Analysis of bone healing with a novel bone wax substitute compared with bone wax in a porcine bone defect model

Beyond Hemostasis: Understanding the Risks of Bone Wax in Orthopedic Surgery - A Case Report

Introduction

Osseous hemorrhage following a surgical incision or traumatic fracture can be a challenging issue to manage. During orthopedic surgeries, bone wax is frequently utilized as a surgical technique to enhance hemostasis and reduce bleeding from bone. The hemostatic effect of bone wax mostly stems from its physical characteristics. The advantages of using bone wax are that it is easy to handle, low cost, inert, malleable, and has good sealing capacity and bone adherence. A review of the literature also shows that the most notable side effects of using bone wax are allergic foreign body reactions, development of granulomas, infection, and disruption of bone healing.

Case Report

We present two cases of exostosis where the main surgical procedure for exostosis excision involved the use of bone wax to achieve hemostasis. A few months later, they presented with delayed migration and discharge of bone wax from the site of the surgery. To remove the bone wax off the primary application site, both of these individuals needed surgical intervention.

Conclusion

When needed, bone wax should only be applied for the duration required to bring about hemostasis. It acts as a foreign body; hence, using bone wax may result in foreign-body granulomas. Bone wax is a cost-effective, user-friendly, and promptly efficient hemostatic substance; nevertheless, its advantages should not be blindly used without prior assessment of the associated hazards. In conclusion, even though bone wax is frequently used in Orthopedic surgeries to help with hemostasis and control bleeding, medical personnel must be aware of any possible risks involved with using it. It is essential to closely follow individuals who have received bone wax treatment to address any issues or problems that may develop.

Effectiveness and Biocompatibility Evaluation of a Novel Absorbable Bone Wax Used in Bone Tissue

This study aims to determine the hemostatic effectivity and biocompatibility of a novel absorbable bone wax in comparison with a commercially available product. Eighteen small fat-tail sheep were used to simulate clinical surface bleeding of sternal injury. Hemostasis effectiveness, the degree of bone healing, micro-computed tomography, and histopathology were evaluated over a period after the application of the material to the surgically created wound. The absorbable bone wax used in the study stopped bleeding immediately and did not affect bone healing. The histopathological results also showed that there were no complications associated with the new material. The results showed that the new absorbable bone wax used in this study was effective and biocompatible.

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.

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.

Novel resorbable bone wax containing β-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, β-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.

Combined Anterior Osteophytectomy and Cricopharyngeal Myotomy for Treatment of DISH-Associated Dysphagia

STUDY DESIGN

Retrospective observational case series.

OBJECTIVE

To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP).

METHODS

This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM.

RESULTS

A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures.

CONCLUSION

Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.

Chitosan Scaffold Containing Periostin Enhances Sternum Bone Healing and Decreases Serum Level of TNF-α and IL-6 after Sternotomy in Rat

BACKGROUND

In the aftermath of bone injuries, such as cranium and sternum, bone wax (BW) is used to control bleeding from the bone surfaces during surgery. Made up of artificial substances, however, it is associated with many complications such as inflammation, increased risk for infection, and bone repair delay. We, therefore, in this study set out to design and evaluate a novel BW without the above-mentioned side-effects reported for other therapies.

METHODS

The pastes (new BW(s)) were prepared in the laboratory and examined by MTT, MIC, MBC, and degradability tests. Then, 60 adult male Wistar rats, divided into six equal groups including chitosan (CT), CT-octacalcium phosphate (OCP), CT-periostin (Post), CT-OCP-Post, Control (Ctrl), and BW, underwent sternotomy surgery. Once the surgeries were completed, the bone repair was assessed radiologically and thereafter clinically in vivo and in vitro using CT-scan, H&E, ELISA, and qRT-PCR.

RESULTS

All pastes displayed antibacterial properties and the CT-Post group had the highest cell viability compared to the control group. In contrast to the BW, CT-Post group demonstrated weight changes in the degradability test. In the CT-Post group, more number of osteocyte cells, high trabeculae percentage, and the least fibrous connective tissue were observed compared to other groups. Additionally, in comparison to the CT and Ctrl groups, higher alkaline phosphatase activity, as well as decreased level of serum tumor necrosis factor-α, interleukin-6, and OCN in the CT-Post group was evident. Finally, Runx2, OPG, and RANKL genes' expression was significantly higher in the CT-Post group than in other groups.

CONCLUSION

Our results provide insights into the desirability of pastes in terms of cellular viability, degradability, antibacterial properties, and surgical site restoration compared to the BW group. Besides, Periostin could enhance the osteogenic properties of bone tissue defect site.

Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update

Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.

The sole and combined effects of gelatin-thrombin matrix and freeze-dried bone allograft on early bone healing

Aims

Gelatin-thrombin matrix (GTM) is a hemostatic agent with applications in maxillofacial surgery consisting of human-derived thrombin and bovine-derived gelatin matrix. The aim of this study was to evaluate the efficacy of GTM alone or with freeze-dried bone allograft (FDBA) in improving early bone healing.

Materials and Methods

Forty-six adult male Sprague-Dawley rats were used. All animals were randomly assigned to a control group (n = 4) and three study groups (n = 14). Each group was divided into two subgroups for histomorphometric and histological analyses at weeks 1 and 4. The new bone formation, inflammation, fibrosis, necrosis, foreign body reaction, and bone healing scores were evaluated based on the histopathological findings. Multiple comparisons were performed using the Kruskal-Wallis test. Variables that were not normally distributed were evaluated using the Mann-Whitney U test.

