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Neutrophil–Lymphocyte Ratio and Lymphocyte–Monocyte Ratio correlate with Chronic Prosthetic Joint Infection but are not useful markers for diagnosis

  • Knee Revision Surgery
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Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript



To investigate reported correlations between Neutrophil-to-Lymphocyte (NLR) and Lymphocyte-to-Monocyte (LMR) ratios and their value in diagnosis of chronic prosthetic joint infection (PJI) in a large cohort of patients from a single specialist hospital.


Diagnostic aspirations of 362 patients under investigation for PJI were identified. Of the included patients 185 patients received a final diagnosis of PJI and 177 were classed as aseptic. Established criteria (ICM 2018) were employed to define PJI. Included in the analysis are differential white cell counts, C-Reactive Protein (CRP), Synovial Leukocyte Count, Synovial Alpha-defensin ELISA and Synovial Leukocyte esterase activity.

Receiver-operator characteristic (ROC) curves were calculated for each of the available diagnostic tests together with the corresponding area under the curve values (AUC). Youden’s index was utilized to identify the optimal diagnostic threshold point for the NLR and LMR. Other diagnostic tests were evaluated as per the threshold values previously defined in the literature and specified in the ICM criteria.


Using Youden’s Index to identify the optimal NLR cut-off within our cohort we established a value of 2.93. This yielded a sensitivity of 0.60 and specificity of 0.64. The area under the curve (AUC) of a receiving operator characteristics (ROC) curve was 0.625. Regarding the LMR the results demonstrate similar findings; a positive correlation with a diagnosis of infection but poor sensitivity and specificity. The AUC for LMR was 0.633 and was not superior to NLR (P = 0.753).


There is a significant correlation between higher Neutrophil–Lymphocyte and Lymphocyte–Monocyte ratios, and a diagnosis of PJI. The sensitivity and specificity of this calculation is poor and the does not add value to the diagnostic algorithm for PJI.

Level of evidence

Level III Retrospective Cohort analysis.

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Data availability

Data is available on request subject to ethical approval.


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Correspondence to Daniel Timothy Burchette.

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Conflict of interest

DTB, BFM, MFD, PL have no declarations to make, MC has received payments from Waldemayer Link not related to this project. TG receives royalties from Waldemar Link, Zimmer, Ceramtec, Heraeus, outside the scope of this article.

Ethical approval

All patients gave informed consent to participate in the present study, which was approved by a regional review board and the Hamburg Medical Chamber ethics committee. The study was carried out in accordance with the World Medical Association Declaration of Helsinki. Patient confidentiality was appropriately protected according to German federal law.

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All patients gave informed consent for their clinical details to be included in this study in anonymised form.

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Burchette, D.T., Dasci, M.F., Fernandez Maza, B. et al. Neutrophil–Lymphocyte Ratio and Lymphocyte–Monocyte Ratio correlate with Chronic Prosthetic Joint Infection but are not useful markers for diagnosis. Arch Orthop Trauma Surg 144, 297–305 (2024).

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