The Efficacy of Bone Wax in Reduction of Perioperative Blood Loss in Total Hip Arthroplasty via Direct Anterior Approach

Abstract

Background:Perioperative blood management in total hip arthroplasty (THA) has become a prime focus of research. Given the morbidity, delayed recovery, and prolonged hospital stay associated with postoperative anemia, various measures have been proposed to reduce perioperative blood loss (PBL). In this trial, we studied the efficacy of bone wax application on the distal cut surface of the femoral neck in reducing PBL during THA through the direct anterior approach.Methods:In a randomized controlled clinical trial, 152 patients underwent THA through the direct anterior approach with use of bone wax (n = 75) or without bone wax (control) (n = 77). The study was triple-blinded. The primary outcomes were apparent PBL (blood in sponges and suction canister) and total PBL on postoperative days (PODs) 3 and 5 (as calculated with the Good and Nadler methods). Transfusion and complications were the secondary outcomes.Results:No significant difference was found between the 2 groups in terms of age, sex, body mass index, American Society of Anesthesiologists score, etiology, preoperative hematologic/coagulation profile, anesthesia, intraoperative mean arterial pressure, or operative time. Apparent PBL, total PBL on POD3, and total PBL, in milliliters, on POD5 were significantly lower in the wax group, with median values of 200 (interquartile range [IQR]: 115 to 310) versus 370 (IQR: 195 to 513.7), 505.2 (IQR: 409.2 to 637.6) versus 747 (IQR: 494.6 to 955.4), and 536.7 (IQR: 430.9 to 689.3) versus 767.8 (IQR: 537.8 to 1,021.9) in the wax and control groups, respectively (p < 0.001). No significant differences in the rates of transfusion and complications were found.Conclusions:Bone wax on the cut surface of femoral neck can significantly reduce PBL during THA through the direct anterior approach. Bone wax is accessible and inexpensive and can be considered a routine part of the surgical technique in THA through the direct anterior approach. This intervention has no impact on complication or transfusion rates.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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

“…The quality assessment tool was used for the randomized control studies, with a total of 14 questions, and another tool was used for the case-control studies, with a total of 12 questions. Moo et al [9] fulfilled all 14 criteria, Mortazavi et al [19] fulfilled 13 out of 14 criteria, and Shin et al [10] fulfilled 11 out of 12 criteria. The questions used for evaluating the risk of bias are shown in Tables 3 and 4 [18].…”

“…These articles included two randomized control trials and one retrospective case-control study. Moo et al [9] and Shin et al [10] studied the hemostatic use of bone wax in TKA and Mortazavi et al [19] studied the use of bone wax in direct THA. Postoperative blood loss as well as transfusion rates were decreased across these three studies examining patients who underwent knee and hip surgery with the application of bone wax.…”

“…Mortazavi et al conducted a randomized controlled clinical trial consisting of 152 patients who underwent THA through the direct anterior approach [19]. The bone wax group consisted of 75 patients and the control group without bone wax consisted of 77 patients.…”

What’s New in Hip Surgery

“…Intraoperative hemostasis also remains of interest in the arthroplasty community. An RCT evaluated the efficacy of femoral neck bone wax application following osteotomy in reducing perioperative blood loss in direct anterior approach THA 22 . The bone wax group, compared with the direct anterior approach group, had lower apparent perioperative blood loss (200 compared with 370 mL; p < 0.001), total perioperative blood loss on postoperative day 3 (505.2 compared with 747 mL; p < 0.001), and total perioperative blood loss on postoperative day 5 (536.7 compared with 767.8 mL; p < 0.001).…”

Hip & Pelvis

“…Sometimes the older treatments are the best and, reasoning that there has been little research on bone wax as a haemostatic agent, this study team from Tehran (Iran) set out to establish if bone wax is effective in reducing blood loss in their own randomized controlled trial. 6 Overall, 152 patients who were undergoing direct anterior approach total hip arthroplasties (THAs) were randomized to receive bone wax (n = 75) or not (n = 75), with their primary outcome being apparent blood loss and total blood loss noted on postoperative days three and five. The total blood loss was calculated with the Good and Nadler methods.…”