Osteomyelitis

Last updated
Osteomyelitis
Other namesBone infection
OsteomylitisMark.png
Osteomyelitis of the 1st toe
Specialty Infectious disease, orthopedics
Symptoms Pain in a specific bone, overlying redness, fever, weakness [1]
Complications Amputation [2]
Usual onsetYoung or old [1]
DurationShort or long term [2]
Causes Bacterial, fungal [2]
Risk factors Diabetes, intravenous drug use, prior removal of the spleen, trauma to the area [1]
Diagnostic method Blood tests, medical imaging, bone biopsy [2]
Differential diagnosis Charcot's joint, rheumatoid arthritis, infectious arthritis, giant cell tumor, cellulitis [1] [3]
Treatment Antimicrobials, surgery [4]
Prognosis Low risk of death with treatment [5]
Frequency2.4 per 100,000 per year [6]

Osteomyelitis (OM) is the infectious inflammation of bone. [4]

Contents

OM may be acute or chronic and can be classified as hematogenous or non-hematogenous. [7]

Symptoms are commonly non-specific but may include pain, swelling and redness around the affected area. [7] In adults, the most commonly affected site is the spine and in pediatric populations the most commonly affected site is the long bones. [8]

OM is commonly caused by bacterial infection, [1] [9] [10] but rarely can be due to fungal infection. [11]

Diagnosis is suspected based on clinical presentation and aided by laboratory and imaging studies with definitive diagnosis via biopsy and culture of the presenting area. [7]

Treatment of bacterial osteomyelitis involves antimicrobials and can involve surgery or amputation. [4] [9] [10] Treatment outcomes of bacterial osteomyelitis are generally good when the condition has only been present a short time. [9] [10]

In humans, the condition was described as early as the 300s BC by Hippocrates. [4] Prior to the availability of antibiotics, the risk of death was significant. [12]

Signs and symptoms

Example of a diabetic foot ulcer, which can lead to infections such as OM. Diabetic Foot Ulcer.jpg
Example of a diabetic foot ulcer, which can lead to infections such as OM.

Symptoms of osteomyelitis are often nonspecific and may include redness, swelling and pain surrounding the affected area. [7] Patients may also experience bone pain and other nonspecific symptoms such as fatigue and night sweats. [13] In acute osteomyelitis, symptom onset may occur more rapidly, such as over a few days and may commonly include fever. [7] In chronic osteomyelitis, systemic symptoms, such as fever, are less commonly seen. [7] Chronic osteomyelitis may also be seen with chronic nonhealing ulcers or fractures. [7] In diabetic patients with neuropathy or vascular insufficiency, skin ulcers may be present and can lead to OM. [8] Inability to bear weight may be seen in acute hematogenous osteomyelitis in children. [9]

The most commonly affected areas for children are the long bones [14] and for adults, the feet, spine, and hips. [2]

Complications

Factors that may commonly complicate osteomyelitis are fractures of the bone, amyloidosis, endocarditis, or sepsis. [15]

Cause

GroupCommon organisms
Infants (<3 months) Staphylococcus aureus , group B Streptococcus (S. agalactiae), E. coli [4]
Infants (>3 months) S. aureus , Streptococcus pneumoniae, Streptococcus pyogenes, Kingella kingae [4]
Children (1 year - 16 years)S. aureus, H. influenzae , Streptococcus pyogenes [16]
AdultsS. aureus, coagulase negative Staphylococcus species, β-hemolytic streptococci, Viridans streptococci, Enterococci, Pseudomonas, Enterobacter, E. coli [4]
Sickle cell anemia patients Salmonella species are most common in patients with sickle cell disease. [17]
Injection drug usersS. aureus, Pseudomonas, Eikenella corrodenes, Candida [4]
Hemodialysis patientsS. aureus, coagulase-negative staphylococci, enterococci, aerobic gram negative bacilli, Candida [4]
Patients with joint prosthetics S. epidermidis [13]

