (cci); joint infection; girdlestone procedures; bmi; bone cement
• Online Access: https://online.boneandjoint.org.uk/doi/epdf/10.1302/2633-1462.28.BJO-2021-0002.R2

Aims: Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods: From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results: Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion: Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671–678.