Bone Wax

What It Is

Bone wax is a mechanical hemostatic agent used intraoperatively to control bleeding from bone surfaces. It was originally formulated by Victor Horsley in the late 19th century. Commercially, it is composed of beeswax with a softening agent such as paraffin or petroleum jelly, which gives it a pliable, putty-like consistency that can be molded to fit irregular bone contours.

Mechanism of Action

Bone wax works purely by physical tamponade - it is smeared or pressed into cancellous bone surfaces (e.g., cut sternal edges, mastoid air cells, skull burr holes) and plugs the vascular channels mechanically, stopping blood from oozing out.

Key points:

It does not activate the coagulation cascade
It does not have intrinsic hemostatic (clotting) properties
It therefore requires relatively intact coagulation and platelet function to work alongside it
(Sabiston Textbook of Surgery, p. 708)

Classification

Bone wax falls under mechanical/physical hemostatic agents, alongside wound packing and digital pressure - as opposed to thermal (electrosurgery), chemical (silver nitrate), or biological (thrombin, fibrin sealant) methods.

(Bailey and Love's Short Practice of Surgery, 28th ed., Summary Box 7.8)

Surgical Uses

Specialty	Application
Cardiothoracic	Sternal bleeding after median sternotomy
Neurosurgery	Skull burr holes, craniotomy defects
ENT / Otolaryngology	Mastoid air cells after mastoidectomy, Eustachian tube occlusion, semicircular canal fistula repair, sigmoid sinus injury
Orthopedics	Cut bone edges in arthroplasty; occipital bone holes in spinal fixation
General surgery	Any bleeding cancellous bone surface

Complications

Because bone wax is non-absorbable (it remains at the implant site indefinitely or is slowly displaced by the foreign body response), it carries several clinically important risks:

Foreign body reaction - chronic low-grade inflammation; granuloma formation
Infection risk - it can act as a nidus for surgical site infection, particularly in spinal and neurological surgery
Impaired bone healing - the physical barrier prevents normal osteogenesis across the treated surface
Migration and extrusion - fragments can migrate from the original site
CSF leak (if used around dura inadequately)

Alternatives

Because of bone wax's non-absorbable nature and associated complications, alternatives have been developed:

Ostene (polyethylene glycol-based) - absorbable, does not impair bone healing, does not cause inflammatory reaction; increasingly preferred where bone regeneration matters (Sabiston, p. 708)
Surgicel (oxidized cellulose) - absorbable, antimicrobial properties
Gelatin-based agents (Gelfoam) - absorbable, platelet aggregation matrix
Microfibrillar collagen (Avitene) - activates intrinsic pathway; useful in heparinized patients

Summary

Property	Bone Wax
Composition	Beeswax + paraffin/petroleum jelly
Mechanism	Physical tamponade
Absorbable?	No (non-absorbable)
Activates coagulation?	No
Bone healing effect	Inhibits osteogenesis
Main risk	Infection, foreign body reaction, granuloma
Main use	Bleeding cancellous bone surfaces

Recent literature note: A 2024 systematic review (PMID 38792294) assessed bone wax use in total knee and hip arthroplasties - no major safety signal was identified, but the authors noted ongoing concerns about impaired bone ingrowth at cemented interfaces.

Sabiston Textbook of Surgery, p. 708
Bailey and Love's Short Practice of Surgery, 28th ed., Summary Box 7.8
Cummings Otolaryngology Head and Neck Surgery (multiple sections)

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