Staphylococcus aureus is the organism most commonly isolated from all forms of osteomyelitis. [15] [18]

Osteomyelitis is a secondary complication in 1–3% of patients with pulmonary tuberculosis. [15] In this case, the bacteria generally spread to the bone through the circulatory system, first infecting the synovium (due to its higher oxygen concentration) before spreading to adjacent bone. [15] In tubercular osteomyelitis the long bones and vertebrae tend to be affected. [15] In adults, vertebral osteomyelitis is commonly caused by S. aureus [19] , but may be caused by Mycobacterium tuberculosis (Pott's disease). [13]

Mycotic infections, such as Coccidioides immitis and Histoplasma capsulatum may also cause OM in patients living in endemic areas. [13]

The Burkholderia cepacia complex has been implicated in vertebral osteomyelitis in intravenous drug users. [20]

Risk Factors

Pathogenesis

In general, microorganisms may infect bone through one or more of the following mechanisms:

In hematogenous OM, the metaphysis is the most commonly affected area of bone due to slowing of blood in the vascular loops of the region [4] [22] . Because of the particulars of their blood supply, the tibia, femur, humerus, vertebrae, maxilla and the mandibular bodies are especially susceptible to osteomyelitis. [23]

The proliferation of bacteria leads to an inflammatory reaction in the acute phase which progresses to death of bone cells and marrow in the first 48 hours. [24] Bacteria continue to spread to the periosteum and in children a subperiosteal abscess may form due to the loose attachment of the periosteum. [24] If the periosteum ruptures, a soft tissue abscess may form. [24] The infection may also spread into a nearby joint leading to septic or suppurative arthritis. [24]

After the first week, areas of devitalized infected bone, known as sequestra , are present due to release of cytokines from the chronic inflammatory cells. [24] Often, the body will try to create new bone around the area of necrosis, resulting in new bone called an involucrum. [15]

Chronic osteomyelitis may be due to the presence of intracellular bacteria. [25] Once intracellular, the bacteria are able to spread to adjacent bone cells. [26] At this point, the bacteria may be resistant to certain antibiotics. [27] In chronic osteomyelitis, Staphylococcus aureus can persist by forming biofilms and invading the osteocyte lacuno‑canalicular network, which contributes to antibiotic tolerance and difficulty eradicating infection [28] .

Diagnosis

Mycobacterium doricum osteomyelitis and soft tissue infection. Computed tomography scan of the right lower extremity of a 21-year-old patient, showing abscess formation adjacent to nonunion of a right femur fracture. Mycobacterium doricum Osteomyelitis and Soft Tissue Infection.jpg
Mycobacterium doricum osteomyelitis and soft tissue infection. Computed tomography scan of the right lower extremity of a 21-year-old patient, showing abscess formation adjacent to nonunion of a right femur fracture.
Extensive osteomyelitis of the forefoot OsteomylitisWorse.png
Extensive osteomyelitis of the forefoot
Osteomyelitis in both feet as seen on bone scan BonescanOsteobothfeet.png
Osteomyelitis in both feet as seen on bone scan

Diagnosis of OM is complex and relies on clinical findings as well as labs and imaging. [7] Laboratory studies in osteomyelitis may show elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), leukocytosis (elevated WBCs), thrombocytosis (elevated platelets) and positive blood cultures. [7] First line imaging will include plan film radiography, though advanced imaging with MRI is often completed due to the high sensitivity and negative predictive value. [7]

Diagnosis of osteomyelitis is often based on radiologic results showing a lytic center with a ring of sclerosis. [15] Radiographs are the first line imaging choice in OM work-up, however, further imaging is typically needed as early changes will not be seen on plain films. [7] Radiographs or CT can show the cortical destruction of advanced osteomyelitis, but can miss nascent or indolent diagnoses. [29]

