The Journal of Arthroplasty xxx (2023) 1e8

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The Journal of Arthroplasty

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Neutrophil to Lymphocyte Ratio and Periprosthetic Joint Infection:

A Systematic Review and Meta-Analysis
Maryam Salimi, MD a, Joseph Albert Karam, MD b, Matthew Willman, MD c,
Jonathan Willman, MD c, Brandon Lucke-Wold, MD d, Shokoufeh Khanzadeh, MD e,
Peyman Mirghaderi, MD f, Javad Parvizi, MD g, *
a
Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
b
Department of Orthopedic Surgery, University of Illinois at Chicago, Chicago, Illinois
c
University of Florida, Gainesville, Florida
d
Department of Neurosurgery, University of Florida, Gainesville, Florida
e
Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
f
Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
g
Department of Orthopedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania

a r t i c l e i n f o a b s t r a c t

Article history: Background: The neutrophil-to-lymphocyte ratio (NLR) has shown promising results as a diagnostic tool
Received 28 November 2022 for periprosthetic joint infection (PJI) after total joint arthroplasty. We conducted a systematic review and
Received in revised form meta-analysis to determine the utility of NLR in the diagnosis of PJI.
17 August 2023
Methods: We searched PubMed, Scopus, and Web of Science from inception up to 2022 and evaluated
Accepted 19 August 2023
Available online xxx
the quality of the included literature.
Results: Based on the 12 eligible studies, NLR levels were significantly higher in patients who had PJI
compared to those who had aseptic loosening (standard mean difference (SMD) ¼ 1.05, 95% Confidence
Keywords:
neutrophil to lymphocyte ratio
Interval (CI) ¼ 0.71 to 1.40, P < .001). In the subgroup analysis according to type of PJI, NLR levels were
periprosthetic joint infection significantly higher in patients who had either acute (SMD ¼ 1.04, 95% CI ¼ 0.05 to 2.03, P < .001) or
meta-analysis chronic PJI (SMD ¼ 1.08, 95% CI ¼ 0.55 to 1.61, P < .001), compared to those who had aseptic loosening.
biomarkers According to type of arthroplasty, NLR levels were significantly higher in patients who had either total
total joint arthroplasty knee arthroplasty (SMD ¼ 1.81, 95% CI ¼ 1.48 to 2.13, P < .001) or total hip arthroplasty (SMD ¼ 1.76, 95%
CI ¼ 1.54 to 1.98, P < .001) compared to aseptic loosening. The pooled sensitivity of the 12 studies was
0.73 (95% CI, 0.65 to 0.79), and the pooled specificity was 0.75 (95% CI, 0.71 to 0.78). The pooled positive
likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of NLR were 2.94 (95% CI ¼ 2.44 to
3.54), 0.35 (95% CI ¼ 0.27 to 0.46), and 8.26 (95% CI ¼ 5.42 to 12.58), respectively.
Conclusion: In summary, this meta-analysis indicates that NLR is a reliable marker in the diagnosis of PJI.
© 2023 Published by Elsevier Inc.

The reported incidence of periprosthetic joint infection (PJI) after
total hip arthroplasty (THA) and total knee arthroplasty (TKA) ranges
from 0.2 to 2.2% after primary surgery and up to 10% after revision
procedures [1]. With an aging population and increased life
One or more of the authors of this paper have disclosed potential or pertinent
conflicts of interest, which may include receipt of payment, either direct or indirect,
institutional support, or association with an entity in the biomedical field which
may be perceived to have potential conflict of interest with this work. For full
disclosure statements refer to https://doi.org/10.1016/j.arth.2023.08.067.
* Address correspondence to: Javad Parvizi, MD, Rothman Orthopaedic Institute
at Thomas Jefferson University, Sheridan Building, Suite 1000125 S 9th Street,
Philadelphia, PA 19107.
expectancy, the number of joint arthroplasties and subsequent in-
fections is expected to rise [2]. The combined cost of PJI treatment
after THA and TKA in the United States was estimated to be $902
million in 2017, and is projected to increase to $1.85 billion per year
by 2030 [3].
The diagnosis of PJI has been traditionally made by initial
screening for elevated serum inflammation markers such as C-
reactive protein (CRP) (mg/dL) and erythrocyte sedimentation rate
(ESR), and subsequently confirmed with the aspiration of the joint
and analysis of the synovial fluid [4]. However, several independent
factors such as sex, age, and the presence or absence of inflam-
matory conditions can affect the values of the aforementioned in-
flammatory biomarkers [5]. In addition, the development and

