title: Staged reimplantation for the treatment of fungal peri-prosthetic joint infection following primary total knee arthroplasty.
abstract: BACKGROUND
  Fungal peri-prosthetic joint infections (PJI) are rare complication following total knee arthroplasty (TKA). There exists no established guidelines in the treatment of these infections and controversies are focused on the usefulness of antifungal-loaded cement spacers, the duration of systemic antifungal treatment and the ideal interval between implant removal and reimplantation. Therefore we ask if: (1) adding antifungal in cement space is a viable solution to manage fungal PJI; (2) there is no adverse effect adding antifungal medication in cement?
  
  
  OBJECTIVE
  We hypothesized that fungal PJI following TKA could be managed successfully by 2-stage reimplantation strategy using antifungal-loaded cement spacer.
  
  
  METHODS
  Five cases of fungal PJI following total knee arthroplasty were treated in our institution between 2007 and 2013 using a 2-stage reimplantation strategy. The median elapsed time from primary arthroplasty to the diagnosis of infection was 7.4 months (range, 5-10 months). The infection was caused by Candida species in 4 cases and Pichia anomala in 1 case. Antibiotic- and antifungal-loaded articulating cement spacer was implanted during the interval between stages. Systemic antifungal agents were administered for at least 6 weeks after removal of prosthesis in all cases. The mean interval between removal and reimplantation was 6 months (range, 3-9 months).
  
  
  RESULTS
  At a mean follow-up of 41.6 months (range, 24-65 months) after reimplantation, no patient had recurrent infection or revision due to any other reasons. The mean global IKS score improved from 58.4 (range, 37-96 points) preoperatively to 152.4 (range, 136-169 points) at final follow-up. The average range of motion of the knee for flexion improved from 63° (range, 10-110°) preoperatively to 98° (range, 80-120°) at final follow-up.
  
  
  CONCLUSIONS
  Fungal PJI following TKA can be successfully treated by a staged reimplantation strategy. Antibiotic- and antifungal-loaded cement spacer implanted during interval period between stages may be an effective adjunct to therapy. Effective antifungal therapy is crucial to a successful result without adverse effect.
  
  
  METHODS
  IV: retrospective or historical series.
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China.
authors: Q-J
authors: QJ
authors: Wang
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China.
authors: H
authors: H
authors: Shen
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China. Electronic address: xlzhang40@gmail.com.
authors: X-L
authors: XL
authors: Zhang
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China.
authors: Y
authors: Y
authors: Jiang
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China.
authors: Q
authors: Q
authors: Wang
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China.
authors: Y S
authors: YS
authors: Chen
authors: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, 200233 Shanghai, PR China.
authors: J-J
authors: JJ
authors: Shao
mesh_terms: D000368:Aged; D000935:Antifungal Agents / Q000627:therapeutic use*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D020878:Device Removal; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000628:therapy*; D016459:Prosthesis-Related Infections / Q000628:therapy*; D012092:Replantation; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000935:Antifungal Agents
keywords: Antifungal therapy; Antifungal-loaded bone cement; Fungal peri-prosthetic infection; Reimplantation; Two-stage revision