Definitions, Criteria and Classifications in Osteomyelitis

Morrey and Peterson’s Criteria

  1. Definite osteomyelitis: the pathogen is isolated from bone or adjacent soft tissue as there is histologic evidence of osteomyelitis.
  2. Probable osteomyelitis: a blood culture is positive in setting of clinical and radiological features of osteomyelitis.
  3. Likely osteomyelitis: typical clinical finding and definite radiographic evidence of osteomyelitis are present and response to antibiotic therapy.

Peltola and Vahvanen’s Criteria for Acute Osteomyelitis

  1. Pus on aspiration
  2. Positive bacterial culture from bone or blood
  3. Presence of classic signs and symptoms of acute osteomyelitis
  4. Radiographic changes typical of osteomyelitis

Two of the listed findings must be present for establishment of the diagnosis.

Waldvogel Classification of Osteomyelitis

It is a simple and practical system based on 3 factors (duration, mechanism and vascular status):

a. Duration:

  • Acute: <2 weeks
  • Subacute: 2-6 weeks
  • Chronic:
    • >6 weeks
    • Persistent or relapsed infection
    • Infection associated with prosthetic devices
    • Histologic evidence of dead or necrotic cortical bone

b. Mechanism:

  • Hematogenous
  • Contiguous source
    • No generalized vascular disease
    • Generalized vascular disease

Gledhill and Robert Classification of Subacute Osteomyelitis

subacute osteomyelitis classification
TypeGledhill ClassificationRobert modification of Gledhill ClassificationDifferential diagnosis
ISolitary localized zone of radiolucency surrounded
by reactive new bone formation
Ia—Punched-out radiolucency
Ib—Punched-out radiolucent lesion with sclerotic margin
Ia – Eosiniophilic granuloma

Ib – Brodie’s abscess
IIMetaphyseal radiolucencies with cortical erosionOsteosarcoma
IIICortical hyperostosis in diaphysis; no onion skin reactionLocalized cortical periosteal reactionOsteoid osteoma
IVSubperiosteal new bone and onion skin layeringOnion skin periosteal reactionEwing’s sarcoma
VCentral radiolucency in epiphysisChondroblastoma
VIDestructive process involving vertebral bodyEosinophilic granuloma
Tuberculous spondylitis

Cierny and Mader Staging for Chronic Osteomyelitis

cierny mader chronic osteomyelitis
Stage 1Medullary osteomyeltitis: infection confined to the intramedullary bone surfacesInfected intramedullary rod
Hematogenous osteomyelitis
Stage 2Superficial osteomyelitis: restricted to outer cortexDiabetic foot ulcer with infection extending to bone
Stage 3Localized osteomyelitis: full-thickness, cortical sequestration without instabilityProgression from stage I or II
Stage 4Diffuse osteomyelitis: through-and-through process with instability requiring intercalary reconstruction of boneProgression from stage I, II or III
A HostNormal physiological, metabolic, and immunologic states
B HostLocal compromise, systemic compromise, or bothSystemic – Diabetes, malnutrition, renal failure, hepatic failure, maliganancy, extremes of age, immune disease

Local – Smoking, chronic lymphedema, major or small vessel compromise, venous stasis, arthritis, large scars, neuropathy
C HostMorbidity of treatment is worse than diseasePatient who is not a surgical candidate or who cannot tolerate long-term antibiotics

Nade’s Principles of Treatment of Acute Hematogenous Osteomyelitis

  1. Appropriate antibiotic will be effective before pus formation
  2. Antibiotics will not sterilize acascular tissues or abscesses and such area require surgical removal
  3. If such removal is effective, antibiotics should prevent their reformation therefore, primary closure should be safe
  4. Surgery should not damage already ischemic bone and soft tissue
  5. Antibiotics should be continued after surgery

Nade’s Indications for Surgery in Acute Osteomyelitis

  1. Abscess formation
  2. Severely ill and moribun child with features of acute osteomyelitis
  3. Failure to respond to antibiotics for >48 hours


Peltola H, Vahvanen V. A comparative study of osteomyelitis and purulent arthritis with special reference to aetiology and recovery. Infection 1984;12(2):75–9.

Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (first of three parts). N Engl J Med 1970;282:198–206.

Cierny G, Mader JT, Pennick JJ. A clinical staging system for adult osteomyelitis. Contemp Orthop 1985; 10:17–37.

Osteomyelitis of the Foot and Ankle: Medical and Surgical Management edited by Troy J. Boffeli

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