The Efficacy of Bone Wax in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

Objectives: This meta-analysis was conducted to study the hemostatic efficacy of bone wax in total joint arthroplasty (TJA) defined in this manuscript as total knee arthroplasty and total hip arthroplasty. Methods: PubMed, Embase, Google Scholar (page 1-20), and Scopus were searched updated to November 2023. Only comparative studies were included. The clinical outcomes evaluated were the transfusion rate, total blood loss, and the loss of hemoglobin on day 1, 3, and 5 post-operatively. Results: Only 3 studies met the inclusion criteria and were included in this meta-analysis. Bone wax was associated with a reduced transfusion rate (p=0.01), reduced total blood loss (p=0.001), and a decrease in hemoglobin loss on day 1 (p<0.00001), day 3 (p<0.0001), and day 5 (p<0.00001) after the surgery. Conclusion: Bone wax reduced the rate of transfusion, total blood loss, and hemoglobin loss after the surgery. This may induce a reduction the cost of correcting post-operative anemia as well as decrease hospital stay and improving functional outcomes in patients undergoing TJA. Better-conducted randomized controlled studies and cost-effectivity studies could strengthen these findings.

The Use of Bone Wax in Hemostatic Control for Total Knee and Hip Arthroplasties: A Systematic Review.

Background/Objectives: Blood loss can be a serious complication in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Various methods are used by surgeons to achieve hemostatic control in these patients. Complications are associated with perioperative blood loss. In this systematic review, we examined the efficacy of using bone wax to control bleeding in patients undergoing THA and TKA. Methods: The PRISMA model was used to systematically identify and aggregate articles for this study. The PubMed and EMBASE databases were used to search individual studies that examined the use of bone wax in THA or TKA. After applying the search term "bone wax", 2478 articles were initially identified. After inclusion and exclusion criteria were applied, three articles were aggregated for this systematic review. Results: The use of bone wax in THA and TKA decreased blood loss in patients undergoing these operations. Postoperative blood loss following surgery was lower in the bone wax groups compared to the control groups as well. Patients in the bone wax groups also required fewer blood transfusions than those who did not receive bone wax. Conclusions: Bone wax appears to be another modality that can be used by physicians to maintain hemostatic control in THA or TKA patients. Reduced blood loss and transfusion rates in surgery can increase patient outcomes. More studies are needed to examine the efficacy of bone wax in comparison with other hemostatic tools.

Evaluating the Clinical Equivalence of Truwax® and Ethicon® Bone Waxes for Sternal Wound Hemostasis: A Prospective Randomized Study.

BACKGROUND: Incidence of sternal dehiscence, wound infection, and mortality are prevalent following sternotomy. Bone wax is widely used over the sternal edges for augmenting hemostasis. This study evaluated the clinical equivalence of Truwax® (Healthium Medtech Limited, Bengaluru, India) with Ethicon® (Johnson & Johnson, New Brunswick, New Jersey, United States) bone wax for sternal wound hemostasis in subjects undergoing surgical procedures by sternotomy. METHODS: The primary endpoint of this prospective (May 2022-April 2023), parallel-group, two-arm, randomized, single-blind, multicenter study was to evaluate the proportion of subjects having sternal dehiscence within 26 weeks of median sternotomy closure. Secondary endpoints assessed the average time to hemostasis on sternum sides, bone wax properties, number of dressing changes, sternal bone instability (clinically/chest radiography), pain, perioperative/postoperative complications, blood and blood products used, duration of intensive care unit (ICU)/hospital stay, reoperations, time taken to return back to work and normal day-to-day activities, subject satisfaction and quality of life (QoL), and adverse events. A probability of <0.05 was considered significant. RESULTS: No incidence of sternal dehiscence or postoperative complications was witnessed. Time to hemostasis, bone wax properties, number of dressing changes, sternal stability, pain, blood and blood products used, duration of ICU/hospital stay, reoperations, time taken to return back to normal day-to-day activities and to work, and subject satisfaction and QoL were comparable between Truwax® and Ethicon® bone wax groups. CONCLUSION: Truwax® and Ethicon® bone waxes are safe and effective and provide sternal wound hemostasis in people undergoing sternotomy.