https://doi.org/10.1016/j.arth.2023.08.067
0883-5403/© 2023 Published by Elsevier Inc.
2 M. Salimi et al. / The Journal of Arthroplasty xxx (2023) 1e8
aggregation of a bacterial biofilm matrix composed of poly-
saccharides, lipids, proteins, and extracellular DNA is believed to
play an integral role in false negative results of culture as well as
antibiotic resistance in these patients [6,7]. It is estimated that 20 to
50% of PJI cases are ‘culture-negative’ and failure to isolate a caus-
ative pathogen in these cases can erroneously result in a diagnostic
conclusion of aseptic failure [8]. Moreover, antimicrobial therapy
may resolve systemic symptoms from pathogens while the sessile
forms in the biofilm remain unaffected [9].
Serum D-dimer has also been suggested as a diagnostic marker
for PJI [10]. Despite its high sensitivity, the specificity was not
persuasive as it can be elevated in venous thromboembolic events
and other conditions. Therefore, there is a need to combine it with
other biomarkers [11].
Several synovial fluid biomarkers have also been used to aid in
the diagnosis of PJI including C-reactive protein (CRP), alpha-
defensin, and synovial fluid leukocyte count and differential
[12e14]. However, the use of these markers is not only invasive, but
also carries the potential for introducing infection into the joint.
Furthermore, the amount of fluid obtained from joint aspiration is
often insufficient to conduct a comprehensive analysis of bio-
markers [15].
Recently, several studies have reported that neutrophil to
lymphocyte ratio (NLR), a novel inflammatory biomarker, may have
a diagnostic role in PJI [16e34]. However, some studies did not find
it relevant and its overall efficacy remains uncertain [35]. Therefore,
the objective of this systematic review and meta-analysis was to
address the diagnostic role of NLR in PJI based on available litera-
ture. The results of this study can serve to validate NLR as an
emerging biomarker for PJI.
Material and methods
Our systematic review and meta-analysis were performed in
accordance with guidelines for the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) [36].
Data Sources and Searches
An electronic search of 3 main databases was performed in
PubMed, Web of Science, and Scopus from inception to May 2022.
Search terms included ((neutrophil AND lymphocyte AND ratio) OR
NLR) AND (“Periprosthetic joint infection” OR “Joint Replacement
Infection”). Reference lists of retrieved articles were investigated to
find additional relevant studies. Unpublished data were not
discovered or used.
Study Selection
We identified eligible studies according to the PICOS (popula-
tion, intervention, control, outcomes, and study design) principle in
order to ensure the systematic search of available literature. We
used the following inclusion criteria.
(1) Population: patients who have PJI
(2) Intervention: NLR
(3) Control: patients who had aseptic loosening of prosthetic
components
(4) Outcomes: the diagnostic performance of NLR in PJI
(5) Study design: we expected papers to involve case-control or
cross-sectional studies. However, we did not limit our search
to any particular study design.
Exclusion criteria were as follows: (1) studies involving animals,
cell lines, or human xenograft experiments; (2) case series, case
reports, or review articles; (3) duplicate publications.
All of the articles found by the search strategy were examined
independently by 2 reviewers. Reviewers of the manuscript were
blinded to the authors and institution of the included studies. We
used the Cohen’s kappa statistic to evaluate the preliminary
agreement between 2 authors in the process of study screening and
selection [36]. In this stage, we solved the disagreement between
authors via debate or via contact to a third author. Consensus was
used to resolve disagreements. After excluding duplicate articles
and irrelevant articles, the full text of all potentially relevant papers
was retrieved and evaluated for eligibility. Any missing or confusing
data was clarified by contacting the corresponding author of the
published paper.
Data Extraction
Predesigned excel forms were used for data collection by 2 au-
thors independently. The following data were extracted: name of
the first author, year of publication, language of the article, version
of the article (peer-reviewed or preprint), study location, type of
arthroplasty (knee, hip or both), type of PJI (acute or chronic), study
design (prospective or retrospective), criteria used for PJI diagnosis,
number of cases and controls, mean NLR level in each study group,
cut-off value for NLR, and its false/true positive and false/true
negative rates from a 2  2 table. When the false/true positive and
false/true negative rates were not reported, we calculated them
using sensitivity and specificity.
Quality Assessment
The Newcastle-Ottawa Quality Assessment Scale (NOS)
including 3 sections of selection, comparability, and outcome was
used to evaluate and score the methodological quality of included
studies [37]. High-quality studies had a score of 6 or higher.
Data Synthesis and statistical Analyses
The standard mean difference (SMD) with 95% CI was used to
pool the NLR differences between 2 groups. Subgroup analyses
were also conducted based on study design, type of arthroplasty,
and type of PJI. We used the random-effects model (DerSimonian-
Laird method) [38], because there was a significant heterogeneity
between included studies. Due to significant heterogeneity be-
tween studies, a random-effects model was adopted in our meta-
analysis. Statistical heterogeneity was assessed using I2 statistics
and Cochran’s Q test. We used the method introduced by Wan et al.
to estimate mean and standard deviation (SD) from the median and
interquartile range and/or range [39]. Summary receiver operating
characteristic (SROC) curve, sensitivity, specificity, diagnostic odds
ratio (DOR), negative likelihood ratio, and positive likelihood ratio
were assessed using "metandi" command and used to determine
the diagnostic value of NLR for PJI. Publication bias was determined
using Begg’s and Egger’s tests and visual inspection of funnel plots
[40]. Statistical significance was considered at P < .05, and all sta-
tistical tests were two-sided. A total of 189 potential studies were
retrieved in the database search and manual search of the citation
list of articles. After the exclusion of duplicates and non-relevant
records, 12 studies were included in the systematic review and
meta-analysis, with a total of 3,011 patients, 1,181 with PJI, and
1,830 with aseptic loosening [35,41e51]. The process of inclusion
and exclusion is detailed in the PRISMA flow diagram (Figure 1).
During study selection, a Cohen’s kappa coefficient of 0.483 (95% CI
0.18 to 0.78) was found, showing moderate agreement.
 M. Salimi et al. / The Journal of Arthroplasty xxx (2023) 1e8 3

