Osteomyelitis classification: Difference between revisions

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{{Osteomyelitis}}
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==Overview==
==Overview==
There are many classification systems for osteomyelitis. In general, there are three major classification systems which include; classification according to the symptom chronology, Lew and Waldvogel classification, and Cierny and Mader classification. Osteomyelitis may be classified according to the symptom chronology into acute, sub-acute (further subdivided into the Glendhill and Robert et al. systems), and chronic. Chronic osteomyelitis may be subdivided into Lew and Waldvogel's classification system and Cierny and Mader's classification system. Osteomyelitis may be classified according to Lew and Waldvogel's system based on the duration and mechanism of infection into 3 subtypes which are; hematogenouos osteomyelitis, contiguous-focus osteomyelitis, and osteomyeltis secondary to [[vascular insufficiency]]. Osteomyelitis may be classified according to Cierny and Mader's classification system based on the anatomy of [[bone]] infection (4 stages) and host physiology (3 levels of compromise).


==Classification==
==Classification==
Two classification schemes exist for osteomyelitis:
There are many classification systems for osteomyelitis:
*Lew and Waldvogel classify osteomyelitis according to duration and mechanism of infection (traditional classification)<ref name="LewWaldvogel1997">{{cite journal|last1=Lew|first1=Daniel P.|last2=Waldvogel|first2=Francis A.|title=Osteomyelitis|journal=New England Journal of Medicine|volume=336|issue=14|year=1997|pages=999–1007|issn=0028-4793|doi=10.1056/NEJM199704033361406}}</ref>
 
*Cierny and Mader classify osteomyelitis according to anatomy of bone infection and host physiology<ref name="MaderShirtliff1997">{{cite journal|last1=Mader|first1=Jon T.|last2=Shirtliff|first2=Mark|last3=Calhoun|first3=Jason H.|title=Staging and Staging Application in Osteomyelitis|journal=Clinical Infectious Diseases|volume=25|issue=6|year=1997|pages=1303–1309|issn=1058-4838|doi=10.1086/516149}}</ref>
*Osteomyelitis may be classified according to symptom chronology into acute, sub-acute (further subdivided into the Glendhill and Robert et al. systems), and chronic
*Lew and Waldvogel classified osteomyelitis according to the duration and mechanism of infection (traditional classification)<ref name="LewWaldvogel1997">{{cite journal|last1=Lew|first1=Daniel P.|last2=Waldvogel|first2=Francis A.|title=Osteomyelitis|journal=New England Journal of Medicine|volume=336|issue=14|year=1997|pages=999–1007|issn=0028-4793|doi=10.1056/NEJM199704033361406}}</ref>
*Cierny and Mader classified osteomyelitis according to the anatomy of [[bone]] infection and host [[physiology]]<ref name="MaderShirtliff1997">{{cite journal|last1=Mader|first1=Jon T.|last2=Shirtliff|first2=Mark|last3=Calhoun|first3=Jason H.|title=Staging and Staging Application in Osteomyelitis|journal=Clinical Infectious Diseases|volume=25|issue=6|year=1997|pages=1303–1309|issn=1058-4838|doi=10.1086/516149}}</ref>
:*The Cierny and Mader system offers a guide to treatment
:*The Cierny and Mader system offers a guide to treatment
===Classification based on symptom chronology===
*'''Acute osteomyelitis''': Osteomyelitis is classified as acute if the duration of the disease has been less than 2 weeks.
*'''Sub-acute''': Sub-acute hematogenous osteomyelitis has a more insidious onset and lacks the severity of symptoms, which makes the diagnosis of this disorder difficult. Typically, diagnosis is delayed for more than 2 weeks.
{|
! style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=3  | {{fontcolor|#FFFFFF|Sub-acute osteomyelitis}}
|
|
|-
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="1" colspan="1" |TYPE
! rowspan="1" colspan="1" |GLEDHILL CLASSIFICATION
! rowspan="1" colspan="1" |ROBERT ET AL. CLASSIFICATION
|-
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|I}}
| style="padding: 5px 5px; background: #F5F5F5;" | Solitary localized zone of radiolucency surrounded<BR> by reactive new bone formation
| style="padding: 5px 5px; background: #F5F5F5;" | Ia—Punched-out radiolucency<BR>Ib—Punched-out radiolucent lesion with sclerotic margin
|-
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|II}}
| style="padding: 5px 5px; background: #F5F5F5;" |Metaphyseal radiolucencies with cortical erosion
| style="padding: 5px 5px; background: #F5F5F5;" | --
|-
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|III}}
| style="padding: 5px 5px; background: #F5F5F5;" | Cortical hyperostosis in diaphysis; no onion skin reaction
| style="padding: 5px 5px; background: #F5F5F5;" | Localized cortical periosteal reaction
|-
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|IV}}
| style="padding: 5px 5px; background: #F5F5F5;" | Subperiosteal new bone and onion skin layering
| style="padding: 5px 5px; background: #F5F5F5;" | Onion skin periosteal reaction
|-
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|V}}
| style="padding: 5px 5px; background: #F5F5F5;" | --
| style="padding: 5px 5px; background: #F5F5F5;" | Central radiolucency in epiphysis
|-
| style="background: #4479BA; padding: 5px 5px;" rowspan=1 colspan=1 |{{fontcolor|#FFFFFF|VI}}
| style="padding: 5px 5px; background: #F5F5F5;" | --
| style="padding: 5px 5px; background: #F5F5F5;" | Destructive process involving vertebral body
|-
|}
*'''Chronic Ostemyelitis''': Chronic osteomyelitis is defined as persistent [[pain]], [[erythema]], or swelling, sometimes in association with a draining sinus tract that mostly lasts for more than 4 weeks.<br>
The following table describes the classification schemes for chronic osteomyelitis.


