Abdul Qayum

Abid Hussain Koka

DR Nelson

M Lavigne

O Verborgt

RB Patel

WK Low

English

PubMed

Crossref

BioMed CentralCases Journal
ssOpen AcceCase Report
Foreign body reaction to bone wax an unusual cause of persistent 
serous discharge from iliac crest graft donor site and the possible 
means to avoid such complication - a case report
Abdul Qayum and Abid Hussain Koka*
Address: Department of Orthopaedics, SKIMS Medical College, Srinagar, India
Email: Abdul Qayum - sirfqayum@yahoo.co.in; Abid Hussain Koka* - abidkoka@yahoo.co.in
* Corresponding author    
Abstract
Introduction: Bone wax is sometimes used in a variety of surgical procedures as a haemostatic.
Bone wax contains beeswax softened with isopropyl palmitate or paraffin. It is nonabsorbable with
no biochemical action. It achieves haemostasis by occluding the blood channels mechanically. Once
applied it essentially never goes away. Bone wax reactions have been reported in literature many
times.
Case presentation: We report a case in which bone wax was used to control bleeding at the
iliac crest from which bone graft was harvested. The foreign body reaction to bone wax caused
persistent discharge from iliac crest graft donor site.
Conclusion: Bone wax is a foreign body and that there is always a possibility of foreign body
granulomas following its use. When necessary, bone wax should be used just for the time needed
to achieve hemostasis. If it is left in place, care should be taken to avoid bone wax accumulation in
the bony craters formed during surgery. Applying bone wax as a smooth layer may lead to this
lumpy formation in the bony craters and one should be careful about it.
Case presentation
A 43 year old female patient of Indian origin came to our
hospital with nonunion fracture shaft of right humerus.
She was treated elsewhere with closed reduction and U-
slab for her fracture initially. Her fracture showed no signs
of union even after 8 weeks of conservative treatment.
Open reduction and internal fixation with narrow
dynamic compression plate with cancellous bone grafting
was done. Graft was taken from iliac crest right side.
She was discharged from the hospital 4th day post surgery
after inspecting her wound sites which were healthy.
Suture removal was done on 11th day.
She reported to hospital again on 14th day with serous dis-
charge from the graft wound. Her wound was alright with
serous discharge coming out of a 3 mm hole in the
wound. The edges were not indurated or red. Her ESR,
CRP and blood counts were within normal limits. Culture
of the discharge persistently was sterile. She was contin-
ued with dressings but the serous discharge was persistent
and copious. Surgical exploration of the graft donor site
was done. A thin layer of tissue was found at the graft
donor site which was curetted out. Bone wax pieces were
found in the craters at the iliac crest (Fig 1 &2) which was
used at the time of bone grafting to control bleeding. The
material was sent for histopathological examination
Published: 27 November 2009
Cases Journal 2009, 2:9097 doi:10.1186/1757-1626-2-9097
Received: 2 October 2009
Accepted: 27 November 2009
This article is available from: http://www.casesjournal.com/content/2/1/9097
© 2009 Qayum and Koka; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2009, 2:9097 http://www.casesjournal.com/content/2/1/9097which confirmed it as wax material. The wound of the
patient healed normally with no discharge in future. Her
fracture of humerus united well.
Discussion
Bone wax was developed by Horsley in1886 [1]. It con-
tains beeswax softened with isopropyl palmitate or paraf-
fin. It is used in many surgical procedures to control
bleeding. It is nonabsorbable with no biochemical action.
It achieves hemostasis by occluding the blood channels
mechanically [1]. Once applied it essentially never goes
away. Surgeon should be aware of the adverse effects of its
use. It is known to interfere with bone healing and osteo-
genesis. It has been shown to reduce bacterial clearance in
cancellous bone and to increase the risk of infection. In
the presence of bone wax, the number of bacteria needed
to produce osteomyelitis is reduced by a factor of 104
(10,000) [2].
Foreign-body granulomatous reaction due to bone wax
has been reported in various surgical sites with different
clinical implications, requiring surgical exploration in
some cases. Bone wax granulomas have been reported in
mastoid [3], sternototomy site, lumbar disc surgical site
[4], at the cerebellopontine angle [5], in the subarachnoid
space near medulla oblongata, in femoral neck osteo-
plasty site [1], in orbits, in cranial defects, after tibial
tubercle elevation surgery and after foot surgery. In one
instance, in which bone wax had been used to stop bleed-
ing from the iliac crest after the harvesting of autogenous
graft, the patient presented 19 years later with a large,
symptomatic, retroperitoneal tumour associated with a
foreign-body reaction, which had to be removed opera-
tively [6].
Conclusion
Though inexpensive, easy to use with immediate effect on
bleeding, bone wax should be used with caution after
weighing the potential complications against the benefits.
Bone wax is a foreign body and that there is always a pos-
sibility of foreign body granulomas following its use.
When necessary, bone wax should be used just for the
time needed to achieve hemostasis. If it is left in place,
care should be taken to avoid bone wax accumulation in
the bony craters formed during surgery. Applying bone
wax as a smooth layer by pasting with finger may lead to
its lumpy formation in the bony craters and one should be
careful about it.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AQ searched the literature and helped in editing. AHK
conceived the idea, searched the literature and wrote the
paper.
Pieces of bone wax curetted out from the bony cratersFigure 1
Pieces of bone wax curetted out from the bony cra-
ters.
Pieces of bone wax curetted out from the bony cratersFigure 2
Pieces of bone wax curetted out from the bony cra-
ters.Page 2 of 3
(page number not for citation purposes)
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References
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2. Nelson DR, Buxton TB, Luu QN, Rissing JP: The promotional
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3. Low WK, Sim CS: Bone Wax Foreign Body Granuloma in the
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(page number not for citation purposes)


Foreign body reaction to bone wax an unusual cause of persistent serous discharge from iliac crest graft donor site and the possible means to avoid such complication - a case report

Abid Koka

Springer - Publisher Connector

Borms T: A retroperitoneal tumor as a late complication of the use of bone wax. Acta Orthop Belg

Cosar Murat, Aslan Adem, Sahin Onder: Bone wax as a cause of foreign body reaction after lumbar disc surgery: A case report. Advances in Therapy

CS: Bone Wax Foreign Body Granuloma in the Mastoid. ORL

Hodosh R: Bone wax as a cause of foreign body granuloma in cerebellopontine angle.

Rissing JP: The promotional effect of bone wax on experimental Staphylococcus aureus osteomyelitis. J Thorac Cardiovasc Surg

Vendittoli P-A: Bone-wax granuloma after femoral neck osteoplasty.

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Foreign body reaction to bone wax an unusual cause of persistent serous discharge from iliac crest graft donor site and the possible means to avoid such complication - a case report

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