Identification of studies via databases and registers Identification of studies via other methods
Identification

Records removed before

Records identified from*: Records identified from:
screening:
Pubmed (n = 27) Citation searching (n = 4)
Duplicate records removed
Scopus (n = 129) Contacted authors’
(n = 26)
Web of Science (n = 27) suggestion (n=1)

Records screened Records excluded**

(n = 157) (n = 129)

Reports sought for retrieval Reports not retrieved Reports sought for retrieval Reports not retrieved
(n = 28) (n = 1) (n = 6) (n = 2)
Screening

Reports assessed for eligibility Reports assessed for eligibility

(n = 27) Reports excluded: (n = 4)
No data of interest (n = 12) Reports excluded:
Review (n = 1) No data of interest (n = 3)
Population not relevant (n = 2)
Abstract (n= 1)

Studies included in review

Included

(n = 12)
Reports of included studies
(n = 12)

Fig. 1. Flow diagram for new systematic reviews which includes searches of databases, registers, and other sources.

Study Characteristics and Quality Assessment
All of the included studies had retrospective designs. Studies
were conducted in China (n ¼ 8) [35,41e47], the USA (n ¼ 2)
[48,49], Turkey (n ¼ 1) [50], and Austria (n ¼ 1) [51]. Two studies,
including 46 cases and 179 controls, related to acute PJI [46, 47], and
5 studies, including 656 cases and 892 controls, pertained to
chronic PJI [35, 41, 45, 48, 49]. One study, reporting the NLR value in
both types of PJI separately, included 31 cases with acute PJI, 51
cases with chronic PJI, and 139 controls [42]. The remaining 4
studies did not report the chronicity of PJI. Two studies, including
only TKA patients, had 236 cases and 435 control [49,50], and one
study, 191 cases and 273 controls, included solely THA patients [48].
The remaining 9 studies included patients who either TKA or THA
[35,41e47,51]. All 12 studies were peer-reviewed journal articles
and written in the English language [35,41e51]. The quality of the
studies was high, with NOS scores ranging from 6 to 8. The char-
acteristics of the 12 included studies is detailed in Table 1.
Figure 3) or chronic PJI (random-effects model: SMD ¼ 1.08, 95%
CI ¼ 0.55 to 1.61, P < .001; Figure. 4).
In the subgroup analysis according to type of arthroplasty, NLR
levels were significantly higher in PJI patients after either TKA
(SMD ¼ 1.81, 95% CI ¼ 1.48 to 2.13, P < .001) or THA (SMD ¼ 1.76,
95% CI ¼ 1.54 to 1.98, P < .001) compared to aseptic loosening cases
(Figure 5).
Diagnostic Value of NLR for PJI
The pooled sensitivity of the 12 studies was 0.73 (95% CI, 0.65 to
0.79), and the pooled specificity was 0.75 (95% CI, 0.71 to 0.78). The
pooled positive likelihood ratio, negative likelihood ratio, and DOR
of NLR were 2.94 (95% CI ¼ 2.44 to 3.54), 0.35 (95% CI ¼ 0.27 to
0.46), and 8.26 (95% CI ¼ 5.42 to 12.58), respectively (Figure 6). The
cut-off point for NLR varied between studies from 2.1 to 3.8
(Table 1).

Publication Bias

