Approaches in surgical treatment of fungal prosthetic joint infection

Background: Fungal prosthetic joint infection (fPJI) is an infrequent but complex complication of arthroplasty, occurring in 0.6% to 2% of cases. Primarily caused by Candida species, these infections are characterized by insidious clinical presentations and the formation of resilient biofilms on prosthetic surfaces. Diagnosis is often delayed due to non-specific inflammatory markers and the requirement for prolonged culture incubation.

Objective: This review synthesizes current literature regarding the epidemiology, risk factors, diagnostic protocols, and surgical management strategies for fPJI to provide evidence-based clinical recommendations.

Key Points: Candida species account for 50% to 80% of cases, frequently involving polymicrobial biofilms with Staphylococcus species. Risk factors include immunosuppression, diabetes, and prior revision surgery. Diagnostic accuracy relies on standardized sampling, as systemic markers like C-reactive protein may remain normal. Surgical options include debridement, antibiotics, and implant retention (DAIR), which demonstrates low success rates (20-30%), and staged revision. Two-stage revision is the most utilized approach, with reported success rates between 47% and 100%. Emerging protocols suggest three-stage revisions or antifungal-loaded spacers containing amphotericin B or voriconazole. However, optimal antifungal duration and reimplantation timing remain controversial.

Conclusion: Management of fPJI requires aggressive surgical debridement combined with prolonged systemic antifungal therapy. While two-stage revision is the current preferred strategy, the lack of high-level evidence necessitates multicenter studies to standardize treatment algorithms and optimize local antifungal delivery methods.