Recalcitrant Fungal Prosthetic Joint Infection of the Knee Cleared Using Voriconazole via Intra-Articular Catheters

Prosthetic joint infection (PJI) is a high-cost and high-morbidity complication of total joint arthroplasty accounting for about 1%-2% of all joint replacements. Rarely, a fungal pathogen may cause coinfection or superinfection and complicate treatment. Fungal PJI is associated with higher morbidity and a lower rate of clearance of infection, with rates as low as 50% or less in the literature. Intra-articular antibiotics as a treatment for PJI may be a promising intervention for challenging PJIs. We present a novel case utilizing voriconazole via intra-articular catheters with successful clearance of a recalcitrant fungal prosthetic joint infection with 2 years' follow-up. A detailed case study and protocol is presented for a 71-year-old male patient who failed two 2-stage revision arthroplasties for complicated and recalcitrant fungal PJI. The patient was indicated for intra-articular administration of antifungal medication. A two-stage, both-component knee revision with placement of two indwelling intra-articular catheters was performed. Subsequently, voriconazole was administered daily for 6 weeks in alternating catheters. After completion of antifungal treatment, the catheters were removed in clinic. The patient demonstrates no evidence of infection after 2 years with a return to baseline function. To our knowledge, this is the first case in which intra-articular voriconazole is administered through indwelling catheters of the knee. We demonstrate successful clearance of a complex and recalcitrant fungal PJI using this novel treatment. Intra-articular use of voriconazole may be an option for patients with fungal PJI.