Lyme Arthritis After Knee Replacement Surgery
Lyme arthritis can mimic prosthetic joint infection
Knee swelling after replacement may need Lyme testing
Recognition may guide testing and treatment decisions
In their article, “Medically Managed Lyme Periprosthetic Joint Infection: A Case Report,” Saar et al. describe a patient with acute Lyme arthritis complicated by a previous total knee arthroplasty.
Lyme arthritis after knee replacement is rare but can mimic prosthetic joint infection, causing swelling, warmth, pain, and difficulty walking.
A 68-year-old man living in Virginia presented to a medical clinic with suprapatellar swelling, pain, heat, and mild erythema of the left knee. “He noted pain with passive flexion and extension of the knee, as well as a noticeable limp,” the authors state.
Twelve years earlier, the man had a total knee arthroplasty for degenerative joint disease.
PCR testing was positive for Borrelia. The patient’s left knee was drained, but follow-up testing still detected Borrelia DNA.
Distinguishing Lyme arthritis from bacterial prosthetic joint infection may be difficult because both can present with inflammatory joint findings.
However, this patient was treated successfully with 3 months of doxycycline.
“Upon completion of 90 days of doxycycline therapy, the patient returned for further evaluation, reporting the cessation of transient swelling and the absence of pain,” the authors state.
“Given our success with oral antibiotics, medical management may be a viable treatment for patients with acute, uncomplicated Lyme [periprosthetic joint infection],” the authors state.
Treatment of Lyme periprosthetic joint infection
Because only a handful of Lyme periprosthetic joint infection cases have been reported in the literature, there are no recommended treatment guidelines.
“This has left physicians trying to blend the treatment guidelines for Lyme arthritis, which is medically managed with antibiotics, and PJIs, which involve invasive surgical procedures,” the authors state.
Lyme periprosthetic joint infections are rare, difficult to recognize, and typically require surgical intervention.
Out of the five cases reported in the literature, 4 patients were treated successfully with surgery and antibiotics, while only 1 patient was treated successfully with IV and oral antibiotics.
Why Lyme arthritis can be mistaken for prosthetic joint infection
Lyme arthritis may present with knee swelling, pain, warmth, and difficulty walking. These findings can overlap with prosthetic joint infection, especially in a patient with a prior knee replacement.
Patients with knee swelling after possible tick exposure may also need evaluation for Lyme disease symptoms, especially in endemic areas.
Testing can be important because Lyme arthritis may be missed if clinicians assume swelling around a prosthetic joint is bacterial infection alone. For broader diagnostic context, see Lyme test accuracy.
When should Lyme arthritis be considered?
Lyme arthritis should be considered when a patient presents with unexplained knee swelling, atraumatic effusion, pain, warmth, or recurrent swelling, particularly in a Lyme-endemic region.
This may be especially important when standard cultures are negative or when symptoms do not follow the expected course for a typical prosthetic joint infection.
Patients with persistent or recurrent joint symptoms may also benefit from reviewing Lyme disease joint pain.
Authors conclude
- “When a patient presents with atraumatic knee effusion, especially in areas where Lyme disease is prevalent, Lyme arthritis should be investigated.”
- Furthermore, “given the prevalence of Lyme arthritis in areas that are endemic to Lyme disease, it may be of benefit to add a synovial fluid PCR test, the gold standard for diagnosis of Lyme arthritis.”
- “Medical management of Lyme PJI may be a viable option for patients who present with new onset symptoms, avoiding the risk of operative interventions.”
Frequently Asked Questions
Can Lyme arthritis occur after knee replacement?
Yes. Lyme arthritis can occur in a patient with a prior knee replacement and may mimic prosthetic joint infection.
Can Lyme disease cause swelling in a prosthetic knee?
Yes. In reported cases, Lyme arthritis has presented with swelling, pain, warmth, and effusion involving a prosthetic knee.
How is Lyme arthritis diagnosed in a swollen knee?
Evaluation may include clinical history, Lyme serology, synovial fluid testing, and in some cases PCR testing for Borrelia DNA.
Can Lyme periprosthetic joint infection be treated without surgery?
In this case report, the patient improved with medical management, but the authors note that there are few cases and no established treatment guidelines.
When should Lyme disease be considered after knee replacement?
Lyme disease should be considered when knee swelling is atraumatic, unexplained, recurrent, or occurs in a Lyme-endemic area.
Can Lyme arthritis cause a failed knee replacement?
Lyme arthritis may mimic prosthetic joint complications, but determining whether symptoms are due to Lyme disease, hardware issues, or infection requires evaluation.
Clinical Takeaway
Lyme arthritis can mimic prosthetic joint infection after knee replacement surgery.
In patients with atraumatic knee swelling, especially in Lyme-endemic regions, clinicians may need to consider Lyme arthritis in the differential diagnosis.
Recognizing Lyme arthritis in a prosthetic joint may help guide testing, treatment decisions, and avoidance of unnecessary surgical intervention when appropriate.
Related Articles
Lyme disease mimics prosthetic joint infection following knee replacement
5 cases of Lyme arthritis following an operation
MRI can help identify Lyme arthritis in children
Persistent Lyme disease symptoms
References
- Saar A, Fairbanks S. Medically Managed Lyme Periprosthetic Joint Infection: A Case Report. Cureus. 2024;16(3):e56457. PMID: 38638742; PMCID: PMC11025306.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