The use of bone wax versus dermal regeneration matrix for the reconstruction of scalp defects.

BACKGROUND: Secondary intention healing is an alternative to consider in large tumors or tumors located in areas of limited skin mobility, such as the scalp. To promote epithelialization, we can use Dermal Regeneration Matrix (DRM) or bone wax. OBJECTIVE: This study aimed to compare the efficacy of DRM and bone wax in secondary intention healing of cutaneous scalp tumors in elderly patients with comorbidities. MATERIALS AND METHODS: The medical records of 18 patients with cutaneous scalp tumor healing by secondary intention from February 2022 to April 2023 were analyzed for demographic variables, tumor and surgical characteristics, time from withdrawal of material to complete epithelialization, and need for subsequent surgical intervention. RESULTS: Bone wax was used in 6 patients and DRM in 12. The mean patient age was 84.3 years, and the mean tumor size was 2.7 cm. There were no significant differences in demographics or postoperative complications between the groups. The median time to complete epithelization was 84.5 (60.2-108.7) days in the bone wax group and 105.0 (91.0-126.0) days in the DRM group, with no significant differences (P = 0.15). CONCLUSIONS: Bone wax is a simple and economical material that can be used for secondary intention healing of scalp tumors in elderly patients with high surgical risk.

Development of novel waxy bone haemostatic agents composed of biodegradable polymers with osteogenic-enhancing peptides in rabbit models.

OBJECTIVES: The use of bone wax (BW) is controversial for sternal haemostasis because it increases the risk of wound infection and inhibits bone healing. We developed new waxy bone haemostatic agents made from biodegradable polymers containing peptides and evaluated them using rabbit models. METHODS: We designed 2 types of waxy bone haemostatic agents: peptide wax (PW) and non-peptide wax (NPW), which used poly(ε-caprolactone)-based biodegradable polymers with or without an osteogenesis-enhancing peptide, respectively. Rabbits were randomly divided into 4 groups based on treatment with BW, NPW, PW or no treatment. In a tibial defect model, the bleeding amount was measured and bone healing was evaluated by micro-computed tomography over 16 weeks. Bone healing in a median sternotomy model was assessed for 2 weeks using X-ray, micro-computed tomography, histological examination and flexural strength testing. RESULTS: The textures of PW and NPW (n = 12 each) were similar to that of BW and achieved a comparable degree of haemostasis. The crevice area of the sternal fracture line in the BW group was significantly larger than that in other groups (n = 10 each). The PW group demonstrated the strongest sternal flexural strength (n = 10), with complete tibial healing at 16 weeks. No groups exhibited wound infection, including osteomyelitis. CONCLUSIONS: Waxy biodegradable haemostatic agents showed satisfactory results in haemostasis and bone healing in rabbit models and may be an effective alternative to BW.

Bone wax reduces blood loss after total hip arthroplasty: a prospective, randomized controlled study.

Background: Previous studies have demonstrated the efficacy of bone wax in reducing blood loss in various orthopedic surgeries. However, the effect of bone wax on total hip arthroplasty (THA) remains unclear. The objective of this study was to assess the efficacy of bone wax in THA. Methods: We enrolled 104 patients in this randomized controlled trial. These patients were randomized (1:1) to either the bone wax or control group. The primary outcome was total blood loss after THA. The secondary outcomes included serum hemoglobin (Hb) level, change in Hb level, lower limb diameters on the first and third postoperative day (POD), range of motion at discharge, length of postoperative hospital stay, and adverse events. Results: Patients in the bone wax group had significantly lower total blood loss on PODs 1 and 3 (p < 0.05). Moreover, patients in the bone wax group performed better in terms of postoperative serum Hb level, change in Hb level on PODs 1 and 3, and length of postoperative hospital stay (all p < 0.05). Patients in the bone wax group did not experience any bone wax-related adverse events. Conclusion: Bone wax administration in THA significantly reduced perioperative blood loss. Therefore, bone wax is promising for optimizing blood-conserving management protocols in THA. Clinical trial registration: [https://clinicaltrials.gov/], identifier [ChiCTR2100043868].