Results As seen in Figure 7, there was no indication of publication bias

Comparison of NLR Between PJI Patients or Aseptic Loosening of
Prosthetic Components
Given the significant heterogeneity observed across studies (I2 ¼
94.2%, P < .01; Figure 2), we decided to use a random effect model in
our meta-analysis. After pooling the data of the 12 studies, we
found that NLR levels were significantly higher in PJI patients
compared to aseptic failure of arthroplasty (random-effects model:
SMD ¼ 1.05, 95% CI ¼ 0.71 to 1.40, P < .001).
When we analyzed the data of acute and chronic PJI separately,
we found that compared to aseptic loosening patients, NLR levels
were significantly higher in patients who had either acute
(random-effects model: SMD ¼ 1.04, 95% CI ¼ 0.05 to 2.03, P < .001;
among studies on the role of NLR in PJI (Egger’s test P ¼ .83, Begg’s
test P ¼ .53).
Discussion
The NLR is an emerging inflammatory marker that has gained
increased attention in the setting of PJI. It is an established marker
of inflammation for a variety of diseases and is well-known for its
prognostic utility. It reflects the dynamic relationship between
neutrophils, the dominant players in innate immunity that serve to
amplify pro-inflammatory responses, and lymphocytes, the com-
ponents of the adaptive immune system which serve to regulate
immune responses [52,53]. It can predict prognosis in a variety of
conditions such as cancer, sepsis, COVID-19 infection,
4 M. Salimi et al. / The Journal of Arthroplasty xxx (2023) 1e8

Table 1
General Characteristics of Included studies.

First Year Country Type of PJI Design Type of Gold Standard Cut-off Sensitivity Specificity PJI Group Aseptic NOS
Author Arthroplasty Point (%) (%) Loosening Group Score

N NLR N NLR

Golge [50] 2018 Turkey Not Declared R TKA MSIS 2006 2.45 90 72 30 3.20 ± 0.70 103 2.10 ± 0.70 6
Sigmund 2020 Austria Not Declared R TKA þ THA EBJIS 2020 3.82 62.7 72.6 75 13.42 ± 9.12 102 6.25 ± 3.43 7
[51]
Tirumala 2020 USA Chronic R TKA MSIS 2018 3.62 81.55 76.70 206 4.86 ± 1.05 332 3.08 ± 0.84 8
[49]
Yu [46] 2020 China Acute R TKA þ THA MSIS 2014 2.13 85 68.3 20 89.72 ± 92.46 101 13.80 ± 7.87 6
Zhao [47] 2020 China Acute R TKA þ THA MSIS 2011 2.77 84.6 89.7 26 2.17 ± 0.40 78 2.11 ± 0.43 6
Maimaiti 2021 China Chronic R TKA þ THA MSIS 2014 2.41 67.2 71.07 152 3.52 ± 2.82 121 2.14 ± 0.81 7
[41]
Wang [42] 2021 China Acute and R TKA þ THA MSIS 2013 2.36 52.44 81.30 82 2.44 ± 1.21 139 1.84 ± 0.59 7
chronic
Wu [43] 2021 China Not Declared R TKA þ THA MSIS 2014 2.71 68.09 70.09 47 4.43 ± 2.98 117 2.61 ± 2.42 7
Ye [45] 2021 China Chronic R TKA þ THA MSIS 2018 2.56 57.41 77.88 54 3.22 ± 2.37 104 2.13 ± 0.97 6
Klemt [48] 2022 USA Chronic R THA MSIS 2018 and EBJIS 3.46 75.92 79.85 191 5.02 ± 1.20 273 3.20 ± 0.90 8
2020
Jiao [35] 2022 China Chronic R TKA þ THA MSIS 2014 2.1 73.58 70.97 53 2.58 ± 1.08 62 1.87 ± 0.71 6
Xu [44] 2022 China Not Declared R TKA þ THA MSIS 2013 2.90 62.8 66.5 245 3.28 ± 1.64 298 2.41 ± 1.04 8

