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



1 Saint Joseph University, Faculty of medicine, Beirut, Lebanon

2 1 Saint Joseph University, Faculty of medicine, Beirut, Lebanon 2 Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon

3 Department of Orthopedic Surgery, Hotel Dieu de France Hospital, Beirut, Lebanon



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. Level of evidence: III


Main Subjects

1. Masaracchio M, Hanney WJ, Liu X, Kolber M, Kirker K. Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis. PLoS One. 2017; 12(6):1-22. doi:10.1371/journal.pone.0178295.
2. Wiener JM, Tilly J. Population ageing in the United States of America: implications for public programmes. Int J Epidemiol. 2002; 31(4):776-781. doi:10.1093/ije/31.4.776.
3. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ. 2003; 81(9):646-656.
4. Bruyère O, Ethgen O, Neuprez A, et al. Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study. Arch Orthop Trauma Surg. 2012; 132(11):1583-1587. doi:10.1007/s00402-012-1583-7.
5. Dailiana ZH, Papakostidou I, Varitimidis S, et al. Patient-reported quality of life after primary major joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord. 2015; 16:366. doi:10.1186/s12891-015-0814-9.
6. Fortin PR, Clarke AE, Joseph L, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999; 42(8):1722-1728. doi:10.1002/1529-0131(199908)42:8<1722::AID-ANR22>3.0.CO;2-R.
7. Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med. 2001; 161(3):454-460. doi:10.1001/archinte.161.3.454.
8. Klasan A, Neri T, Oberkircher L, Malcherczyk D, Heyse TJ, Bliemel C. Complications after direct anterior versus Watson-Jones approach in total hip arthroplasty: results from a matched pair analysis on 1408 patients. BMC Musculoskelet Disord. 2019; 20(1):77. doi:10.1186/s12891-019-2463-x.
9. Parvizi J, Rasouli MR, Jaberi M, et al. Does the surgical approach in one stage bilateral total hip arthroplasty affect blood loss? Int Orthop. 2013; 37(12):2357-2362. doi:10.1007/s00264-013-2093-0.
10. Wang H, Shen B, Zeng Y. Blood Loss and Transfusion after Topical Tranexamic Acid Administration in Primary Total Knee Arthroplasty. Orthopedics. 2015; 38(11):e1007-16. doi:10.3928/01477447-20151020-10.
11. Carson JL, Duff A, Poses RM, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet (London, England). 1996; 348(9034):1055-1060. doi:10.1016/S0140-6736(96)04330-9.
12. Ponnusamy KE, Kim TJ, Khanuja HS. Perioperative blood transfusions in orthopaedic surgery. J Bone Joint Surg Am. 2014; 96(21):1836-1844. doi:10.2106/JBJS.N.00128.
13. Browne JA, Adib F, Brown TE, Novicoff WM. Transfusion rates are increasing following total hip arthroplasty: risk factors and outcomes. J Arthroplasty. 2013; 28(8 Suppl):34-37. doi:10.1016/j.arth.2013.03.035.
14. Song JH, Park JW, Lee YK, et al. Management of Blood Loss in Hip Arthroplasty: Korean Hip Society Current Consensus. Hip pelvis. 2017; 29(2):81-90. doi:10.5371/hp.2017.29.2.81.
15. Kapadia BH, Torre BB, Ullman N, et al. Reducing perioperative blood loss with antifibrinolytics and antifibrinolytic-like agents for patients undergoing total hip and total knee arthroplasty. J Orthop. 16(6):513-516. doi:10.1016/j.jor.2019.06.025.
16. Richman JM, Rowlingson AJ, Maine DN, Courpas GE, Weller JF, Wu CL. Does neuraxial anesthesia reduce intraoperative blood loss? A meta-analysis. J Clin Anesth. 2006; 18(6):427-435. doi:10.1016/j.jclinane.2006.02.006.
17. Zhou H, Ge J, Bai Y, Liang C, Yang L. Translation of bone wax and its substitutes: History, clinical status and future directions. J Orthop Transl. 2019; 17:64-72. doi:10.1016/
18. Schonauer C, Tessitore E, Barbagallo G, Albanese V, Moraci A. The use of local agents: bone wax, gelatin, collagen, oxidized cellulose. Eur Spine J. 2004; 13 Suppl 1:S89-96. doi:10.1007/s00586-004-0727-z.
