Dilution of humoral immunity: Results from a natural history study of healthy total knee arthroplasty patients

Abstract

The incidence of prosthetic joint infection (PJI) following elective primary total knee arthroplasty (TKA) is very low but serious risk remains. To identify unknown risk factors, we completed a natural history study of IgG specific for Staphylococcus aureus antigens previously phenotyped as protective (anti-Atl) and pathogenic (anti-Isd). Twenty-five male and 25 female optimized patients 50–85 years of age and BMI 24–39 undergoing primary TKA were prospectively enrolled. Blood sampling was performed preoperatively, postoperative Day 1, and at 2, 6, and 12 weeks, to assess serum cytokine, anti-staphylococcal IgG levels and anti-tetanus toxoid IgG measured via custom Luminex assay. Clinical, demographic, and PROMIS-10 data were collected with outcomes to 2 years postop. All participants completed the study and 2-year follow-up. No patients were readmitted or noted to develop a surgical site infection or serious adverse event, and patient-reported outcomes were improved. Serology revealed a highly significant decrease in six out of eight antibody titers against specific S. aureus antigens on Day 1 (p < 0.0001), five of which normalized to preoperative levels within 2 weeks. These changes were commensurate with a decrease and recovery of anti-tetanus toxoid titers, and a 20% drop in hemoglobin 13.8 ± 1.7 at preop to 11.1 ± 1.8 mg/dL on Day 1 (p < 0.0001). After TKA, a significant decrease in humoral immunity commensurate with blood loss and hemodilution was recorded. This decrease in circulating anti-staphylococcal antibodies in the early postop period may represent a periprosthetic joint infection risk factor for patients.