CIERNY CLASSIFICATION CIERNY CLASSIFICATION. Classification of Infection according to Severity LAUTENBACH CLASSIFICATION OF MUSCULO SKELETAL INFECTION

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1 CIERNY CLASSIFICATION Classification of Infection according to Severity E E G LAUTENBACH Division of Orthopaedics Faculty of Health Sciences August 2008 University of Texas staging system for adult osteomyelitis Anatomic Type I Medullary osteomyelitis Superficial osteomyelitis Localised osteomyelitis Diffuse osteomyelitis CIERNY CLASSIFICATION Physiological Class A host B1 host BS host C host Good immune system and delivery Compromised locally Compromised systemically Requires suppression or no treatment. Minimal disability. Treatment worse than disease. Not candidate for surgery. Clinical stage = type + class LAUTENBACH CLASSIFICATION OF MUSCULO SKELETAL INFECTION A. CLINICAL B. LABORATORY C. RADIOLOGICAL LAUTENBACH CLASSIFICATION OF INTENSITY OF ACUTE INFECTION LAUTENBACH CLASSIFICATION OF INTENSITY OF CHRONIC INFECTION Grade 1 Acute Fulminating Grade 2 Sub-Acute Grade 3 a) Insiduous onset b) Acute exacerbation of chronic Grade 4 Overwhelming Grade 5 Diffuse inflammation Grade 6 Low grade extensive Grade 7 Localised infection Grade 8 Non infective pathology 1

2 CLINICAL FEATURES Grade 1 Acute Fulminating Pyrexia Inflammation Calor, dolor, rubor tumor, functio liso Grade 2 Sub-Acute Settling acute infection Apyrexial - not toxic Minor oedema Mild or no discharge Grade 3 Acute Infection Grade 4 - Overwhelming 3a) Insiduous onset without pyrexia and minor inflammation 3b) Chronic infection with acute exacerbation of pain, inflammation, oedema and discharge Joint movement often suddenly restricted Large necrotic lesions Copious Discharge (>10ml) Poor Containment (scarring) Oedema Cahexia - Protein Deficiency Procalcitonin Elevated X-ray Grade 4 Bone destruction > sclerosis and callus formation Grade 5 Extensive and Inflamed Extensive lesion Red, Swollen Glands Low-grade pyrexia Moderate containment More than 5 ml pus per day 2

3 Xray Grade 5 Irregular Periosteal Reaction Cavitation Sclerosis Perhaps sequestra Grade 6 Extensive without Inflammation Extensive lesion (whole bone) Good containment of infection Warm, indurated, established sinus with moderate discharge 2 ml + per day Membranous periosteal reaction X-Ray Grade 6 Membranous periosteal reaction Sclerosis, cavities, obliterated medulla Grade 7 Localised Lesion Warm not inflamed or indurated Pinhole sinus with spotting Internal barriers with free passage to exterior Compatible with good health Skin Thermometer X-Ray Grade 7 X-Ray well contained Sclerosis with normal bone beyond Periosteal reaction = fuzzy cortex 3

4 Grade 8 Non-Infective Lesion Tumours, RSD, Haematoma, aseptic loosening Non infective inflammatory disease Completely resolved infection Soft mature scar normal texture NB A sinus is not a sine qua non for infection. MONITORING THE PROGRESS OF INFECTION Most infections have no sinus A draining sinus can be quite compatible with excellent health EEG Lautenbach University of the Witwatersrand Johannesburg April OBJECTIVES Establish : diagnosis Duration of therapy Safety for implantation Classify clinical trials Medico-legal disputes ANAEMIA OF CHRONIC INFECTION Aetiology RBC turnover Iron retention in RES Malabsorbtion of dietary iron Renal haemopoietin Marrow activity 4

5 ANAEMIA OF CHRONIC INFECTION Effects WHITE CELLS IN CHRONIC INFECTION Iron, ferritin Hypochromia, microcytosis Anisocytosis, anisochromia, basophilia Protein (transferrin-carrier) Result smaller, paler, fewer red blood cells Neutrophil leucocytosis Lymphocytosis Thrombocytosis Toxic granulation Shift to left PROTEIN DISTURBANCE IN INFECTION C-reactive protein Sedimentation rate Plasma viscosity Mucoproteins Rouleaux formation Transferrin (iron carrier) IRON PROFILE Serum Iron Transferrin Iron Binding Cap. Iron Saturation Ferritin INTERPRETATION OF PROCALCITONIN (PCT) TEST RESULTS S-PCT (ng/ml) INTERPRETATION < 0.5 Systemic bacterial infection unlikely Local infection possible. Severe sepsis or septic shock unlikely Systemic (bacterial or fungal) infection likely. 10 Severe bacterial infection with systemic inflammation probable (sepsis with organ failure and possible shock). NOTE: PCT DETECTABLE WITHIN 6 HOURS OF ONSET. PCT HAS A HALF-LIFE OF 24 HOURS Jan 1982 to Dec 1988 (7 years) 1191 Patients 1874 incl. changed grades 3170 records 5

