Treatment for Lyme Arthritis: When Symptoms Persist After Knee Replacement
Treatment for Lyme arthritis typically involves antibiotic therapy and may prevent unnecessary orthopedic surgery. Doctors described a 67-year-old avid outdoorsman who developed Lyme arthritis after knee replacement surgery and was successfully treated with antibiotics.
Key Question: Can Lyme arthritis be missed—even after knee replacement surgery?
In some cases, persistent joint swelling after surgery is not mechanical failure but an untreated infection such as Lyme disease. Recognizing this distinction can prevent unnecessary procedures and lead to effective treatment.
Joint swelling is one of many presentations covered in our Lyme disease symptoms guide, where musculoskeletal and neurologic patterns are explained in context.
Persistent joint inflammation may reflect broader patterns seen in persistent Lyme disease mechanisms, including ongoing infection and immune activation.
Ten months earlier, the patient had received a partial knee replacement of the left knee for advanced single-compartment degenerative arthritis.
Over a three-month period, the man developed progressive left knee pain and swelling. When evaluated, he had a moderate joint effusion but did not have an erythema migrans rash, warmth, instability, or significant pain with range of motion.
There was no history of a tick bite or trauma to the knee, and imaging showed no evidence of infection or Baker’s cyst.
Why Lyme Arthritis May Be Missed After Knee Surgery
Clinical Insight: Persistent joint swelling after orthopedic procedures is not always due to mechanical complications. In endemic areas, Lyme disease should remain on the differential diagnosis—even without a known tick bite or rash.
Diagnosis of Lyme Arthritis
Aspiration of the knee revealed turbid purulent pleocytosis with 91.8% neutrophils, elevated C-reactive protein, and a positive Borrelia burgdorferi polymerase chain reaction (PCR).
Serologic tests were also positive. Laboratory results included an elevated erythrocyte sedimentation rate (ESR), elevated inflammatory markers, a positive B. burgdorferi antibody enzyme immunoassay (EIA), and 10 of 10 IgG Western blot bands were reactive.
Based on detection of Borrelia burgdorferi sensu stricto DNA by PCR, clinicians diagnosed Lyme arthritis involving a prosthetic knee joint.
The diagnosis met criteria established by the Musculoskeletal Infection Society and the Infectious Disease Society of America (IDSA).
“Although there was no communicating sinus tract or direct result from traditional microbiological culture, our patient met these criteria for periprosthetic joint infection based upon elevated synovial fluid leukocyte count (>3000 cells/µL), elevated synovial neutrophil percentage (>65%), purulence, and evidence of a microorganism identified to the level of genus and species,” according to Wright and colleagues.
Periprosthetic Joint Infection Risk
The authors emphasized the seriousness of periprosthetic joint infections.
“Periprosthetic joint infection is a devastating complication following joint arthroplasty that causes significant morbidity with an estimated cumulative incidence of 1%–2% for both hip and knee replacements,” the authors wrote.
Why Standard Lyme Arthritis Guidelines Did Not Apply
Wright and colleagues concluded that standard IDSA treatment recommendations for Lyme arthritis were not fully applicable in this case.
Two commonly cited treatment recommendations include:
- Late Lyme arthritis can usually be treated successfully with oral antibiotics such as doxycycline, amoxicillin, or cefuroxime for 28 days.
- Previous studies have demonstrated the effectiveness of once-daily intravenous ceftriaxone (2 g) for 14–28 days in the treatment of late Lyme disease.
Because this infection involved a prosthetic knee joint, clinicians pursued a more aggressive antibiotic strategy.
Treatment for Lyme Arthritis With Antibiotics
The patient was initially started on oral doxycycline 100 mg twice daily for one week while confirmatory testing was pending.
After Lyme arthritis was confirmed, treatment was transitioned to a six-week course of intravenous ceftriaxone (2 g daily).
The antibiotic treatment for Lyme arthritis was successful. According to Wright, the patient experienced:
- Resolution of knee pain
- Disappearance of joint effusion
- Normalization of inflammatory markers
- Negative end-of-therapy PCR testing for Borrelia burgdorferi
The patient recovered without the need for surgical incision and drainage or prosthetic joint removal.
The authors cautioned that prolonged intravenous antibiotic therapy may not produce similar outcomes in other types of prosthetic joint infections.
“Although this patient’s clinical outcome was achieved without surgical incision and drainage or staged excision arthroplasty, it is unclear whether this strategy would produce similar results in other joint arthroplasty infections,” the authors wrote.
Clinical Implications
This case highlights the importance of considering Lyme arthritis in patients with unexplained joint inflammation, particularly in regions where Lyme disease is endemic.
When persistent swelling follows surgery, the answer is not always mechanical failure or routine postoperative inflammation. In some patients, early recognition and prompt treatment for Lyme arthritis may prevent additional surgery and lead to recovery with antibiotic therapy alone.
“This case highlights how early prompt diagnosis and adequate antimicrobial therapy may obviate the need for additional aggressive orthopedic surgical intervention,” Wright concluded.
FAQ: Treatment for Lyme Arthritis
Can Lyme arthritis occur after knee replacement?
Yes. Lyme arthritis can present after knee replacement and may mimic other causes of joint inflammation.
Does treatment for Lyme arthritis always require surgery?
No. In some cases, antibiotic therapy can resolve symptoms without additional surgery.
Can Lyme arthritis be diagnosed without a known tick bite?
Yes. Many patients do not recall a tick bite or rash, and diagnosis may depend on laboratory findings and clinical evaluation.
