Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a serious complication with substantial functional and prognostic impact. Although multidisciplinary treatment combining surgical debridement and systemic antimicrobial therapy is standard, chronic cases often require repeated interventions, and implant removal or even limb amputation may ultimately be considered. In chronic PJI, repeated antimicrobial exposure and alterations in the infectious environment may promote microbial shift, and fungal PJI has been increasingly reported. Consequently, fungal PJI is no longer considered exceedingly rare and is encountered more frequently. Despite its increasing recognition, fungal PJI remains among the most challenging conditions to treat, and consensus regarding optimal management is lacking.
Fungi form robust biofilms on implant surfaces and adapt a low-metabolic state, reducing susceptibility to antifungal agents and complicating eradication. Infection may recur even after two-stage revision arthroplasty, with suboptimal outcomes,.
Povidone-iodine is a broad-spectrum antiseptic active against bacteria and fungi and is widely used for surgical irrigation and wound management,. However, repeated intra-articular administration has rarely been reported and is not established treatment. Prolonged local povidone-iodine irrigation has been reported in other refractory implant-related infections, suggesting that local environmental control may provide therapeutic benefit beyond systemic antimicrobial therapy alone. Repeated intra-articular low-dose povidone-iodine may therefore reset the biofilm-containing infectious environment, although evidence in fungal PJI is scarce.
In this report, we describe a rare case of refractory fungal TKA infection resistant to standard surgical and antifungal treatments in which limb amputation was considered. Repeated daily intra-articular instillation of low-dose povidone-iodine achieved infection control and implant preservation, suggesting a potential salvage strategy for fungal PJI.