6 Grades of Infection Acute 1. Fulminating 2. Subacute 3. Insidious 6/3 Acute on chronic 7/3 exacerbation Grades of Infection Chronic 4. Overwhelming 5. Inflammation 6. Diffuse 7. Localised 8. Not Infected GROUP 4 OVERWHELMING Large necrotic lesions Copious pus (> 20 ml/day) Toxin producing bacteria Impaired immunity Cahexia Poor containment (scarring) Bone destruction > sclerosis and callus formation GROUP 5 EXTENSIVE + INFLAMMATION Extensive lesion Red, Swollen Glands Low-grade pyrexia Moderate containment Moderate pus (> 5 ml/day) Florid periosteal reaction GROUP 6 EXTENSIVE NOT INFLAMED Extensive lesion (whole bone) Warm, indurated, sinus mild pus (>2 ml/day) Good containment of lesion Membranous periosteal reaction 6

7 GROUP 7 LOCALISED LESION Local Warmth No induration Pinhole with spot Well contained lesion Sclerotic border - normal bone beyond Periosteal reaction: none/irregular or fuzzy cortex GROUP 8 - NOT INFECTED Tumours, Reflex Sympathetic Dystrophy Haematoma, Aseptic loosening Non infective inflammatory disease Haemoglobin normal (g/dl) Grade Median Above % % % % % White Cell Count normal (1E) Grade Median Under % % % % % 7

8 Sedimentation Rate Normal 1-10 or 20 (mm/hr) Grade Median Under 10 Under % 15% % 30% % 56% % 89% % 94% Serum Iron normal (umol/ml) Grade Median Over % % % % % Iron Saturation normal 15-50% Grade Median Above % % % % % 8

9 Transferrin normal (g/l) Grade Median Above % % % % % Ferritin normal (ng/ml) Grade Median Under 100 Under % 50% % 54% % 64% % 79% % 80% PERCENTAGE WITH NORMAL VALUES TEST Grade 7 Grade 8 % Variation FE %> FERRITIN %< FERRITIN %< HB %> ESR %< ESR %< SATURATION %>

10 MEDIAN VALUES TEST Grade 7 Grade 8 % Variation IRON median FERRITIN median HB median ESR median SATURATION median Serum Ferritin : Iron Ratio Grade % Variation Haemoglobin Sedimentation Serum Iron Iron Saturation Ferritin Clinical History Signs & Symptoms X-RAY RED CELL COUNT (g/dl M F HAEMOGLOBIN (g/dl) M F HAEMATOCRIT (%) M F MEAN CELL VOLUME (l) MEAN CELL HB MEAN CELL HB CONC (g/dl) RED BLOOD CORPUSCLES LEUCOCYTES Grade RBC ± - - ± - - HB - - ± - PCV - - ± - MCV ± - - ± - MCH ± - - ± - MCHC ± - - NEUTROPHILS (40-75%) MONOCYTES (2-10%) LYMPHOCYTES (20-45%) EOSINOPHILS (0-6%) BASOPHILS (0-2.5%) PLATELETS

11 LEUCOCYTES Grade WBC ± ± - - NEUT ± ± - - LYMPH - - ± TOX GRAN - - ± - - L SHIFT - - ± - - PLATES - - ± - - ABNORMAL CELLS (size, colour, shape, Basophilia Nuclei) ROULEAUX FORMATION ERYTHROCYTE SED RATE M 0 10 mm/hr F 0 15 mm/hr ABNORMALITIES OF RED CORPUSCLES Grade ABNORMAL ± - - ± - - ROULEAUX ± SED RATE ± ± - IRON PROFILE SERUM IRON (umol/l) M F TOTAL IRON (umol/l) M F SATURATION (%) M F TRANSFERRIN (g/l) M 2 4 F 2 4 FERRITIN (ng/ml) M F IRON STUDIES Grade IRON ± - ± TIBC SATURATION ± TRANSFERRIN FERRITIN ± - 11

12 Radiological Features of Osteitis The Features pertaining to bone infection will be discussed under the different headings as we deal with them viz. Haemotogenous osteomyelitis Septic Arthritis Infection of fractures and fracture implants Infection around arthroplasties Radiological Features of Osteitis (cont.) In Medico-Legal disputes and research it is often necessary to determine the end point or cure of infection. Definition of Grades 5 Definite Infection 4 Probable Infection 3 Equivocal 2 Probable Cure 1 Definite Cure or Absence of Infection Evaluation of Degree of Infection Grade Clinical Laboratory Radiological Scoring 5 Pyrexia Exudate Neutrophilia CRP ESR Plasma Viscosity Bone lysis Sequestrum Good Fair Poor 4 Inflammation Oedema Anaemia Periosteal Reaction Lymphadenopathy Induration MCV MCH Serum Iron No change 2 Local warmth Ferritin Sclerosis 1 Nothing Ferritin:Iron Ratio less than 5:1 Trabecula normal Negative isotope 12