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

Abstract

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.

Impact of occlusive material and cochlea‐carotid artery relation on eustachian tube occlusion in subtotal petrosectomy

“…Although rare, such complication has been previously reported, and its application in subtotal petrosectomy should therefore be carefully reconsidered. 13,14 In contrast to bone wax, on histopathological examination Surgicel provokes fewer foreign body giant cells and elicits no inflammation. 15 It is not the material alone, but rather the occlusion technique which seems to play the decisive role.…”

“…In none of our cases was there a clinically relevant foreign body reaction of the used bone wax. Although rare, such complication has been previously reported, and its application in subtotal petrosectomy should therefore be carefully reconsidered 13,14 . In contrast to bone wax, on histopathological examination Surgicel provokes fewer foreign body giant cells and elicits no inflammation 15 …”

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

“…Although bone wax has several benefits, the usage has always raised a concern and is reported to exert clinical problems, including foreign body reaction, poor bone regeneration, infection, and thrombosis 54 . Bone wax is not absorbed by bone spongiosa and it remains at the site impairing bone healing and also aids in bacterial implantation at the site 16,55 …”

“…Studies have reported that bone wax significantly reduced the number of bacteria required to initiate infection. It can also inhibit the migration of osteoblasts to the wound site, thereby impairing osteogenesis 55,56 . Its usage was considered as a risk factor for sternal dehiscence and infections, and has come under Class III category (potentially harmful) as per the recent consensus guidelines on sternal wound infection 16 …”

Ratlarda gecikmiş testis torsiyon modelinde subkapsüler orşiyektomi sonrası protez olarak bone-wax implantasyonunun sonuçları

“…Günümüzde üretilen testis protezlerinin ameliyathanelerde kolaylıkla stoklanamaması ve tedavi maliyetinin hala yüksek olması gibi dezavantajları vardır. [7] Özellikle beyin cerrahi ve ortopedi alanında yıllarca kullanılmasına rağmen, ciddi bir reaksiyona yol açmayan bone-wax parafin, [8] düşük maliyeti, hemen her ameliyathanede kolayca ulaşılabilmesi ve tunika albuginea içinde çok iyi uyum sağlaması gibi nedenlerle bu çalışmada testis protezi olarak kullanılmıştır.…”