Proposed classification system of septic arthritis according to Tan et al [126

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Part of the difficulty in reporting outcomes in infected shoulder patients is the lack of a uniform classification system for septic joints. A number of systems exist to describe osteomyelitis or infection around a total joint, but none are universally accepted. The ideal system will allow for stratification of the disease, improve decision making, and facilitate outcome reporting that is suitable for meaningful comparison. To our knowledge, a comprehensive classification system for septic arthritis of the shoulder, as such, does not exist at this time.

Therefore, we propose a new classification system for septic joints based on (a) the site and extent of tissue involvement; (b) the host's status, systemically and locally; und (c) the duration of symptoms and virulence of the organism. Clearly, all three of these factors must be considered when assessing treatment results and efficacy of treatment alternatives. In this system, the infectious process is staged using four anatomic types, three host physiologic classes, and two clinical settings.

■ Joint name (glenohumeral, elbow, hip, knee, etc.)

I: Periarticular soft-tissue infection without pyarthrosis II: Isolated septic arthritis

III: Septic arthritis with soft-tissue extension, but no osteomyelitis IV: Septic arthritis with contiguous osteomyelitis

A: Normal immune system B: Compromised system

Bl: Local tissue compromise BS: Systemic immune compromise C: Risk associated with aggressive treatment unwarranted

■ Clinical setting

1: Less than 5 days of symptoms and nonvirulent organism 2: Symptoms for 5 days or more, or a virulent organism

■ Clinical stage for the septic joint

Anatomic type+host class+clinical setting = stage

The anatomic types include infection isolated to the periarticular soft tissue only, to the joint only, involvement of the joint and soft tissue, and involvement of the joint and bone. Anatomic type I is periarticular soft-tissue infection without pyarthrosis. Such a case may occur in a post surgical deep wound infection. Isolated glenohumeral sepsis (type II) occurs when the purulent material is confined within the capsule. Anatomic type III exists when there is involvement of the joint and surrounding soft tissue, such as deep wound infection or septic bursitis, along with the joint sepsis. There is no bony involvement in type Ill. When there is osteomyelitis contiguous with a joint infection, it is classified as type IV. In the shoulder girdle, this usually involves the proximal humerus but may occasionally develop in the acromion, distal clavicle, or glenoid.

The host is classified into either an A, H, or C physiologic group, according to the system of Cierny and Mader [20]. An A host represents a patient with normal metabolic and immune status. The B host is com promised either locally (BL) or systemically (Bs). Local issues include retained nonabsorbable suture or other biomaterial, local irradiation, scarring from multiple procedures, and lymphedema. Systemic compromise includes extreme age, chronic disease, or any condition causing suppression of the immune system. The C host status is reserved for those patients in whom the risks associated with aggressive treatment would outweigh the negative aspects of the infection.

The clinical setting takes into account the duration of symptoms and aggressiveness of the organism. We have grouped patients with less than 5 days or symptoms and infection with a less virulent bacterial strain into group 1. Those patients who are infected with a virulent organism or with symptoms for 5 days or greater fall into group 2. The cut-off was chosen at 5 days because animal studies have shown that irreversible joint damage occurs if septic arthritis persists beyond this time. The virulent organisms may vary between hospitals and geographic locations but generally include methicillin-resistant S. aureus, gram-negative bacilli, vancomycin-resistant enterococcal species, and clostridia.

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