MRI is often indicated following plain films and contrast may be utilized to evaluate for other concerns, though is not necessary for the diagnosis of OM. [7] In certain situations, such as severe Charcot arthropathy, diagnosis with MRI is still difficult. [29] Similarly, it is limited in distinguishing avascular necrosis from osteomyelitis in sickle cell anemia. [30]

Confirmation is most often by MRI, [31] though PET scans can also be used to diagnose OM. [7] PET scans may be utilized in patients with contraindications to MRI, though notably there is a risk for false positives in patients with recent trauma, healed OM and arthritis among other conditions. [7]

Positive culture from a biopsy of the affected site is needed for definitive diagnosis. [7] Culture of material taken from a bone biopsy is needed to identify the specific pathogen; [32] alternative sampling methods such as needle puncture or surface swabs are easier to perform, but cannot be trusted to produce reliable results. [33] [34] A probe to bone test is indicative of OM in patient's with OM of the lower extremity secondary to vascular insufficiency. [4]

Classification

OM may be classified in several ways. [4] Acute OM develops within days to weeks while chronic OM develops over months to years. [7] OM may also be classified based on pathogenesis (hematogenous spread, contiguous spread, or OM due to vascular insufficiency). [4] The Cierny-Mader staging system is another way OM may be classified and includes anatomic and physiologic types in classification: [4]

Several classification systems exist for OM related to the jawbones and may include the following differentiations: [35]

Treatment

Treatment of OM can include antibiotics and surgical interventions. [7] The Cierny-Mader staging system can help determine which treatment will be pursued. [7] The Infectious Diseases Society of America provides guidelines for diagnosis and treatment of diabetic foot infections [36] , native vertebral osteomyelitis [37] , and pediatric acute hematogenous OM [38] (in conjunction with the Pediatric Infectious Diseases Society).

Antibiotic regimen is tailored to the specific organism(s) in the positive culture, though hospitalized patients may receive empiric antibiotic coverage. [7] The most common empiric regimen includes vancomycin with a third generation cephalosporin or beta lactam/beta-lactamase inhibitor in order to provide broad spectrum coverage. [4] In adult patients, parenteral antibiotics followed by continuation with oral antibiotics has been shown to be as effective as continuation with long-term parenteral antibiotics. [7] Local and sustained availability of drugs have proven to be more effective in achieving prophylactic and therapeutic outcomes. [39] Antibiotic regimens of 4-6 weeks are recommended and for patients continuing with parenteral antibiotics post-discharge, a PICC line may be utilized. [4] Some studies of children with acute osteomyelitis report that antibiotic by mouth may be justified due to PICC-related complications. [40] [41]

Surgical debridement with drainage of associated soft tissue abscesses may be required. [7] Open surgery for chronic osteomyelitis, whereby the involucrum is opened and the sequestrum is removed or sometimes saucerization [42] can be done.

Hyperbaric oxygen therapy has been shown to be a useful adjunct to the treatment of refractory osteomyelitis. [43]

There is tentative evidence that bioactive glass may also be useful in long bone infections. [44] Support from randomized controlled trials, however, was not available as of 2015. [45]

Due to insufficient evidence it is unclear what the best antibiotic treatment is for osteomyelitis in people with sickle cell disease as of 2019. [46]

Hemicorporectomy is performed in severe cases of Terminal Osteomyelitis in the Pelvis if further treatment won't stop the infection. [47]

Prevention or Screening

There are no specific vaccinations which prevent OM. [13] Most often, prophylactic antibiotics are not utilized. [13]

In patients with diabetes, quality foot care may prevent development of OM. [13]

Epidemiology

About 2.4 per 100,000 people are affected by osteomyelitis each year. [6] The young and old are more commonly affected. [9] [1] Males are more commonly affected than females. [3]

History

The word is from Greek words ὀστέον osteon, meaning bone, μυελός myelos meaning marrow, and -ῖτις -itis meaning inflammation.