Evaluating the Efficacy of Water-Soluble Bone Wax (Tableau Wax) in Reducing Blood Loss in Spinal Fusion Surgery: A Randomized, Controlled, Pilot Study.

Background and Objectives: Lumbar decompression with fusion surgery is an effective treatment for spinal stenosis, but critical postoperative hematoma is a concern. Bone wax has been widely used to control bone bleeding but it has some drawbacks. This study aimed to evaluate the efficacy of Tableau wax, a bioabsorbable hemostatic material, in patients undergoing spinal fusion surgery through a pilot study design. Materials and Methods: A total of 31 patients were enrolled in this single-surgeon, single-institution study. The participants underwent transforaminal lumbar interbody fusion surgery and were randomly assigned to the control group (Bone wax) or test group (Tableau wax). Demographic data, pre- and post-operative hemoglobin levels, blood loss volume, surgical time, Oswestry Disability Index, and EQ-5D scores were recorded. Results: The study showed no significant difference in preoperative and postoperative hemoglobin levels, Oswestry Disability Index, and EQ-5D scores between the groups. However, the Tableau wax group had a significantly lower reduction in hemoglobin levels (1.3 ± 1.0 g/dL) and blood loss (438.2 mL) compared to the Bone wax group (2.2 ± 0.9 g/dL and 663.1 mL, respectively; p = 0.018 and p = 0.022).

A Simple Technique to Prevent Screw Stripping During Hardware Removal Using Bone Wax.

Hardware removal is a common procedure in orthopedics, but it can be challenging and time-consuming. Difficulties in screw removal may arise due to bone growth or cement covering the screw heads, leading to screw damage, and increased surgical time. In this article, we describe a simple and inexpensive technique utilizing bone wax to protect screw heads from bone growth or cement, facilitating future implant removal. The application of bone wax over screw heads acts as a barrier, preventing bone growth or cement from engaging with the screw heads.

Bone wax technique for full-endoscopic lumbar laminotomy.

Hemostatic procedures in endoscopic spine surgery have not yet been established, especially in full-endoscopic spine surgery (FESS) performed under continuous irrigation, which has been a major concern for surgeons. Chu et al. had previously reported a technique to convey bone wax during full-endoscopic cervical spine surgery via intracorporeal route by using ball tip of the drill in 2018. However, to the best of our knowledge, there has been no report by surgeons to adopt bone wax as a hemostatic material in full-endoscopic lumbar surgery to date, probably because of difficulty in handling bone wax under continuous irrigation and through a narrow and long working channel in endoscope. We have renewed the bone wax technique (BWT) for hemostasis in FESS, improving its handling by introducing a nozzle applicator, without which the bone wax would stick to the working channel of the endoscope on the way to the bleeding target. This would result in significant loss of bone wax and repeated bone-wax contact would cause dirt build-up on the endoscope lens, which would then be pushed out from the wall of the working channel, thereby disturbing the laminectomy procedure and obfuscating the visual field. Technical details using nozzle-loaded bone wax have been demonstrated.

Influence of bone wax on bone healing: a case report and literature review.