'''Lew and Waldvogel Etiologic System'''
'''Lew and Waldvogel Etiologic System'''
{| style="font-size: 85%;"
! style="width: 180px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Mechanism of Infection}}
! style="width: 720px; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Description}}
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Hematogenous Osteomyelitis'''
| style="background: #F5F5F5; padding: 5px;" | Osteomyelitis develops after [[bacteremia]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Contiguous-focus Osteomyelitis'''
| style="background: #F5F5F5; padding: 5px;" | Direct inoculation of bone via [[trauma]]/[[fracture]], surgery, [[Prosthesis|prosthetic devices]], or spread from [[soft tissue]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Osteomyelitis Secondary to Vascular Insufficiency'''
| style="background: #F5F5F5; padding: 5px;" | Reduced blood supply, usually in [[diabetic]] patients
|}


'''Cierny and Mader Staging System'''
'''Cierny and Mader Staging System'''
{| style="font-size: 85%;"
! style="background: #4479BA; text-align: center;" colspan="2" | {{fontcolor|#FFF|Classification}}
! style="width: 720px; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Description}}
|-
| style="width: 110px; background: #DCDCDC; padding: 5px; text-align: center;" rowspan="4" | '''Anotomic Type'''
| style="width: 50px; background: #DCDCDC; padding: 5px; text-align: center;" | '''Stage 1'''
| style="background: #F5F5F5; padding: 5px;" | ''Medullary osteomyeltitis'': infection confined to the [[intramedullary]] bone surfaces
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Stage 2'''
| style="background: #F5F5F5; padding: 5px;" | ''Superficial osteomyelitis'': true contiguous infection (bone surface undergoes [[necrosis]] at the base of a [[soft tissue]] wound)
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Stage 3'''
| style="background: #F5F5F5; padding: 5px;" | ''Localized osteomyelitis'': full-thickness, cortical sequestration
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''Stage 4'''
| style="background: #F5F5F5; padding: 5px;" | ''Diffuse osteomyelitis'': through-and-through process requiring intercalary reconstruction of bone
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3" | '''Physiological Class'''
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''A Host'''
| style="background: #F5F5F5; padding: 5px;" | Normal physiological, metabolic, and immunologic states
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''B Host'''
| style="background: #F5F5F5; padding: 5px;" | Local compromise, systemic compromise, or both
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" | '''C Host'''
| style="background: #F5F5F5; padding: 5px;" | Morbidity of treatment is worse than disease
|}


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nate Michalak, B.A., Seyedmahdi Pahlavani, M.D. [2]