In 1875, American artist Thomas Eakins depicted a surgical procedure for osteomyelitis at Jefferson Medical College, in an oil painting titled The Gross Clinic . [48]

Canadian politician and premier of Saskatchewan Tommy Douglas suffered from osteomyelitis as a child, and in 1910, underwent several surgeries, which the surgeon performed for free in exchange for allowing his medical students to observe the procedures (which Douglas's parents could not have otherwise afforded). This experience convinced him that medical care should be free for everyone. [49] Douglas became known as the Canadian "Father of Medicare". [50]

Before the widespread availability and use of antibiotics, blow fly larvae were sometimes deliberately introduced to the wounds to feed on the infected material, effectively scouring them clean. [51] [52]

Fossil record

Evidence for osteomyelitis found in the fossil record is studied by paleopathologists, specialists in ancient disease and injury. It has been reported in fossils of the large carnivorous dinosaur Allosaurus fragilis . [53] Osteomyelitis has been also associated with the first evidence of parasites in dinosaur bones. [54]

See also

References

  1. 1 2 3 4 5 6 "Osteomyelitis". NORD (National Organization for Rare Disorders). 2005. Archived from the original on 11 February 2017. Retrieved 20 July 2017.
  2. 1 2 3 4 5 "Osteomyelitis". Genetic and Rare Diseases Information Center (GARD). 2016. Archived from the original on 9 February 2017. Retrieved 20 July 2017.
  3. 1 2 Ferri, Fred F. (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 924. ISBN   978-0-323-52957-0. Archived from the original on 2017-09-10.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Schmitt, SK (June 2017). "Osteomyelitis". Infectious Disease Clinics of North America. 31 (2): 325–38. doi:10.1016/j.idc.2017.01.010. PMID   28483044. S2CID   257184257.
  5. ↑ Bennett, John E.; Dolin, Raphael; Blaser, Martin J. (2014). Principles and Practice of Infectious Diseases. Elsevier Health Sciences. p. 2267. ISBN   978-1-4557-4801-3. Archived from the original on 2017-09-10.
  6. 1 2 Hochberg, Marc C.; Silman, Alan J.; Smolen, Josef S.; et al. (2014). Rheumatology E-Book. Elsevier Health Sciences. p. 885. ISBN   978-0-7020-6303-9. Archived from the original on 2017-09-10.
  7. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Bury, David C.; Rogers, Tyler S.; Dickman, Michael M. (2021). "Osteomyelitis: Diagnosis and Treatment". American Family Physician. 104 (4). ISSN   1532-0650. Archived from the original on 2025-09-15.
  8. 1 2 Colston, Julia; Atkins, Bridget (March 18, 2018). "Bone and joint infection". Clinical Medicine. 18 (2): 150–154. doi:10.7861/clinmedicine.18-2-150. PMC   6303448 . PMID   29626020.
  9. 1 2 3 4 5 El-Sobky, T; Mahmoud, S (July 2021). "Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills". EFORT Open Reviews. 6 (7): 584–592. doi: 10.1302/2058-5241.6.200155 . PMC   8335954 . PMID   34377550.
  10. 1 2 3 "Osteomyelitis". Genetic and Rare Diseases Information Center (GARD). 2016. Archived from the original on 9 February 2017. Retrieved 20 July 2017.