Results

At 1 week, the GTM + FDBA group showed less bone formation (mean ± SD: 0.08 ± 0.03 mm²), compared with the study and control groups (FDBA: 0.15 ± 0.06 mm²; GTM: 0.13 ± 0.06 mm²). At 4 weeks, the GTM group (0.48 ± 0.1 mm²) showed more bone formation than the GTM + FDBA group (0.33 ± 0.17 mm²). Foreign body reactions were observed at weeks 1 and 4 in all GTM-containing groups.

Conclusions

Within the limitations of this study, GTM group did not show a significant difference in bone formation compared with the control group. GTM did not inhibit bone healing at 1 and 4 weeks, and no significant difference was observed compared with the control groups. GTM was more effective for bone healing when administered without FDBA. GTM is considered safe when bone hemorrhage is encountered.

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.

Interpositional arthroplasty of post-traumatic temporomandibular joint ankylosis: A modified method

The purpose of this study was to evaluate a modified method of interpositional arthroplasty for post-traumatic temporomandibular joint ankylosis. All patients were treated with a modified interpositional arthroplasty that included: navigation-assisted accurate bone dissection with minimal removal of only 5 mm of the ankylosed bony mass, novel application of bone wax and porcine acellular dermal matrix to prevent re-ankylosis, and a unique 3D-printed splint for occlusal stabilization and gap maintaining. The pre- and post-operative physical and radiological examinations of patients were recorded during routine follow-up visits. Postoperative follow-up visits lasted at least 12 months. Twelve patients, seven males and five females, ranging from 21 years to 59 years, were enrolled in this retrospective case series. All of the twelve patients with eighteen bony ankylosed temporomandibular joints were treated by our new method. The post-operative follow-up periods ranged from 1 year to 4 years. During the follow-up visits within at least 1 year, no one manifested re-ankylosis. The mean maximum incisor opening changed from 7.4 ± 5.3 mm (p < 0.001, before surgery) to 37.6 ± 3.9 mm (p < 0.001, last follow-up visit). No sign of post-operative infection or foreign body rejection was observed during the follow-up visits. The post-operative occlusal relationship was sound and stable. It is suggested that the modified method of interpositional arthroplasty provides favorable clinical and radiographic outcomes after a short-term follow up.

Recent developments in controlling sternal wound infection after cardiac surgery and measures to enhance sternal healing

One of the major risks of cardiac surgery is the occurrence of infection at the sternal wound site. Sternal wound infections are primarily classified into superficial infection and deep sternal wound infection or mediastinitis. A patient is diagnosed with mediastinitis if microorganisms are present in their mediastinal tissue/fluid or with the observation of sternal wound infection during operation and with characteristic symptoms including chest pain, fever, and purulent drainage from the mediastinum. It is usually caused by Staphylococcal organisms in 75.8% of cases and the rest is caused by gram-negative bacteria. Currently, in cardiac surgery, hemostasis is achieved using electrocautery and bone wax, and the sternum is closed using wire cerclage. Several studies show that bone wax can act as a nidus for initiation of infection and the oozing blood and hematoma at the site can promote the growth of infectious organisms. Many research groups have developed different types of biomaterials and reported on the prevention of infection and healing of the sternum. These materials are reported to have both positive and negative effects. In this review, we highlight the current clinical practices undertaken to prevent infection and bleeding as well as research progress in this field and their outcomes in controlling bleeding, infection, and enhancing sternal healing.

Translation of bone wax and its substitutes: History, clinical status and future directions

Bone wax, primarily composed of beeswax and softening agent, is a century-old material used to control bleeding of disrupted bone surfaces by acting as a mechanical barrier to seal the wound. The current bone wax products are commonly packed in easy-to-open foil in the form of sterile sticks or plates, with excellent malleability and smooth consistency, enabling cost-effective and easy handling approach for bleeding control. It has also been reported that the inert nature of bone wax causes complications including foreign body reaction, infection promotion and bone healing inhibition. With the advances in biomaterials and the market boost of bone haemostatic materials, the arena of bone wax substitute research has expanded to a wide spectrum of material formulations and forms. However, the development of substitutes of bone wax for translation is a pivotal yet challenging topic because currently a potential candidate is recommended to be just as simple to use, effective and inexpensive to produce as traditional bone wax but also be absorbable and osteogenic. This review provides an overview of bone wax including its history, clinical applications and associated complication. In addition, emerging substitutes of bone wax and outlooks of future directions including the standardised evaluation methods are also discussed as an effort to catalyse the innovation and translation of bone haemostatic agents in the near future. The translational potential of this article: Occurrence of osseous haemorrhage is common in surgically incised or traumatically fractured bone. It is essential to stop bone bleeding to avoid further pathologic consequences such as tissue necrosis and eventually mortalities due to blood loss. Medical sterile bone wax is a classical material for haemostasis of bone during orthopaedic surgeries, thoracic surgeries, neurological surgeries and so on. Along with its widespread use, complications such as foreign body reaction, bone healing inhibition and infection promotion associated with bone wax are observed. With the growing knowledge in biomaterials and the boost of market of bone haemostatic materials, bone wax substitute research is thriving. An overview of bone and its substitutes together with evolution of their design criteria is carried out in this work, providing information for the innovation and translation of bone haemostatic agents in the near future.