The history of bone marrow in orthopaedic surgery (part I trauma): trepanning, bone marrow injection in damage control resuscitation, and bone marrow aspiration to heal fractures.

PURPOSE: One of the oldest procedures performed by man is trepanning of the bone and yet it was only in the last 40 years that bone marrow aspiration has been used to treat nonunion disorders. MATERIAL AND METHODS: These advances were possible due to improvements in instruments and in techniques to make holes in the bone, an history that began with skull trephinations around 8000-10,000 years ago, and continued with sternum bone marrow injection for trauma resuscitation in the beginning of the twentieth century; this procedure had improved at the beginning of the twenty-first century to allow pelvis bone marrow aspiration for the treatment of nonunion. RESULTS: Trephined skulls from antiquity have been found in many parts of world, showing that trephining was ancient and widespread. Beginning with Neolithic period and the pre-Columbian Andean civilizations, the authors have traced the development of this surgical skill by describing the various surgical tools used to perform holes in the skull. These tools (trephines or trepan) were proposed at the end of the nineteenth century to study the bone marrow. At the beginning of the twentieth century, the sternum became the center of interest for the "in vivo" study of the bone marrow and the fluid injection in the sternum's bone marrow was described for resuscitation from shock during the World War II. With the introduction of plastic catheters and improved cannulation techniques, the need for intraosseous infusion as an alternative route for intravenous access diminished and sometimes abandoned. However, during the mid-1980s, James Orlowski allowed renaissance of the use of intraosseous infusion for paediatric resuscitation. Since then, this technique has become widespread and is now recognized as an alternative to intravenous access in adult emergencies; particularly, the intraosseous access has received class IIA recommendation from the Advanced Trauma Life Support program supported by the American College of Surgeons Committee on Trauma and bone marrow infusion is now recommended for "Damage Control" resuscitation. Although the pelvis bone contains half of the body's marrow volume, it was only in 1950 that the pelvis was proposed as a source for bone marrow aspiration and bone marrow-derived mesenchymal stem cells to improve healing of fractures. CONCLUSION: It will be many years before doing holes in the bone as orthopaedic trauma procedure will be relegated to the annals of history.

A primer on intraosseous access: History, clinical considerations, and current devices.

OBJECTIVE: Intraosseous (IO) access is a method recommended by the American Heart Association and the European Resuscitation Council to administer resuscitative drugs and fluids when intravenous (IV) access cannot be rapidly or easily obtained. Many clinicians have limited knowledge or experience with the IO route. The purpose of this review was to provide the reader with a succinct review of the history, clinical considerations, and devices associated with IO access. DESIGN: Narrative review. SETTING: University-based academic research cell. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Not applicable. CONCLUSIONS: IO access is a lifesaving bridge to definitive vascular access that may be considered when an IV cannot be rapidly attained and the patient's outcome may be negatively affected without prompt circulatory access. The IO route has few contraindications for use and a low rate of serious complications. Multiple manual and powered devices that may be placed in several anatomic sites are commercially available. All clinicians who provide acute care or respond to cardiovascular emergencies should obtain training and maintain proficiency in placing and using IO devices as the IO route is recommended by the major resuscitation organizations as the preferred route of infusion when rapid, reliable IV access is unavailable.

Discovery of the intraosseous route for fluid administration.

One of the many problems in the resuscitation of the shocked patient is how to gain access to the circulation to provide fluids or drugs. Since the 1830s fluids have been administered intravenously. Intravenous access is not always possible in the very shocked patient. An alternative, used in the first world war, was the rectal route. This has rarely been used on a large scale since. Just before the outbreak of the second world war a chance discovery resulted in the development of intraosseous infusions of fluid and drugs. From its discovery it was used in adults and children. For many years it seemed to be ignored in adult resuscitation, but there are now signs of renewed interest in the technique. This brief review traces the discovery of the intraosseous route to put the current developments into a historical context.