11444.00

Fluconazole-impregnated beads in the
management of fungal infection of prosthetic
joints
A. S. W. Bruce, R. M. Kerry, P. Norman, I. Stockley
From the Northern General Hospital NHS Trust, Sheffield, England
We report two cases of fungal infection of
over deep and superficial drains. Four days later treatment prosthetic joints which were successfully treated
with oral fluconazole (200 mg twice daily) was started. The by the incorporation of fluconazole into
levels of fluconazole were measured in the fluid in the drain polymethylmethacrylate beads inserted at the time of
for six days after operation (Fig. 1). Specimens of tissue debridement.
taken in February 1992, when the beads were removed,were sterile. In June 1992, a prosthesis was reimplanted J Bone Joint Surg [Br] 2001;83-B:183-4.
Received 12 June 2000; Accepted after revision 26 September 2000 with fluconazole again added to the cement. Specimens oftissue again did not grow any organisms. Oral fluconazolewas not administered. There has been no evidence of To our knowledge, only 25 cases of fungal infection around recurrence of infection for seven years.
Case 2. A 68-year-old woman underwent a replacement of
eral agreement about the need for excision arthroplasty and the femoral head for a subcapital hip fracture in 1994. In prolonged intravenous administration of antifungal agents, 1996, the implant was clinically and radiologically loose.
usually amphotericin B. Staged reimplantation was attemp- Aspirate from the hip grew Candida albicans. First-stage ted in six patients and was successful in four.
exchange surgery was carried out as described above and tual mycological cure may have been achieved, although infection with Candida albicans confirmed. Again 2 g of the follow-up was less than a year in half of the cases. We fluconazole were placed in 'home-made' Palacos R beads, incorporated fluconazole into polymethylmethacrylate and oral fluconazole was administered by the same regime.
(PMMA) in the form of beads as part of a two-stage The levels of fluconazole measured from the deep and surgical procedure in two patients. Infection of the joint by superficial drains are shown in Figure 2. Reimplantation Candida was successfully eradicated in both.
was undertaken three months later without an interveningbiopsy or administration of systemic fluconazole. Tissue specimens were sterile. The patient died more than fouryears later with no sign of recurrence of the infection, Case 1. A 51-year-old woman who had had a right total hip
either clinically or radiologically.
replacement in 1984 presented with hip pain in 1987. Abiopsy, in 1990, revealed infection with Candida parap-silosis. In August 1991, a first-stage exchange procedurewas undertaken with removal of all foreign material andinfected tissue. Candida parapsilosis was again grownfrom the specimens. Methylmethacrylate beads were pre-pared by adding 2 g of fluconazole powder to one mix ofPalacos R bone cement (Schering Plough Ltd, Mildenhall,UK), and made into chains. These were inserted into theacetabulum and femoral shaft before the wound was closed A. S. W. Bruce, FRCS, Senior House OfficerR. M. Kerry, FRCS Orth, Consultant Orthopaedic SurgeonP. Norman, FRCPath, Consultant Medical MicrobiologistI. Stockley, FRCS, Consultant Orthopaedic SurgeonNorthern General Hospital NHS Trust, Herries Road, Sheffield S5 7AU,UK.
Correspondence should be sent to Mr I. Stockley.
Case 1. The fluconazole concentration in the fluid from the deep and 2001 British Editorial Society of Bone and Joint Surgery superficial drains (arrow indicates the commencement of oral A. S. W. BRUCE, R. M. KERRY, P. NORMAN, I. STOCKLEY administered fluconazole. The high local levels obtainedfrom impregnated PMMA seem to be predictable andreliable, and oral supplementation may not be required, ashas been our experience with pyogenic deep sepsis.
No benefits in any form have been received or will be received from acommercial party related directly or indirectly to the subject of thisarticle.
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