Cierny-Mader classification of chronic osteomyelitis: Preoperative evaluation with cross-sectional imaging

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1 Cierny-Mader classification of chronic osteomyelitis: Preoperative evaluation with cross-sectional imaging Poster No.: C-590 Congress: ECR 2009 Type: Topic: Educational Exhibit Musculoskeletal Authors: M. Wisniewska, I. Babiak, P. D. Palczewski, J. Swiatkowski, M. Golebiowski; Warsaw/PL Keywords: DOI: imaging, osteomyelitis, Staging /ecr2009/C-590 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 5

2 Learning objectives 1. To know the anatomical part of Cierny-Mader classification of chronic osteomyelitis. 2. To understand the role of cross-sectional imaging in pre-treatment staging of osteomyelitis. Background Chronic osteomyelitis is a polymorphous entity that takes different forms during its course. Many staging systems were proposed to describe the extent of the disease and facilitate treatment planning [1,2,3]. The Cierny-Mader classification is an anatomico-physiological staging system that defines both the extent of bone infection and immunological status of the host. This classification has been widely accepted by orthopedic practitioners due to its practical value, however it is rarely mentioned in radiologic literature. The anatomical part of Cierny-Mader classification comprises four stages of disease that differ as regards treatment options [Table 1]. on page The Cierny-Mader classification is used in our department to describe findings in cross-sectional studies. While plain films and scintigraphy are useful in establishing the diagnosis, they are limited in evaluating the actual extent of the disease [4]. The purpose of this article is to present the complimentary role of computed tomography and magnetic resonance imaging in preoperative staging of chronic osteomyelitis. Page 2 of 5

3 Images linked within the text of this section: Fig.: Cierny-Mader classification of osteomyelitis [1]. Page 3 of 5

4 Imaging findings OR Procedure details Stage 1 represents a process contained to medullary cavity. The clinical entities that present as a stage 1 disease include hematogenous osteomyelitis and intramedullary rod infection. Plain film features of stage 1 osteomyelitis may be subtle and resemble acute osteomyelitis with soft-tissue swelling, periosteal elevation, and later sclerosis. If no evident osteolysis is seen on plain films antibiotic treatment may be sufficient in some cases. Sonography may be helpful in assessing the soft tissues for a presence of fluid collections. If there is no response to antibiotics, CT and MR are helpful in excluding sequestration and soft tissue involvement, respectively. When Stage 1 disease is confirmed by cross-sectional studies, the therapy consists of debridement of medullary cavity followed by another course of antibiotics Stage 2 disease results from penetrating wounds that expose the bone surface. Plain films reveal focal sclerosis of the outer cortical layer, which may be accompanied by obliteration of soft tissue plains and periosteal reaction When treatment is delayed, stage 2 can progress to stage 3. Cross-sectional imaging is not always necessary, but may be helpful in cases with unclear clinical manifestation, extensive soft-tissue involvement, and when progression to stage 3 is suspected. Stage 3 and 4 osteomyelitis are difficult to assess with plain film radiography due to abundant sclerosis. Only in selected cases plain films will be sufficient to plan treatment CT allows precise visualization of bone destruction and sequestra, which helps in differentiating stage 3 and 4 disease MRI is indispensable in cases with prominent extension of inflammation into soft tissues, which is essential for planning soft tissues excision and reconstruction. PET/CT, which is increasing in availability, allows the precise gradation of inflammatory changes intensity both in axial and longitudinal plane. However, due to a scarce experience with this method, its potential benefits in preoperative staging are still to be assessed. Conclusion Staging of osteomyelitis according to Cierny-Mader classification can be performed with a combined use of CT and MRI improving communication between radiologist and clinician and facilitating treatment planning. Personal Information Page 4 of 5

5 Malgorzata Wisniewska, MD, I Dept. of Clinical Radiology, Medical University of Warsaw, Chalubinskiego 5 St Warsaw, tel/fax , mavi1980@o2.pl References 1. Cierny G, Mader JT, Pennick H: A clinical staging system of adult osteomyelitis. Contemp Orthop, 1985;10: Cierny G, Mader JT: Approach to adult osteomyelitis. Orthop Rev, 1987;16: Mader JT, Shirtliff M, Calhoun JH: Staging and Staging Application in Osteomyelitis. Clinical Infectious Diseases, 1997;25: Gold RH, Hawkins RA, Katz RD: Bacterial Osteomyelitis: Findings on Plain Radiography, CT, MR, and Scintigraphy. AJR, 1991;157: Page 5 of 5