The purposes of this article are to report the clinical case of a patient who exhibited a foreign body reaction associated with the use of bone wax after extraction of an impacted third molar and to present an integrative literature review addressing the possible influences of this hemostatic agent on bone healing. A 26-year-old woman who underwent the extraction of her mandibular right third molar developed intense alveolar bleeding during surgery, requiring the use of bone wax. In the 2-month postoperative period, the patient presented with intraoral edema and discharge of a purulent secretion via the alveolar route. After cone beam computed tomographic images revealed increased hyperdensity inside the alveolus, alveolar curettage was performed and the material that was obtained was submitted to histopathologic examination. The results of the histopathologic analysis proved conclusive for an inflammatory foreign body reaction associated with exogenous material. A search of the PubMed, SciELO, and LILACS databases identified 22 studies that evaluated the influence of this hemostatic agent on bone healing, and an integrative review involving 367 animals and 75 humans was compiled. Bone wax is a nonresorbable material capable of negatively influencing bone healing. It is suggested that the product be used cautiously in amounts that are just enough to promote the sealing of the bone channels.

Novel resorbable bone wax containing ß-TCP and starch microspheres for accelerating bone hemostasis and promoting regeneration.

Traditional non-resorbable bone wax has been used in clinical surgery for more than 100 years. However, residual bone wax has been proven to cause numerous complications. In this study, a novel resorbable bone wax was designed to overcome the disadvantages of traditional non-resorbable bone wax. Alkylene oxide copolymers were used as the main component of resorbable bone wax; additionally, ß-tricalcium phosphate and starch microspheres were added to enhance bone regeneration and hemostatic ability. This novel resorbable bone wax has a high potential for clinical translation and is expected to be developed as a substitute for traditional bone wax.

Bone wax in the treatment of partial epiphysiodesis of distal femoral growth plate: Case report at 10-year follow-up.

The growth plate is the weakest structure in the skeleton of a child and a frequent site of injury or fracture; physeal injuries represent 15%-30% of all fractures in children. Of all growth plate fractures, the incidence of growth arrest and disorders is around 15%. Here, we discuss a female patient who, at the age of 5 years, was treated for a polytrauma that involved a complex lesion of the growth plates of the knee. Four days after trauma, she underwent closed reduction surgery and internal fixation with cannulated screws for femoral and tibial fractures of the growth plate. A 20° valgus deviation of the left knee was found at 3-month postoperative clinical check-up likely as a result of a growth disorder of the femur. She was diagnosed with valgus knee secondary to epiphysiodesis of the lateral portion of the femoral physis and she was readmitted to the hospital. In the operating theater, an open femoral de-epiphysiodesis was performed with a burr; the drilled hole was then filled with bone wax. At 20-month post-trauma follow-up, the left knee was still valgus about 20° relative to the other side. During follow-up, a slow but progressive improvement in the axis of the lower limbs was noted. Clinical and radiographic control 10 years after the trauma showed a complete recovery of the axis of the lower limbs. In the initial stages, the presence of bone wax in the area of de-epiphysiodesis allowed for stabilization of the deformity on the 20° of preoperative valgus. The interpretation of the growth cartilage activity occurred in an asymmetrical way such as to realign the femoral load axis, it can be based on the different mechanical stimulus on the two knee areas due to the preexisting deformity. There is no unanimous evidence in the literature in terms of management of growth disorders resulting from this type of injury. Bone wax resulted in effectively filling the hole of de-epiphysiodesis in the distal femoral growth plate and allowed us to obtain the response of the growth plate and to improve the recovery time in young children.

Development of Biodegradable Osteopromotive Citrate-Based Bone Putty.

