Clinical Applications and Emerging Roles of Bone Wax in Orthopaedic Surgery: A Scoping Review.

Background

Perioperative bleeding from cancellous bone remains a clinically relevant challenge in orthopaedic surgery. Bone wax has long been used as a simple and inexpensive mechanical hemostatic agent, but previous reviews have focused mainly on total joint arthroplasty or on the material history of bone wax and its substitutes. The broader clinical evidence across orthopaedic subspecialties has not been comprehensively mapped.

Methods

This scoping review followed the Arksey and O'Malley framework, with methodological refinements proposed by Levac et al., and was reported in accordance with PRISMA-ScR. Five electronic sources and grey literature were searched through May 2025. Clinical studies evaluating bone wax in orthopaedic surgery were eligible regardless of study design; a relevant clinical trial registry record with sufficient methodological detail was also retained to map ongoing evidence. Preclinical and purely material-based studies were excluded. The protocol was registered in the Open Science Framework (DOI: 10.17605/OSF.IO/K3ZAV).

Results

Of 486 identified records, 15 met the inclusion criteria. Eight records concerned joint replacement, two spinal surgery, three excision of abnormal bony structures, and two sealing applications. The strongest comparative evidence came from arthroplasty, where bone wax was generally associated with reduced intraoperative or perioperative blood loss without clear evidence of adverse effects on early postoperative recovery outcomes reported in the included studies. Evidence for spinal and nontraditional applications was more heterogeneous and was derived mainly from small observational studies, case series, technical reports, or a trial registry record. Complications such as foreign-body reaction and chronic inflammation were described primarily in spine-related reports of retained nonabsorbable wax.

Conclusions

Bone wax remains a useful and inexpensive adjunct for hemostasis in orthopaedic surgery. The strongest clinical evidence is concentrated in arthroplasty, whereas spinal and nontraditional applications remain supported by limited and heterogeneous data. Future research should clarify indication-specific benefits and risks and evaluate the safety and effectiveness of bioresorbable alternatives in well-designed clinical studies.