Lyme Arthritis After Surgery: Five Reported Cases

Lyme arthritis can develop after orthopedic surgery and may be mistaken for postoperative infection. In a review of the medical literature, Hess and colleagues describe five cases in which patients developed Lyme arthritis after joint procedures. Hess et al. reported these cases to highlight an important diagnostic challenge for clinicians practicing in Lyme-endemic regions. [1]

Lyme arthritis most often causes swelling of large joints, particularly the knee, and may occasionally appear after orthopedic surgery.

Lyme Arthritis Can Cause Knee Swelling After Surgery

Lyme arthritis typically affects large joints and most commonly involves the knee. When joint swelling develops after orthopedic surgery, clinicians often suspect prosthetic joint infection or mechanical complications. However, in Lyme-endemic regions, Lyme arthritis should also be considered.

Case 1

The first case involved a 38-year-old woman who had undergone knee surgery.

She received a “bone-patellar tendon-bone reconstruction of her anterior cruciate ligament along with a staged autologous chondrocyte transplantation to repair a traumatic cartilage lesion of her medial femoral condyle,” Hess writes.

The woman was treated with oral amoxicillin (500 mg three times daily for three weeks) and experienced improvement in her arthritis.

However, the authors reported that the chondrocyte graft failed three months after transplantation, likely secondary to the infection.

Cases of Lyme Arthritis Mimicking Prosthetic Joint Infection

The authors describe four additional cases in which Lyme arthritis presented as a possible periprosthetic joint infection (PJI).

Case 2

A 67-year-old man developed progressive knee pain and swelling over a three-month period.

“Twelve months prior, he had undergone unicompartmental joint arthroplasty of the medial compartment of the same knee,” the authors write.

The patient recovered after treatment with intravenous ceftriaxone for six weeks.

Case 3

An 83-year-old man had undergone a left total knee arthroplasty six years before presenting with three days of fever and a moderate joint effusion.

His symptoms resolved after treatment with doxycycline and intravenous ceftriaxone.

Cases 4 and 5

An 89-year-old woman presented to the emergency department with knee pain, swelling, and stiffness. She had undergone a total knee arthroplasty six years earlier.

An 80-year-old woman presented with anterior proximal tibia erythema and tenderness four months after total knee arthroplasty.

“Both were ultimately diagnosed with Lyme arthritis as the cause of their symptoms,” Hess writes.

Why Lyme Arthritis May Occur After Surgery

The authors proposed three possible explanations for Lyme arthritis following surgery:

1. The spirochete Borrelia burgdorferi may evade complete eradication and remain dormant in host tissue, particularly in joints, nervous tissue, and skin.
2. Surgical procedures may alter immune surveillance or mechanically expose dormant spirochetes, triggering inflammation when immune cells enter the joint.
3. Lyme arthritis may present as a periprosthetic joint infection (PJI), possibly related to biofilm formation by B. burgdorferi.

“These cases highlight the importance for providers practicing in Lyme-endemic regions to keep such an infection in mind when evaluating postoperative joint pain and swelling,” Hess writes.

Clinical Takeaway

Postoperative joint pain and swelling are commonly attributed to mechanical complications or bacterial prosthetic joint infection. However, in Lyme-endemic areas, Lyme arthritis should be included in the differential diagnosis.

Recognizing Lyme arthritis after surgery may help prevent unnecessary procedures and allow appropriate antibiotic treatment.

Lyme arthritis is one of the most common late manifestations discussed in our overview of Lyme disease symptoms.

Additional examples of Lyme arthritis following orthopedic procedures are described in related reports of Lyme arthritis after knee surgery and Lyme disease mimicking prosthetic joint infection.