The burden of bone fractures demands development of effective biomaterial solutions, while additional acute events such as noncompressible bleeding further motivate the search for multi-functional implants to avoid complications including osseous hemorrhage, infection, and nonunion. Bone wax has been widely used in orthopedic bleeding control due to its simplicity of use and conformation to irregular defects; however, its nondegradability results in impaired bone healing, risk of infection, and significant inflammatory responses. Herein, a class of intrinsically fluorescent, osteopromotive citrate-based polymer/hydroxyapatite (HA) composites (BPLP-Ser/HA) as a highly malleable press-fit putty is designed. BPLP-Ser/HA putty displays mechanics replicating early nonmineralized bone (initial moduli from ≈2-500 kPa), hydration induced mechanical strengthening in physiological conditions, tunable degradation rates (over 2 months), low swelling ratios (<10%), clotting and hemostatic sealing potential (resistant to blood pressure for >24 h) and significant adhesion to bone (≈350-550 kPa). Simultaneously, citrate's bioactive properties result in antimicrobial (≈100% and 55% inhibition of S. aureus and E. coli) and osteopromotive effects. Finally, BPLP-Ser/HA putty demonstrates in vivo regeneration in a critical-sized rat calvaria model equivalent to gold standard autograft. BPLP-Ser/HA putty represents a simple, off-the-shelf solution to the combined challenges of acute wound management and subsequent bone regeneration.

Experimental Rat Model of Bony Defects in the Facet Joint Maintained with Bone Wax for the Study of Spinal Pain.

PURPOSE: Studies using experimental rat models for low back pain due to facet-joint defects are scarce. This study used a novel experimental rat model to determine whether bony defects induced by facetectomy could be maintained by bone wax, thus mimicking spondylolysis, and to analyze the effect of the facetectomy on rat behavior. PATIENTS AND METHODS: Twelve 10-week-old male Wistar rats weighing 300-350 g were divided into group A (n = 6) that underwent unilateral facetectomy of the right L5-6 facet joint and group B (n = 6) that additionally applied water-soluble bone wax at the facetectomy site. The difference in the left and right stride length, detected by the footprint test, and change in the left and right facet joint area were compared before and 4 weeks after the experiment. RESULTS: Even though the difference between the left and right stride lengths of groups A and B was not statistically significant, in contrast to group A, group B showed a shorter stride length on the right side (p = 0.22 and 0.46, in group A and group B, respectively). The right facet joint area, where the facetectomy was performed, was significantly smaller in group B 4 weeks after surgery, but not in group A (p = 0.50 and < 0.01, in group A and group B, respectively). CONCLUSION: Based on the results, we concluded that the bony defects, induced by facetectomy at the L5-6 facet joint, were maintained with bone wax. This study will provide an experimental model for bony defects in the facet joint.

Evaluation of the effects of Ankaferd haemostat application on bone regeneration in rats with calvarial defects: histochemical, immunohistochemical and scintigraphic study.

BACKGROUND: Bone wax, a haemostatic agent, is widely used in craniospinal surgical procedures for a long time, in spite of controversial results regarding its negative influence upon bone regeneration. In this experimental study, the effects of Ankaferd Blood Stopper (ABS), as an alternative haemostatic agent, were evaluated through histochemical, immunohistochemical and scintigraphic studies. MATERIALS AND METHODS: The total of 30 adult female Wistar albino rats was randomly divided into three groups: intact control group (n = 10), bone wax group (n = 10), and ABS group (n = 10). Surgically, a 3.0 mm hole in diameter was drilled on the right side of calvarium of the rats using a Class Mini Grinder set in all three groups, as described previously. At the end of 8 weeks, bone healing and connective tissue alterations surrounding drilled calvarial defect areas of the rats were determined via haematoxylin and eosin and the Mallory's trichrome staining and anti-bone sialoprotein immunohistochemistry. Image Pro Express 4.5 programme was used for histomorphometric calculation of new bone and fibrotic tissue areas. All statistical analyses were made with SPSS 25.0 and analysis of variance (one-way ANOVA) followed by Bonferroni post hoc test was performed, p < 0.001 was considered as significance level. RESULTS: Histomorphometrically, it was found that he had the largest hole diameter and the least fibrotic scar area in the bone-wax group. In the bone wax group, it was observed that the material closed the hole and there was only a fibrotic scar tissue in the area between the bone tissue at the edge of the hole and bone wax, and a fibrotic tissue was formed in the bone wax area. During the histological procedure, this bone-wax material was poured and the sections were seen as a gap in this area. In the ABS haemostat group, the smallest hole diameter and the least fibrotic scar tissue were observed. Fibrotic scar tissue close to each other was found in the ABS haemostat and bone wax groups. Histological analysis of samples also showed a statistical significance for fibrotic connective tissue area between groups (p < 0.05). Scintigraphically, osteoblastic activity related to blood flow in the animal taken from the group with application of ABS haemostat was more pronounced compared to the other two groups. CONCLUSIONS: In our study, it has been concluded that the ABS yields affirmative effects on the bone healing, while bone wax leads to negative impact on the bone regeneration. Scintigraphic, histochemical and immunohistochemical data support the affirmative impact of the ABS haemostat application upon the bone regeneration apart from the quick stop of haemorrhage.