  11. ↑ El-Sobky, TA; Haleem, JF; Samir, S (2015). "Eumycetoma Osteomyelitis of the Calcaneus in a Child: A Radiologic-Pathologic Correlation following Total Calcanectomy". Case Reports in Pathology. 2015 129020. doi: 10.1155/2015/129020 . PMC   4592886 . PMID   26483983.
  12. ↑ Brackenridge, R. D. C.; Croxson, Richard S.; Mackenzie, Ross (2016). Medical Selection of Life Risks 5th Edition Swiss Re branded. Springer. p. 912. ISBN   978-1-349-56632-7. Archived from the original on 2017-09-10.
  13. 1 2 3 4 5 6 7 8 9 10 11 Chin-Hong, Peter; Joyce, Elizabeth A.; Karandikar, Manjiree; Matloubian, Mehrdad; Rubio, Luis Alberto; Schwartz, Brian; Levinson, Warren (2024). "Chapter 70: Bone & Joint Infections". Levinson’s Review of Medical Microbiology & Immunology: A Guide to Clinical Infectious Diseases, Eighteenth Edition (18th ed.). Access Medicine: McGraw Hill LLC. ISBN   978-1-265-12600-1.{{cite book}}: CS1 maint: date and year (link)
  14. ↑ El-Sobky, T; Mahmoud, S (July 2021). "Acute osteoarticular infections in children are frequently forgotten multidiscipline emergencies: beyond the technical skills". EFORT Open Reviews. 6 (7): 584–592. doi: 10.1302/2058-5241.6.200155 . PMC   8335954 . PMID   34377550.
  15. 1 2 3 4 5 6 7 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Mitchell, Richard N. (2007). Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 810–11 ISBN   978-1-4160-2973-1
  16. ↑ Carek, P.J.; L.M. Dickerson; J.L. Sack (2001-06-15). "Diagnosis and management of osteomyelitis". Am Fam Physician . 63 (12): 2413–20. PMID   11430456.
  17. ↑ Burnett, M.W.; J.W. Bass; B.A. Cook (1998-02-01). "Etiology of osteomyelitis complicating sickle cell disease". Pediatrics . 101 (2): 296–97. doi:10.1542/peds.101.2.296. PMID   9445507.
  18. ↑ "Osteomyelitis". Mayo Clinic. 8 November 2022. Retrieved 25 July 2023.
  19. ↑ Berbari, Elie F.; Kanj, Souha S.; Kowalski, Todd J.; Darouiche, Rabih O.; Widmer, Andreas F.; Schmitt, Steven K.; Hendershot, Edward F.; Holtom, Paul D.; Huddleston, Paul M.; Petermann, Gregory W.; Osmon, Douglas R. (2015-09-15). "2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa". Clinical Infectious Diseases. 61 (6): e26–e46. doi:10.1093/cid/civ482. ISSN   1537-6591.
  20. ↑ Weinstein, Lenny; Knowlton, Christin A.; Smith, Miriam A. (2007-12-16). "Cervical osteomyelitis caused by Burkholderia cepacia after rhinoplasty". Journal of Infection in Developing Countries . 2 (1): 76–77. doi: 10.3855/jidc.327 . ISSN   1972-2680. PMID   19736393.
  21. 1 2 3 4 Yang, Ze; Lin, Bingyuan; Ren, Haiyong; Liu, Yiyang; Huang, Kai; Guo, Qiaofeng; Wang, Xiang (August 1, 2025). "Risk factors for osteomyelitis: a systematic review and meta-analysis". International Journal of Surgery. 111 (8): 5606–5622. doi:10.1097/JS9.0000000000002811. ISSN   1743-9159.
  22. 1 2 Luqmani, Raashid; Robb, James; Daniel, Porter; Benjamin, Joseph (2013). Orthopaedics, Trauma and Rheumatology (second ed.). Mosby. p. 96. ISBN   978-0-7234-3680-5.
  23. ↑ King MD, Randall W, Johnson D (2006-07-13). "Osteomyelitis". eMedicine . WebMD. Archived from the original on 2007-11-09. Retrieved 2007-11-11.
