The Classic: A Clinical Staging System for Adult Osteomyelitis

Abstract

INTRODUCTION Jon Terry Mader (Fig 1) was born on March 21, 1944 in Madison, WI. He earned his BA and MD degrees at Wabash College at Indiana University in 1966 and 1970, respectively. He trained in Internal Medicine at the University of Texas Medical Branch in Galveston, TX and made his career there in the Division of Infectious Disease in the Department of Internal Medicine. At the time of his death on October 25, 2002, he had risen to the positions of Professor of Medicine, Professor of Pathology, and Adjunct Professor of Orthopaedic Surgery. During his life, he published more than 145 peerreviewed papers on osteomyelitis, antibiotic therapy, hyperbaric oxygen, joint infections, the foot in patients with diabetes, and the use of the Ilizarov technique for the treatment of musculoskeletal infections. He also was the principle investigator in numerous funded research projects and the coauthor of Musculo-Skeletal Infection. He died when the book was in its final stages of production.Fig 1.: John T. Mader, MDIn addition, Dr. Mader was a gifted athlete, Eagle Scout, captain in the U.S. Naval Reserve, and regarded with respect and affection by his patients and colleagues. Henry H. Sherk, MD At the University of Texas Medical Branch (UTMB) in Galveston, Texas, the adult osteomyelitis service now treats ten new cases of osteomyelitis each month. Since January 1981, 425 patients have been evaluated and 900 procedures performed to treat 240 lesions. In our experience, the treatment of adult osteomyelitis is influenced by four factors: the condition of the host, the functional impairment caused by the disease, the site of involvement, and the extent of bony necrosis. Without reference to these factors, it is difficult to compare the results of different treatment protocols 1–5 and the effectiveness of new therapeutic modalities. 6–9 The UTMB classification of adult osteomyelitis 10 combines four anatomic types (the disease) with three physiologic classes (the host) to define 12 clinical stages (Table I). A distinction between the acute and chronic process has not been necessary. 11 The classification system incorporates the four prognostic factors, delineates treatment for progressive stages of the disease, and provides guidelines for the use of adjunctive therapies.TABLE I: The UTMB Staging System for Adult OsteomyelitisTHE UTMB TREATMENT PROTOCOL FOR ADULT OSTEOMYELITIS ( TABLE II)TABLE II: UTMB Treatment Protocol for Adult OsteomyelitisTABLE II: UTMB Treatment Protocol for Adult Osteomyelitis (Continued)The UTMB prospective study of adult osteomyelitis began in June 1981. The methods have remained unchanged except for the antibiotic recommendations for emergency coverage and for acrylic bead mixtures. The protocol itself is unique: patient selection and medical/surgical treatment are predetermined by the clinical staging system; the preoperative antibiotic program is based on outpatient biopsy data, and the patient follow-up system correlates a clinical and biologic response to therapy. Patient Evaluation Condition of the host. Host deficiencies influence treatment options, prognosis, and the interpretation of treatment results. Following debridement surgery, the host must be able to impede infection, resist contamination, heal surgical wounds, and tolerate the metabolic stress of sequential surgeries. A list of factors influencing the ability of the host to elicit an effective response to infection and treatment is found in Table III. Local factors lead to a vascular compromise of bone and soft tissue. Systemic compromise affects immune surveillance, metabolism, leukocyte function, and/or large vessel disease. Local and systemic factors may combine (e.g., diabetes mellitus).TABLE III: Systemic or Local Factors that Affect Immune Surveillance, Metabolism, and Local VascularityDisability of the patient. The functional impairment caused by the disease, the reconstruction options, and the metabolic consequences of aggressive therapy influence the selection of treatment candidates. A draining sinus with minimal pain and/or dysfunction is not, by itself, an indication for surgical treatment. At times, the procedures required to arrest or palliate the disease are of such magnitude that treatment can lead to loss of function, limb, or life. In these latter instances, quality of life is the major factor influencing the decision to pursue therapy. Physiologic Classification (Host). At UTMB, the condition of the host and the relative disability caused by the disease are combined in a physiologic classification (Table I). A patient with a normal physiologic response to infection and surgery is designated an A-Host; a compromised patient is classified a B-Host and will have either local (BL), systemic (BS) or combined (BL,S) deficiency in wound healing (Table III). When the treatment or results of treatment are more compromising to the patient than the disability caused by the disease itself, the patient is classified a C-Ho