Full bibliography

Summary:

Fungal PJI is rare but challenging to treat. Risk factors for fungal PJI include immunosuppression and prolonged antibiotic use.

1. Materials and Methods: The authors conducted a systematic search of medical literature to identify studies reporting cases of fungal PJI in TKA patients. 36 studies including 45 cases of fungal knee PJI were included. Data on patient demographics, clinical presentation, diagnostic methods, surgical treatments, and outcomes were collected.
2. Preoperative Findings and Diagnostic Steps: Clinical symptoms of fungal PJI included pain, local and systemic signs of infection, and increased serological infection markers. Radiological evaluation often showed prosthesis loosening or bone destruction. Fungal pathogens were detected through preoperative joint aspirations or intraoperative tissue samples. Candida species were the most commonly identified pathogens.
3. Surgical Treatment: The initial surgical treatment for fungal PJI varied, with resection arthroplasty being the most common approach. Radical debridement and removal of all cement were emphasized. Some patients received intra-articular spacers, and a few had cement impregnated with antifungal agents. One-stage procedures without prosthesis removal were performed in some cases.
4. Medical Therapy: All but one patient received systemic antifungal therapy, primarily with drugs like fluconazole and amphotericin B. Some patients received a combination or sequential therapy with different antifungal drugs. Local antifungal medication, such as impregnated cement spacers or intra-articular powder, was used in some cases.
5. Resection Arthroplasty with Delayed Re-Implantation: A two-stage approach involving resection arthroplasty followed by delayed re-implantation was commonly used. During this period, systemic antifungal medication was sometimes continued, and intraoperative cultures were checked before re-implantation. The duration between resection and re-implantation varied.
6. Outcome and Monitoring: The average follow-up period was approximately 37 months. Some patients experienced treatment failure, with recurrent fungal PJI or secondary bacterial PJI. Above-knee amputation was performed in cases of treatment failure. Monitoring during the follow-up phase involved clinical, radiographic, and serological examinations.
7. Discussion: The article discussed the definition of fungal PJI and the importance of diagnostic steps, including joint aspirations and tissue sample collection. It highlighted the need for systemic antifungal therapy and the challenges of local antifungal treatment. Surgical treatment options, especially resection arthroplasty with delayed re-implantation, were recommended, with a focus on infection control. Monitoring during the postoperative phase was discussed.