Comparative Effects of Treatment Strategies for Fungal Periprosthetic Joint Infection: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Fungal periprosthetic joint infection (FPJI) is extremely rare, but has devastating outcomes and lower treatment success rates than bacterial PJI. However, optimal management remains unclear due to limited and heterogeneous evidence. We aimed to examine the comparative effects of different interventions for infection eradication using a network meta-analysis approach. METHODS: There were four databases searched from their inception to September 2025. Cohort studies and case series reporting more than 10 cases were included. The quality of the included studies was assessed using Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). A total of 691 FPJI cases (including 335 hips and 356 knees) from 17 articles were included. Network meta-analysis was performed using a random-effects model in a frequentist framework. The effect was measured using odds ratios (OR) with 95% confidence intervals (CI). RESULTS: The odds of treatment success with DAIR (debridement, antibiotic, and implant retention) were 68% lower than with one-stage revision (OR = 0.32, 95% CI 0.11 to 0.90) and 60% lower than with two-stage revision (OR = 0.40, 95% CI 0.24 to 0.69). There were no statistically significant differences observed in other treatment comparisons (three-stage revision, definite implant resection, arthrodesis, amputation, and anti-fungal suppression). There was no clear evidence that joint type (knee or hip) modified the treatment effect. CONCLUSIONS: There were no significant differences observed between most surgical treatment strategies for FPJI. However, DAIR was associated with significantly lower treatment success and should be considered as a contraindication in FPJI.