Joint Replacement in a Patient with Fungal Skin Infection
Joint replacement surgery should be postponed until the fungal skin infection is completely eradicated, as any active infection—including superficial fungal infections—represents an absolute contraindication to elective prosthetic implantation.
Pre-operative Infection Clearance Requirements
All potential infectious foci must be eliminated before joint replacement surgery. 1 This fundamental principle applies to fungal skin infections, which can serve as a source of hematogenous seeding to the prosthetic joint during or after surgery.
Specific Pre-operative Steps:
Identify and document the type of fungal infection through clinical examination and, if necessary, culture or KOH preparation to guide appropriate antifungal therapy 2
Initiate targeted antifungal treatment based on the specific pathogen:
Confirm complete clinical resolution with absence of erythema, scaling, maceration, or other signs of active infection before proceeding 1
Wait at least 2-4 weeks after clinical resolution before scheduling surgery to ensure the infection has truly cleared and will not recrudesce perioperatively 2
Rationale for Strict Pre-operative Clearance
The evidence strongly supports this conservative approach for several critical reasons:
Fungal prosthetic joint infections are catastrophic complications. When they occur, they require aggressive two-stage revision with success rates of only 72-85% even with optimal treatment 3, 4, 5. The treatment protocol involves:
- Complete removal of all prosthetic components
- Extensive debridement of infected tissue
- Minimum 6 weeks of systemic antifungal therapy
- Delayed reimplantation after 9-33 weeks 3, 4, 5
Fungal infections have unique characteristics that make prevention paramount:
- Candida species account for 88% of fungal prosthetic joint infections 4
- Co-infection with bacteria occurs in 33% of cases, complicating treatment 4
- Initial fungal cultures are often dismissed as contamination in 21% of cases, leading to delayed diagnosis 4
- Treatment failure rates reach 28% even with optimal two-stage revision 5
Common Pitfalls to Avoid
Do not proceed with surgery if any signs of active infection remain, even if the patient is asymptomatic or the infection appears minor 1. Superficial fungal infections can seed the prosthetic joint through bacteremia during surgical manipulation.
Do not rely solely on visual inspection—obtain mycological confirmation of clearance if the infection was culture-proven initially 2. Some fungal infections may appear resolved clinically but harbor persistent organisms.
Do not abbreviate the waiting period after treatment to accommodate surgical scheduling pressures 1. The consequences of prosthetic joint infection far outweigh any inconvenience from surgical delay.
Risk Factors Requiring Extra Vigilance
Patients with the following characteristics require particularly careful pre-operative assessment 4, 5:
- Immunosuppression (corticosteroids, biologics, chemotherapy)
- Diabetes mellitus with poor glycemic control
- Chronic kidney disease
- Multiple prior surgeries at the planned operative site
- Concurrent bacterial colonization or infection
For patients with ≥2 host risk factors, consider even more conservative timing and potentially prophylactic antifungal therapy perioperatively, though this remains controversial 5.
Perioperative Antifungal Prophylaxis Considerations
While standard antibacterial prophylaxis is mandatory for all joint replacements 1, routine antifungal prophylaxis is not recommended for patients with a history of treated fungal skin infection if complete clearance has been documented 2.
However, for high-risk immunocompromised patients (transplant recipients, those on chronic corticosteroids >20 mg/day, or with recent invasive fungal infections), consider fluconazole 400 mg daily starting 24 hours pre-operatively and continuing for 48-72 hours post-operatively 2.