  24. 1 2 3 4 5 Kumar, Vinay; Abbas, Abul K.; Aster, Jon C.; Deyrup, Andrea T. (2023). "Bones, Joints, and Soft Tissue Tumors". Robbins & Kumar basic pathology (Eleventh ed.). Philadelphia, PA: Elsevier. ISBN   978-0-323-79018-5.{{cite book}}: CS1 maint: date and year (link)
  25. ↑ Ellington. "Microbial Pathogenesis" (1999).[ page needed ]
  26. ↑ Ellington Journal of Bone and Joint Surgery (2003).[ page needed ]
  27. ↑ Ellington. Journal of Orthopedic Research (2006).[ page needed ]
  28. ↑ Hofstee, Marloes I.; Muthukrishnan, Gowrishankar; Atkins, Gerald J.; Riool, Martijn; Thompson, Keith; Morgenstern, Mario; Stoddart, Martin J.; Richards, Robert G.; Zaat, Sebastian A. J.; Moriarty, Thomas F. (June 2020). "Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods". The American Journal of Pathology. 190 (6): 1151–1163. doi:10.1016/j.ajpath.2020.02.007. ISSN   1525-2191. PMID   32194053.
  29. 1 2 Howe, B. M.; Wenger, D. E.; Mandrekar, J; Collins, M. S. (2013). "T1-weighted MRI imaging features of pathologically proven non-pedal osteomyelitis". Academic Radiology. 20 (1): 108–14. doi: 10.1016/j.acra.2012.07.015 . PMID   22981480.
  30. ↑ Delgado, J; Bedoya, M. A.; Green, A. M.; et al. (2015). "Utility of unenhanced fat-suppressed T1-weighted MRI in children with sickle cell disease – can it differentiate bone infarcts from acute osteomyelitis?". Pediatric Radiology. 45 (13): 1981–87. doi:10.1007/s00247-015-3423-8. PMID   26209118. S2CID   7362493.
  31. ↑ Arachchige, Arosh S. Perera Molligoda; Verma, Yash (2024-01-03). "State of the art in the diagnostic evaluation of osteomyelitis: exploring the role of advanced MRI sequences—a narrative review". Quantitative Imaging in Medicine and Surgery. 14 (1): 1070085–1071085. doi: 10.21037/qims-23-1138 . ISSN   2223-4306. PMC   10784094 . PMID   38223108.
  32. ↑ Zuluaga AF; Galvis W; Saldarriaga JG; et al. (2006-01-09). "Etiologic diagnosis of chronic osteomyelitis: A prospective study". Archives of Internal Medicine. 166 (1): 95–100. doi:10.1001/archinte.166.1.95. ISSN   0003-9926. PMID   16401816. S2CID   2599315.
  33. ↑ Zuluaga, Andrés F; Galvis, Wilson; Jaimes, Fabián; Vesga, Omar (2002-05-16). "Lack of microbiological concordance between bone and non-bone specimens in chronic osteomyelitis: An observational study". BMC Infectious Diseases. 2 (1): 8. doi: 10.1186/1471-2334-2-8 . PMC   115844 . PMID   12015818.
  34. ↑ Senneville E, Morant H, Descamps D, et al. (2009). "Needle puncture and transcutaneous bone biopsy cultures are inconsistent in patients with diabetes and suspected osteomyelitis of the foot". Clinical Infectious Diseases. 48 (7): 888–93. doi:10.1086/597263. PMID   19228109. S2CID   28498296.
  35. 1 2 3 Morrison, Annie; Magliocca, Kelly (January 21, 2026). "Mandible & maxilla Osteomyelitis and inflammatory conditions Osteomyelitis overview". Pathology Outlines.
  36. ↑ IDSA. "Diabetic Foot Infections". www.idsociety.org. Retrieved 2026-01-22.
  37. ↑ IDSA. "Vertebral Osteomyelitis". www.idsociety.org. Retrieved 2026-01-22.
  38. ↑ IDSA. "Acute Hematogenous Osteomyelitis in Pediatrics". www.idsociety.org. Retrieved 2026-01-22.
