Interactive Cardiovascular and Thoracic Surgery 2:410-412(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Does liberal use of bone wax increase the risk of mediastinitis?
Farah Bhatti and
Joel Dunning*
Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
* Corresponding author. Tel./fax: +44-780-154-8122
joeldunning{at}doctors.org.uk
Received August 11, 2003;
received in revised form August 12, 2003;
accepted August 13, 2003
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bone wax increases the risk of mediastinitis in patients undergoing cardiac surgery. Altogether 276 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that animal studies indicate that there are strong reasons for concern over the liberal usage of bone wax.
Key Words: Mediastinitis; Waxes; Evidence-based medicine; Thoracic surgery
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1. Clinical scenario
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You are a registrar performing the sternotomy on a 65 year old patient who is undergoing an aortic valve replacement, supervised by your consultant. You open the chest and start liberally applying bone wax to the sternal edges. Your Consultant is greatly alarmed and tells you that bone wax is ‘poison’ and should only be used for friable, bleeding sternums. You heed his advice but wonder what evidence exists for his strongly held views.
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2. Three-part question
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In [patients undergoing cardiac surgery] does liberal use of [bone wax] increase the risk of [mediastinitis].
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3. Search strategy
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Medline 1966-July 03 using the OVID interface [(exp mediastinitis or mediastinitis.af) AND (exp waxes or wax.af)] OR [bone wax.af] OR [(exp mediastinitis or mediastinitis.af)LIMIT to review articles.]
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4. Search outcome
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Two hundred seventy six papers were found of which five were deemed to be relevant [1–5]. These are summarised in Table 1.
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5. Results
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There are no human cohort studies that have made the link between bone wax and mediastinitis. One 1978 case series postulated that bone wax may have been a causal factor in an outbreak of Mycobacterium fortuitum mediastinitis, although no evidence was presented to support this. A review by Milano et al. looking for risk factors associated with mediastinitis found no evidence for bone wax causing mediastinitis and in fact associated poor haemostasis with an increased risk.
However animal studies have shown that bone wax can embolise to the lungs, that bone wax markedly reduces the inoculum of Staphlococcus aureus required to cause osteomyelitis, and that bone wax is still present in large quantities 4 weeks post-operatively.
Bone wax is still routinely used in clinical practise and thus a clinical trial is urgently needed in this area to investigate whether these troubling pre-clinical findings cause harm to patients in the clinical setting.
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6. Clinical bottom line
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Animal studies indicate that there are strong reasons for concern over the liberal usage of bone wax.
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Appendix A
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ICVTS on-line discussion
Author: Dr. Francies Robicsek, Chairman, Department of Cardiovascular and Thoracic Surgery, The Carolinas Heart Institute, University of North Carolina, 1001 Blythe Boulevard, Suite 300, Charlotte, NC 28202-5866, USA.
Date: 02-Oct-2003
Message: Bhatti and Dunning did a good job reviewing the issue as how application of bone wax may enhance sternal infections. Their conclusion is that there are "strong reasons for concern over liberal usage of bone wax". I would add that if anybody ever looked at surgical "bone wax" under a microscope and could see all the insect ova, legs and fragments of wings, - he would think it over twice before using bone wax again!
I would also be inclined to "turn the questions around" on the use of bone wax. In our previous studies (Annals of Thoracic Surgery, 1980;31:357-359), we found not only that the bone wax has a potential of embolizing into the lungs but also that it did not decrease blood loss in patient cohorts where bone wax was not used. Adding to this the potential of increase in infections, one may ask the question why should anybody use bone wax at all?
doi:10.1016/S1569-9293(03)00180-4
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References
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- Milano CA, Kesler K, Archibald N, Sexton D. Mediastinitis after coronary artery bypass graft surgery: risk factors and long-term survival. Circulation. 1995;92:2245–2251[Abstract/Free Full Text]
- Solheim E, Pinholt EM, Bang G, Sudmann E. Effect of local hemostatics on bone induction in rats: a comparative study of bone wax, fibrin-collagen paste, and bioerodible polyorthoester with and without gentamicin. J Biomed Mater Res. 1992;26:791–800[Medline]
- Nelson DR, Buxton TB, Luu QN, Rissing JP. The promotional effect of bone wax on experimental Staphylococcus aureus osteomyelitis. J Thorac Cardiovasc Surg. 1990;99:977–980[Abstract]
- Robicsek F, Masters TN, Littman L, Born GV. The embolization of bone wax from sternotomy incisions. Ann Thorac Surg. 1981;31:357–359[Abstract]
- Robicsek F, Daugherty HK, Cook JW, Selle JG, Masters TN, O'Bar PR, Fernandez CR, Mauney CU, Calhoun DM. Mycobacterium fortuitum epidemics after open-heart surgery. J Thorac Cardiovasc Surg. 1978;75:91–96[Abstract]
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Abstract
1. Clinical scenario