NLR, neutrophil to lymphocyte ratio; N, number; NOS, the Newcastle-Ottawa quality assessment scale; R, Retrospective; P, Prospective; THA, Total hip arthroplasty; TKA, Total
knee arthroplasty; MSIS, the Musculoskeletal Infection Society; EBJIS, The European Bone and Joint Infection Society.

cardiovascular disease, diabetes, as well as PJI [54,55]. In the setting
of a high NLR, the pro-inflammatory activity of neutrophils may
outweigh the regulatory function of lymphocytes, setting up a
landscape for unregulated peripheral inflammation to transmit
onto a vulnerable joint.
Prior studies on the role of NLR in diagnosing PJI presented
conflicting results, but the findings of our meta-analysis indicate
that NLR can serve as a reliable diagnostic tool for PJI after THA or
TKA.
In addition, the use of NLR as a screening tool for PJI offers a
number of advantages. The NLR is a cheap and readily available
measure obtained from a white blood cell count differential that
can be readily adapted into clinical practice. More importantly, this
tool may allow early detection of PJI. Indeed, early diagnosis of PJI is
very beneficial as it can affect therapeutic options for the patient
and allow for increased success rates of less invasive interventions
such as debridement, antibiotics, and implant retention (DAIR)
versus one- or two-stage exchange arthroplasty [56e58]. In

Fig. 2. Meta-analysis of differences in neutrophil to lymphocyte ratio between patients with prosthetic joint infection and those with aseptic loosening of prosthetic components.
 M. Salimi et al. / The Journal of Arthroplasty xxx (2023) 1e8 5

Fig. 3. Meta-analysis of differences in neutrophil to lymphocyte ratio between patients who have acute prosthetic joint infection and those who have aseptic loosening of prosthetic
components.

addition, there is strong evidence that early intervention may
inhibit the growth of the highly virulent biofilm by invading bac-
teria, which may account for increased rates of success [59,60]. The
primary, non-invasive screening tools currently employed for PJI
detection include ESR, CRP, and less frequently D-dimer. However,
CRP levels often peak within 3 days of the surgery and can remain
elevated above baseline for 6 weeks and ESR peaks by day 5 to 14
and does not go back to baseline preoperative levels until post-
operative week 12 to 26 [61e64]. These prolonged periods of
postoperative elevation limit the use of both CRP and ESR as
screening tools for the early detection of PJI. The D-dimer does have
the advantage of a comparatively brief postoperative rise and fall to