19. Sterne JA, Hernán MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12:355:i4919. doi:10.1136/bmj.i4919.
20. Moo IH, Chen JYQ, Pagkaliwaga EH, Tan SW, Poon KB. Bone Wax Is Effective in Reducing Blood Loss After Total Knee Arthroplasty. J Arthroplasty. 2017; 32(5):1483-1487. doi:10.1016/j.arth.2016.12.028.
21. Mortazavi SMJ, Razzaghof M, Ghadimi E, Seyedtabaei SMM, Ardakani MV, Moharrami A. The Efficacy of Bone Wax in Reduction of Perioperative Blood Loss in Total Hip Arthroplasty via Direct Anterior Approach: a prospective randomized clinical trial. J Bone Joint Surg Am. 2022; 104(20):1805-1813. doi: 10.2106/JBJS.22.00376.
22. Shin KH, Choe JH, Jang KM, Han SB. Use of bone wax reduces
blood loss and transfusion rates after total knee arthroplasty. Knee. 2020; 27(5):1411-1417. doi:10.1016/j.knee.2020.07.074.
23. Demey G, Servien E, Pinaroli A, Lustig S, Aït Si Selmi T, Neyret P. The influence of femoral cementing on perioperative blood loss in total knee arthroplasty: a prospective randomized study. J Bone Joint Surg Am. 2010; 92(3):536-541. doi:10.2106/JBJS.H.01159.
24. Saaiq M, Zaib S, Ahmad S. Electrocautery burns: experience with three cases and review of literature. Ann Burns Fire Disasters. 2012; 25(4):203-206.
25. Kim HJ, Fraser MR, Kahn B, Lyman S, Figgie MP. The efficacy of a thrombin-based hemostatic agent in unilateral total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2012; 94(13):1160-1165. doi:10.2106/JBJS.K.00531.
26. Ko PS, Tio MK, Tang YK, Tsang WL, Lam JJ. Sealing the intramedullary femoral canal with autologous bone plug in total knee arthroplasty. J Arthroplasty. 2003; 18(1):6-9. doi:10.1054/arth.2003.50001.
27. Chen JY, Rikhraj IS, Zhou Z, et al. Can tranexamic acid and hydrogen peroxide reduce blood loss in cemented total knee arthroplasty? Arch Orthop Trauma Surg. 2014; 134(7):997-1002. doi:10.1007/s00402-014-1958-z.
28. Izzo F, Di Giacomo R, Falco P, et al. Efficacy of a haemostatic matrix for the management of bleeding in patients undergoing liver resection: results from 237 cases. Curr Med Res Opin. 2008; 24(4):1011-1015. doi:10.1185/030079908x280392.
29. Wang H, Shan L, Zeng H, Sun M, Hua Y, Cai Z. Is fibrin sealant effective and safe in total knee arthroplasty? A meta-analysis of randomized trials. J Orthop Surg Res. 2014;9:36. doi:10.1186/1749-799X-9-36.
30. Wang C, Han Z, Zhang T, et al. The efficacy of a thrombin-based hemostatic agent in primary total knee arthroplasty: a meta-analysis. J Orthop Surg Res. 2014; 9:90. doi:10.1186/s13018-014-0090-7.
31. Oz MC, Rondinone JF, Shargill NS. FloSeal Matrix: new generation topical hemostatic sealant. J Card Surg. 2003; 18(6):486-493. doi:10.1046/j.0886-0440.2003.00302.x.
32. Gromov K, Kjærsgaard-Andersen P, Revald P, Kehlet H, Husted H. Feasibility of outpatient total hip and knee arthroplasty in unselected patients. Acta Orthop. 2017; 88(5):516-521. doi:10.1080/17453674.2017.1314158.
33. Hartog YM den, Mathijssen NMC, Vehmeijer SBW. Total hip arthroplasty in an outpatient setting in 27 selected patients. Acta Orthop. 2015; 86(6):667-670. doi:10.3109/17453674.2015.1066211.
34. Conlon NP, Bale EP, Herbison GP, McCarroll M. Postoperative anemia and quality of life after primary hip arthroplasty in patients over 65 years old. Anesth Analg. 2008; 106(4):1056-1061, table of contents. doi:10.1213/ane.0b013e318164f114.
35. Jans Ø, Bandholm T, Kurbegovic S, et al. Postoperative anemia and early functional outcomes after fast-track hip arthroplasty: a prospective cohort study. Transfusion. 2016; 56(4):917-925. doi:10.1111/trf.13508.
36. Maezawa K, Nozawa M, Yuasa T, et al. Postoperative hemoglobin and recovery of hip muscle strength after total hip arthroplasty. J Orthop. 2018; 15(3):886-888. doi:10.1016/j.jor.2018.08.016.