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
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. 1. MacGregor RR, Schimmer BM, Steinberg ME. Results of com-
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