Fig. 4. Meta-analysis of differences in neutrophil to lymphocyte ratio level between patients who have chronic prosthetic joint infection and those who have aseptic loosening of
prosthetic components.
6 M. Salimi et al. / The Journal of Arthroplasty xxx (2023) 1e8
Fig. 5. Subgroup analysis of differences in neutrophil to lymphocyte ratio level between patients who have chronic prosthetic joint infection and those who have aseptic loosening
of prosthetic components, according to the type of arthroplasty.
baseline by day 2 with a second peek by day 14 [65]. Consequently,
preliminary studies have shown that serum D-dimer may offer
some value as an adjuvant screening tool [11].
Fig. 6. Summary receiver operating characteristic curve of included studies.
Moreover, CRP and ESR are serum markers of general inflam-
mation and may be elevated in a number of extraneous circum-
stances, including inflammatory bowel disease and rheumatoid
arthritis [66,67]. The D-dimer can also be elevated in a number of
inflammatory processes and is obviously elevated in situations of
venous thromboembolic events [68].
Neutrophils reach a peak by day 2 and pre-operative levels by
day 21 [69,70]. Lymphocytes reach a low by day 2 and pre-operative
levels by day 14 to 21 [70]. Thus, changes in NLR may offer earlier
detection for PJI compared to other routinely used screening tools.
We identified a pooled sensitivity of 0.73 and specificity of 0.75
for diagnosing PJI based on the available literature, as well as a
positive likelihood ratio of 2.94, negative likelihood ratio of 0.35
and direct odds ratio of 8.3. This is comparable to the performance
of other serum markers currently used for PJI as reported in the
literature. Indeed, in their meta-analysis on the role of D-dimer in
the diagnosis of PJI, Li et al. found a pooled sensitivity of 0.75,
specificity of 0.69, positive likelihood ratio of 3.01, negative odds
ratio of 0.32 and diagnostic odds ratio of 10.20 [71]. They included
1,285 patients from 7 studies. Zhang et al. in a similar work
included 9 studies with 1,592 patients and using a random effects
model identified a pooled sensitivity of 0.82, specificity of 0.73,
positive likelihood ratio of 2.99 and negative likelihood ratio of 0.25
[72]. Huerfano et al. analyzed the positive and negative likelihood
ratios of ESR and CRP based on 12 studies including 2,736 patients
and found for ESR a positive likelihood ratio of 3.42 and a negative
likelihood ratio of 0.22 and for the CRP a positive likelihood ratio of
4.18 and a negative likelihood ratio of 0.20.
 M. Salimi et al. / The Journal of Arthroplasty xxx (2023) 1e8
Fig. 7. Funnel plot assessing publication bias.
Cut-off points for NLR have varied in the literature with a range
from 2.1 to 3.8 in the studies included in our analysis. De Yager et al.
recommended an NLR >10.0 for the screening of bacteremia and
reported a sensitivity and specificity greater than CRP alone [1]. In a
prospective study of 587 TKA patients, Yombi et al. subsequently,
demonstrated that only 1% of patients without PJI presented with
an NLR greater than 10 on postoperative day 21 [70]. This supports
the use of an NLR >10.0 cut-off as a screening tool for PJI. In a
retrospective study of TKA and THA, Yu et al. reported that NLR
showed greater sensitivity, negative predictive value, and AUC than
either CRP or ESR in the screening of early PJI [46]. However, there is
evidence that as PJI becomes increasingly chronic, CRP and ESR gain
similar or higher specificity and sensitivity over NLR [48,51]. This
indicates that NLR may offer improved insight when combined
with other screening methods and constitutes an additional
invaluable tool in our armamentarium of diagnostic markers for PJI
after THA and TKA.
Potential Limitations and strengths
Our study has potential limitations that are important to
mention. The studies included in our analyses exhibited high het-
erogeneity. Although this was accounted for by the use of a random
effects model, such measures may not entirely eliminate the issue of
heterogeneity. High heterogeneity could be due to the different
methods used to diagnose PJI, the different study patient pop-
ulations, the variation in laboratory techniques used, as well as other
factors. Furthermore, all the included studies were retrospective in
design, which introduces its own bias. Further prospective studies
are therefore recommended to more reliably evaluate this topic.
Nevertheless, we used robust inclusion and exclusion criteria and a
random effects model to account for the heterogeneity. Moreover,
our systematic search, in conjunction with a manual review of ref-
erences from resulting articles without any limitation on language or
date, has ensured a thorough and reliable evaluation of the literature
and serves as a notable strength of this study.
Conclusion
The results of our study validate the NLR as a diagnostic tool in
the diagnosis of PJI after THA and TKA, and support its use within
the armamentarium of biomarkers currently employed in the
work-up of PJI on a routine basis. The NLR is cheap, readily available,
and may have a particular advantage in the acute setting and in
early detection of PJI compared to other available biomarkers. The
NLR represents a unique inflammatory marker whose elevation in
PJI reflects an immune system imbalance that may be involved in
7
the pathogenesis of the disease. Ultimately, we hope that the
continued development and use of new biomarkers and thera-
peutic modalities can help better prevent, identify and treat PJI,
thus alleviating the major morbidity and mortality this devastating
complication leads to after THA or TKA.
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