Overview

There are many classification systems for osteomyelitis. In general, there are three major classification systems which include; classification according to the symptom chronology, Lew and Waldvogel classification, and Cierny and Mader classification. Osteomyelitis may be classified according to the symptom chronology into acute, sub-acute (further subdivided into the Glendhill and Robert et al. systems), and chronic. Chronic osteomyelitis may be subdivided into Lew and Waldvogel's classification system and Cierny and Mader's classification system. Osteomyelitis may be classified according to Lew and Waldvogel's system based on the duration and mechanism of infection into 3 subtypes which are; hematogenouos osteomyelitis, contiguous-focus osteomyelitis, and osteomyeltis secondary to vascular insufficiency. Osteomyelitis may be classified according to Cierny and Mader's classification system based on the anatomy of bone infection (4 stages) and host physiology (3 levels of compromise).

Classification

There are many classification systems for osteomyelitis:

  • Osteomyelitis may be classified according to symptom chronology into acute, sub-acute (further subdivided into the Glendhill and Robert et al. systems), and chronic
  • Lew and Waldvogel classified osteomyelitis according to the duration and mechanism of infection (traditional classification)[1]
  • Cierny and Mader classified osteomyelitis according to the anatomy of bone infection and host physiology[2]
  • The Cierny and Mader system offers a guide to treatment

Classification based on symptom chronology

  • Acute osteomyelitis: Osteomyelitis is classified as acute if the duration of the disease has been less than 2 weeks.
  • Sub-acute: Sub-acute hematogenous osteomyelitis has a more insidious onset and lacks the severity of symptoms, which makes the diagnosis of this disorder difficult. Typically, diagnosis is delayed for more than 2 weeks.
Sub-acute osteomyelitis
TYPE GLEDHILL CLASSIFICATION ROBERT ET AL. CLASSIFICATION
I Solitary localized zone of radiolucency surrounded
by reactive new bone formation 		Ia—Punched-out radiolucency
Ib—Punched-out radiolucent lesion with sclerotic margin
II Metaphyseal radiolucencies with cortical erosion --
III Cortical hyperostosis in diaphysis; no onion skin reaction Localized cortical periosteal reaction
IV Subperiosteal new bone and onion skin layering Onion skin periosteal reaction
V -- Central radiolucency in epiphysis
VI -- Destructive process involving vertebral body


  • Chronic Ostemyelitis: Chronic osteomyelitis is defined as persistent pain, erythema, or swelling, sometimes in association with a draining sinus tract that mostly lasts for more than 4 weeks.

The following table describes the classification schemes for chronic osteomyelitis.

Lew and Waldvogel Etiologic System

Mechanism of Infection Description
Hematogenous Osteomyelitis Osteomyelitis develops after bacteremia
Contiguous-focus Osteomyelitis Direct inoculation of bone via trauma/fracture, surgery, prosthetic devices, or spread from soft tissue
Osteomyelitis Secondary to Vascular Insufficiency Reduced blood supply, usually in diabetic patients

Cierny and Mader Staging System

Classification Description
Anotomic Type Stage 1 Medullary osteomyeltitis: infection confined to the intramedullary bone surfaces
Stage 2 Superficial osteomyelitis: true contiguous infection (bone surface undergoes necrosis at the base of a soft tissue wound)
Stage 3 Localized osteomyelitis: full-thickness, cortical sequestration
Stage 4 Diffuse osteomyelitis: through-and-through process requiring intercalary reconstruction of bone
Physiological Class A Host Normal physiological, metabolic, and immunologic states
B Host Local compromise, systemic compromise, or both
C Host Morbidity of treatment is worse than disease

References

  1. ↑ Lew, Daniel P.; Waldvogel, Francis A. (1997). "Osteomyelitis". New England Journal of Medicine. 336 (14): 999–1007. doi:10.1056/NEJM199704033361406. ISSN 0028-4793.
  2. ↑ Mader, Jon T.; Shirtliff, Mark; Calhoun, Jason H. (1997). "Staging and Staging Application in Osteomyelitis". Clinical Infectious Diseases. 25 (6): 1303–1309. doi:10.1086/516149. ISSN 1058-4838.
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