  39. ↑ Soundrapandian, C; Datta S; Sa B (2007). "Drug-eluting implants for osteomyelitis". Critical Reviews in Therapeutic Drug Carrier Systems. 24 (6): 493–545. doi:10.1615/CritRevTherDrugCarrierSyst.v24.i6.10. PMID   18298388.
  40. ↑ Keren, Ron; Shah, Samir S.; Srivastava, Rajendu; et al. (2015-02-01). "Comparative Effectiveness of Intravenous vs Oral Antibiotics for Postdischarge Treatment of Acute Osteomyelitis in Children". JAMA Pediatrics. 169 (2): 120–28. doi:10.1001/jamapediatrics.2014.2822. ISSN   2168-6203. PMID   25506733.
  41. ↑ Norris, Anne H; Shrestha, Nabin K; Allison, Genève M; et al. (2019-01-01). "2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapya". Clinical Infectious Diseases. 68 (1): e1–e35. doi: 10.1093/cid/ciy745 . ISSN   1058-4838. PMID   30423035.
  42. ↑ "Saucerization".
  43. ↑ Kawashima M, Tamura H, Nagayoshi I, et al. (2004). "Hyperbaric oxygen therapy in orthopedic conditions". Undersea and Hyperbaric Medicine. 31 (1): 155–62. PMID   15233171.
  44. ↑ Aurégan, JC; Bégué, T (December 2015). "Bioactive glass for long bone infection: a systematic review". Injury. 46 (Suppl 8): S3–7. doi:10.1016/s0020-1383(15)30048-6. PMID   26747915.
  45. ↑ van Gestel, NA; Geurts, J; Hulsen, DJ; et al. (2015). "Clinical Applications of S53P4 Bioactive Glass in Bone Healing and Osteomyelitic Treatment: A Literature Review". BioMed Research International. 2015 684826. doi: 10.1155/2015/684826 . PMC   4609389 . PMID   26504821.
  46. ↑ Martí-Carvajal, AJ; Agreda-Pérez, LH (7 October 2019). "Antibiotics for treating osteomyelitis in people with sickle cell disease". The Cochrane Database of Systematic Reviews. 10 (4) CD007175. doi:10.1002/14651858.CD007175.pub5. PMC   6778815 . PMID   31588556.
  47. ↑ Jeffrey, Janis (2009). "A 25-Year Experience with Hemicorporectomy for Terminal Pelvic Osteomyelitis" (PDF).
  48. ↑ Floryan, Meg. "Eakins's The Gross Clinic". Smarthistory . Khan Academy. Archived from the original on October 21, 2020. Retrieved February 11, 2013.
  49. ↑ Thomas, Lewis, ed. (1982). The Making of a Socialist: The Recollections of T.C. Douglas. Edmonton: The University of Alberta Press. pp. 6–7. ISBN   978-0-88864-070-3.
  50. ↑ Bryan Eneas. "Tommy Douglas honoured as person of national historic significance". CBC News. Retrieved 19 March 2019.
  51. ↑ Baer M.D., William S. (1 July 1931). "The Treatment of Chronic Osteomyelitis with the Maggot (Larva of the Blow Fly)". Journal of Bone and Joint Surgery. 13 (3): 438–75. Archived from the original on 22 December 2007. Retrieved 2007-11-12.
  52. ↑ McKeever, Duncan Clark (June 2008). "The Classic: Maggots in Treatment of Osteomyelitis: A Simple Inexpensive Method". Clinical Orthopaedics and Related Research . 466 (6): 1329–35. doi:10.1007/s11999-008-0240-5. PMC   2384033 . PMID   18404291.
  53. ↑ Molnar, R. E. (2001). "Theropod paleopathology: a literature survey". In Tanke, D. H.; Carpenter, K.; Skrepnick, M. W. (eds.). Mesozoic Vertebrate Life. Bloomingon: Indiana University Press. pp. 337–63. ISBN   0-253-33907-3.
  54. ↑ Langlois, Jill (18 Nov 2020). "First Evidence of Parasites in Dinosaur Bones Found". Smithsonian Magazine. Retrieved 2020-11-24.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.