Efficacy and safety of a novel hemostatic material, BoneStat, compared with Ostene and Bone Wax in a rat calvarial defect model.

Hemostasis has critical significance during surgical procedures. Bone Wax has traditionally been commonly used for bone hemostasis despite well-documented undesirable side effects: hindering osteogenesis and induction of inflammatory reactions with consequent increase in infection rates. A later developed formulation, Ostene, offers an alternative to Bone Wax with lesser undesired effects. In this study, BoneStat, a newly developed bone hemostatic formulation comprising water-soluble alkylene oxide co-polymers, was evaluated for water solubility, hemostatic efficacy, ease of handling, bone healing efficacy, and inflammatory reactions compared with Bone Wax and Ostene in a rat calvarial defect model. More than 95% of BoneStat was dissolved in water within 48 h, as was Ostene, but not Bone Wax. The time to hemostasis using BoneStat was significantly faster than with Ostene or Bone Wax. BoneStat also improved ease of handling compared to Ostene or BoneWax. BoneStat- and Ostene-treated groups constantly showed better bone healing than with Bone Wax. The BoneStat and Ostene groups presented no evidence of chronic inflammation reaction contrary to Bone Wax. These results suggest improved hemostasis, ease of handling, non-hindering bone healing, and unnoticeable chronic inflammatory reactions with BoneStat. Thus, Bonestat is a useful and reliable formulation for mechanical hemostasis.

The role of hemostatic devices in neurosurgery. A systematic review.

Hemostasis represents a fundamental step in every surgical procedure. During neurosurgical procedures, proper and robust hemostasis into confined spaces can significantly reduce the odds of perioperative complications. Over the decades, multiple methods have been applied, and several medical devices have been developed to promote and guarantee proper hemostasis. This study presents a systematic review of the most used intraoperative hemostatic methods and devices in neurosurgery. Insightful research was performed on the PubMed database according to the PRISMA guidelines. This comprehensive review of scientific literature represents a synoptic panel where the most used intraoperative hemostatic methods and devices available today in neurosurgery are classified and described.

Bone Wax as an Intra-Cavitary Fiducial for Intra-Operative Magnetic Resonance Imaging Guided Resections of Eloquent Cortex Glioma.

BACKGROUND: The extent of resection of eloquent cortex low-grade glioma is improved by intraoperative magnetic resonance imaging (IOMRI) which is faced with challenges such as difficulty in automated registration after the MRI and prolongation of operative time. OBJECTIVE: We describe an easier and foolproof method of resection using bone wax as fiducial. SURGICAL PROCEDURE: A young male with right-frontal low-grade glioma anterior and superficial to the motor fibers was operated using IOMRI and awake craniotomy under neuromonitoring. Motor cortex mapping using phase reversal and continuous motor evoked potential (MEP) monitoring was used initially followed by continuous sub-cortical suction stimulation for deeper decompression until stimulation was seen. Bone wax in a triangular shape was placed at the suspicious margin and IOMRI was done. RESULTS: The tumor residue was seen anterior and deeper to the bone wax and removed subsequently. CONCLUSION: The use of bone wax as a fiducial can aid in IOMRI-guided resection of eloquent cortex glioma in awake patients.