Volume VII, Number 1 | April 2023

A True Consensus on Lyme Prosthetic Joint Infection in Total Knee Arthroplasty: A Literature Review

1Ali M, 1Kamson A, 2King S
1UPMC Pinnacle, Harrisburg, PA, United States; 2UPMC – Arlington Orthopedics, Harrisburg, PA, United States

INTRODUCTION/OBJECTIVE: A Lyme prosthetic joint infection (PJI) is a rare occurrence, however, it is important to consider this disease as a possible cause of PJI’s in endemic regions. As far as we know, there have only been 4 cases of Lyme arthritis associated with total knee prosthetic joint infections reported in the literature. Diagnosis of a PJI remains difficult and when associated with Lyme disease, becomes very complicated. The Musculoskeletal Society Infection (MSIS) criteria are often used to assist in diagnosis, which include major and minor criteria which are collectively comprised of a positive culture, presence of a sinus tract, ESR, CRP, synovial fluid cell count, and neutrophil differential. To diagnose a Lyme PJI, synovial fluid cultures must remain negative for any other organism, but synovial fluid Lyme PCR will be positive. Timely diagnosis and early intervention decreases the morbidity and mortality associated with PJIs. Of the reported cases, 75% have been treated successfully with surgical intervention. The purpose of the study is to raise awareness and initiate the development of a treatment algorithm for Lyme PJI.

METHODS: We searched PubMed for reports of prosthetic joint infections secondary to Lyme disease published prior to February 2, 2021 and found four reported cases. Our keywords were ‘Lyme,’ ‘Lyme disease,’ culture negative,’ ‘total knee arthroplasty,’ ‘TKA,’ and ‘prosthetic joint infection.’ Cases were analyzed for diagnostic protocols, knee aspiration results, treatment pathways, and outcomes.

RESULTS: All four patients resided in the Northeastern United States. Synovial fluid Lyme PCR and serological tests were positive and Lyme disease was confirmed via enzyme-linked immunofluorescence assay and western blot in all patients. Three cases were treated with surgery and post-operative antibiotics. One patient was treated with antibiotics alone. At their latest follow up, all patients had a painless, functional knee.

CONCLUSIONS: Lyme disease is caused by the spirochete Borrelia burgdorferi, transported through the bite of an Ixodes tick. It is most common in the Northeastern and upper Midwestern United States. Arthritis is frequently a late sign of Lyme disease and symptoms appear months after a tick bite in most untreated cases. With appropriate antibiotic therapy, joint inflammation resolves in most patients. B. burgdorferi leads to the production of biofilm and matrix metalloproteinase (MMP) which causes degradation of extracellular matrix proteins, collagen, and proteoglycans. Elevated levels of MMPs in the synovial fluid can lead to implant loosening. Considering these factors, theoretically non-surgical treatment would likely be unsuccessful. With the increasing number of arthroplasties performed, more Lyme PJI cases are likely to be encountered. Taking into account the current literature, we recommend having a higher suspicion for Lyme disease as a cause of culture-negative prosthetic joint infections especially in endemic regions, as well as, considering surgical intervention as a treatment for Lyme PJI to potentially decrease the likelihood of recurrent infections, implant failure, and dreadful systemic complications associated with longstanding Lyme disease.

The Journal of the American Osteopathic Academy of Orthopedics

Steven J. Heithoff, DO, FAOAO

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