Related Articles:
5 cases of Lyme arthritis following an operation
Will steroid injections help children with Lyme arthritis of the knee?
Preventing unnecessary surgery for children with Lyme arthritis
References:
- Wright WF, Oliverio JA. First Case of Lyme Arthritis Involving a Prosthetic Knee Joint. Open Forum Infect Dis. 2016;3(2):ofw096.
- Cohen JR, Bradley AT, Lieberman JR. Preoperative Interventions and Charges Before Total Knee Arthroplasty. J Arthroplasty. 2016.
- Fallon BA, Keilp JG, Corbera KM et al. Neurology. 2008.
- Cameron DJ. J Eval Clin Pract. 2007.
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
My son has chronic lyme disease. He has it in his left knee. We have tried antibiotics, biofilm busters, oxidative therapies Iv antibiotics( only once)
Any suggestions we live in Maine
Call the office at 914 666 4665 if you need any information
Dr Cameron, I contracted Lyme Disease in 1989 and have been treated and manage my Chronic Lyme Disease. I had a knee replacement 4 years ago and I need another as soon as I can solve this problem. In January my knee replacement knee became inflamed and after careful evaluation for loose parts and bakers cyst, no reason could be found. I am anxious about getting another knee replacement and have the same problem, so I am trying to find out more. My primary care is Dr. Daniel Peterson of Incline Village Nevada, I am also part of studies at Columbia with Dr. Brian Falon. I would like to arrange to have the fluid remove from the knee replacement to see if the bacteria could be cultured. Where could I send the sample. I live in Santa Rosa, California. I would be able to travel to get this done. Thank you, Barbara McKenna, age 69. st****@***il.com
Barbara S. McKenna, st****@***il.com
New York has supported cultures. We are not clear on where to sent the fluid.
I acquired a patient who had total knee arthroplasty after delayed treatment for EM rash just 2 months earlier. previous to this he had Lyme diagnosed in past with IDSA treatment. I believe at time of surgery for knee he was not treated adequately for his very recent and remote infections, then underwent the surgery. I met him a year later when informed he had to retire early due to persistent pain in the knee and has declined since, with multi system symptoms. Tried oral combinations then Bicillin with no benefit. Not clear if persistent infection, biofilm, immune activation. Is there value in IV Ceftriaxone at this point? surgery was 2017, met him 2019
Hello,
My name is JoAnne Hopkins. I am a 61 year old female status post bilateral total knee replacements in Jan 2016. Initially the result was very good and the pain was alleviated. However, I was diagnosed about a year later with Lyme disease when I had a spontaneous rupture of my extensor pollicis longus tendon of my left thumb. I never had a rash so my lyme went untreated for quite sometime. I see a lyme specialist regularly since then and have been on and off oral antibiotics for 4 1/2 years. After being off the antibiotics for approximately 6 months (this was about 2 years ago) I developed increased pain in both of my knees. I have since been back on oral antibiotics but feel the damage has been done and the knee pain is getting worse. The orthopedist has taken X rays at least 2 or 3 times since then and he states that there is no orthopedic reason for my increased pain. He states that he could aspirate but as there is no real edema present, he didn’t think it was a good idea due to risk of infection. My Lyme specialist is also not familiar with this. I have asked numerous doctors about the lyme being the cause of this increased pain but none seem to have any experience with it. I recently had lumbar surgery, 4 months ago, for chronic pain due to spondylolysthesis, and am starting to have increased pain again. I an fearing that the Lyme has now invaded that region as well. When I saw this article about the lyme infection post knee surgery I was very excited. I am hoping you may have some suggestions that I could relay to my lyme specialist. Some questions I have are should I proceed with the aspiration? Should I see an infectious disease specialist? I don’t live very far from New York as I reside in west central New Jersey. Thank you for your time. I look forward to hearing from you.
I have patients who have a history of orthopedic surgery or an orthopedic injury who have benefits from antibiotics. It is hard to judge whether additional antibiotics would be helpful.
Dr. Cameron
First thank you for all the information you put out for us with Lymes and co-infections (babesia).
I had arthritis in my feet, surgery was done several screw put in. In the same timeframe surgery on my wrists and elbows.
Two years later the pain in my feet continued to get worse we could see the rejection of hardware and the hardware was removed All but on screw right big toe.
June I had L-4 L-5 laminectomy and fusion. 4 screws, disk and bone graph from hip.
I have continually worried about another rejection, the pain has been extreme in left buttock to toes since the surgery.
Anxiety has been high since surgery
I have written all this and can’t remember my original thought. This happens often. Any thoughts from you on this
Same here, knee replacement 8/19, no problems, tick bite, 4/21, 4 weeks doxycycline, therapy, 2 aspirations now, clear fluids . Thought replacement would help me enjoy grandchildren, but instead dealing with pain, swelling, can’t do flowerbeds, limited activities with children, at 71 I’m not to old to enjoy retirement, instead dealing with pain, swelling, limit Ed activities, depressing…both drs don’t seem to have all the facts on this!
Same here, knee replacement 8/19, no problems, tick bite, 4/21, 4 weeks doxycycline, therapy, 2 aspirations now, clear fluids . Thought replacement would help me enjoy grandchildren, but instead dealing with pain, swelling, can’t do flowerbeds, limited activities with children, at 71 I’m not to old to enjoy retirement, instead dealing with pain, swelling, limit Ed activities, depressing…both drs don’t seem to have all the facts on this!