Fungal Periprosthetic Joint Infection Following Total Knee Arthroplasty as Easily Overlooked but the Most Dreaded Complication: Case Report and Systematic Review

Abstract

Background: Total knee arthroplasty is an effective procedure for the treatment of severe knee osteoarthritis. However, periprosthetic joint infection is one of the serious complications after arthroplasty. Most of the periprosthetic joint infections are caused by bacteria, while fungal periprosthetic joint infection is rare, accounting for about 1% of the total number of periprosthetic joint infections. Currently, there is a lack of reliable systemic and topical antifungal drugs, and no international guidelines have yet defined a gold standard for the medical and surgical treatment of fungal periprosthetic joint infection following total knee arthroplasty. Methods: In this paper, we report of a case of fungal periprosthetic joint infection healed with debridement, antibiotics and implant retention after total knee arthroplasty. At the same time, we searched PubMed, Embase, and Google Scholar for fungal periprosthetic joint infection following total knee arthroplasty between January 1980 and August 2022. Results: Forty-nine full-text articles and 62 finished cases were included for comparison with the present case. In all 63 included cases, 18 fungal pathogens were identified. Thirty-nine patients (62%) had other comorbidities or risk factors. For patient symptoms, pain (47/63) was the most common, followed by swelling (40/63) and localized skin warmth (12/63). Candida parapsilosiswas the most common fungal pathogen, with 22 positive cultures, followed by Candida albicans with nine positive cultures. Forty-one patients were treated with two-stage revision arthroplasty or one-stage revision arthroplasty. The results showed that of 32 patients who underwent two-stage revision arthroplasty, 28 patients were successfully treated, three patients had controlled infections awaiting prosthetic reimplantation, and one patient had mild postoperative pain. Of nine patients who underwent one-stage revision arthroplasty, eight patients were successfully treated, and one had infection recurrence. Overall, two-stage revision arthroplasty could be considered the better choice. Conclusions: Fungal periprosthetic joint infection is a rare complication of total knee arthroplasty. It lacks specific clinical manifestations, but it can lead to severe debilitating symptoms and impaired patient function. Candida is the most common cause. A fungal culture is difficult yet critical. Two-stage revision arthroplasty is the most used surgical treatment, offering a higher chance of success, but it is still controversial.