Bone Wax Research Articles

Management of a Life Threatening Bleeding following Extraction of Deciduous Second Molar Related to a Capillary Haemangioma

Various forms of vascular lesion affect the head and neck region. The head and neck vascular lesions are classified into neoplasms and malformations. Neoplasm presents either as hemangioma or lymphangioma; neoplasm usually presents in young age compared with vascular malformation. A 9-year-old female patient presented to the outpatient clinic referred from the department of pedodontics after extraction of a right mandibular second deciduous molar. Extraction was done by dental GP in outpatient clinic. Massive bleeding followed the extraction. Bleeding was controlled by electrocoagulation of bleeding site and systemic and local application of antifibrinolytic agent. An intravenous line was placed to provide fluid replacement. Injection of intravenous cyklokapron was given to stabilize the blood clot. Selective embolization was performed 24 hours prior to surgical resection of lesion and the lesion was removed under general anesthesia followed by peripheral ostectomy of bone to remove any feeders. Different protocols are used to control life-threatening bleeding. Primary local measures such as Gelfoam packing, Tranexamic or Aminocaproic topical application, Surgicel application, Electrocautery, Bone wax, Ligation of External Carotid or Common Carotid Artery, or Selective Embolization of feeder vessel may be used to control the bleeding. Interventional radiographic blockage of feeder vessel currently shows high success rate in the management of life-threatening bleeding compared with previous techniques.

Knee reserved operation for knee osteoarthritis: proximal fibular osteotomy and high tibial osteotomy using absorbable balance spacer

Purpose: A new combination of knee reserved operation, proximal fibular osteotomy with high tibial osteotomy (HTO) using an absorbable balance spacer implantation is proposed to treat medial compartment OA with serious varus deformities. Methods: Under epidural anesthesia, the patients were placed in the supine position with the lower limb tourniquet inflated. A 4 cm long lateral incision was made at the proximal third of the fibula. After exposing the fibula, a 2 cm long section of fibula was removed with oscillating saw. The fibula ends were sealed with bone wax. After the fibular osteotomy, a medial longitudinal incision then was made and the periosteum was striped. Retract the pesanserinu to expose the front and medial aspect of tibia. A guidewire was inserted beginning at the anteromedial tibia at the level of the superior border of the tibial tubercle, approximately 4-5 cm distal to the joint line. The guidewire direction was towards the tip of the fibular head. Partial osteotomy was performed with osteotomes. We originally designed a wedge-shape absorbable spacer with barbs on both surfaces aiming to prevent the spacer from escaping. The spacer was made of 70% PLGA (85/15) and 30% β-TCP. The spacer was then inserted into the osteotomy in order to achieve the planned degree of correction. The muscles, fascia and skin were sutured separately. Results: From Jul 2016 to Sep 2016, a total of 8 patients with an average of 61.8 years (range, 49 to 76) were enrolled into this study, including 7 females and 1 male. All patients were diagnosed with medial compartment KOA, all being grade 4 according to Kellgren-Lawrence Grading Scale. Anteroposterior and lateral weight-bearing radiographs were taken and the femorotibial angle (FTA) was measured. The Hospital for Special Surgery knee score (HSS) and the visual analog scale (VAS) score of the knee joint were evaluated preoperatively, 7thday postoperatively and at subsequent follow-ups. The FTA was 163.1° ± 1.7° measured on the preoperative anteoroposterior radiograph. The operations were performed uneventfully without intraoperative complications. The operative time was 81.3 ± 12.7 minutes. At 7th day postoperative follow-up, mean FTA was 175.5° ± 1.5°, which was significantly smaller than those measured preoperatively (P < 0.05). Mean VAS score and interquartile range were 1.5 and 1.0, significantly lower than the preoperative data (6.5 and 1.5, respectively; P < 0.001). The similar results were acquired in the 1-mouth postoperative follow-up for 3 patients and 2-mouth postoperative follow-up for 5 patients. Conclusions: The knee reserved operation, proximal fibular osteotomy and HTO using the originally designed wedge-shape absorbable spacer, was a minimally invasive, safe, simple, and effective procedure for the management of medial compartment OA of the knee joint.

Surgical treatment for fracture-dislocation of upper cervical spine complicated with vertebral artery injury

Objective To explore the perioperative management and surgical outcomes of fracture-dislocation of the upper cervical spine complicated with vertebral artery injury. Methods We ret-rospectively analyzed the clinical data of 19 patients diagnosed with fracture-dislocation of the upper cervical spine complicated with vertebral artery injury who had been treated at our department from January 2008 through December 2012. They were 14 males and 5 females, aged from 22 to 53 years (mean, 35.2 years). All the patients had fractures of the atlas and/or axis, and disordered atlanto-axial relationship as well. According to Frankel grading system, 8 cases were Grade D and 11 Grade E. The cervical posterior fixation with pedicle screws was adopted for all and hemostasis was conducted for those with bleeding from the broken vertebral artery. Their Frankel grade, Japanese Orthopedic Association (JOA) score and visual analogue scale (VAS) score were compared between preoperation and final follow-up. Results Intraoperative hemor-rhage occurred in 2 patients from the injured vertebral artery. Hemostasis was achieved through direct tamponade with bone wax and gelatin sponge in one and through endovascular intervention after bleeding control by direct tamponade in another. Neither of them presented with symptoms of posterior circulation ischemia after operation. The mean operation time was 153.5 min, and the mean blood loss was 542.1 mL. All the patients were followed up for an average time of 28 months. Bony union was obtained in all after an average time of 13.5 weeks. Follow-ups revealed no ischemic stroke in this series. Symptoms of transient ischemic attack, like transient dizziness and blurred vision, appeared in 2 patients. At the final follow-up, all the patients were assessed as Frankel Grade E. Their mean JOA and VAS scores were significantly improved from 8.1±1.2 and 7.0±1.7 preoperatively to 12.7±1.6 and 1.3±1.2, respectively (P< 0.05). Conclusions An-giography examination is routinely indicated for the patients with fracture-dislocation of the upper cervical spine perioperatively. Preoperative evaluation of the vertebral artery and its adjacent structures and effective intra-operative hemostasis can avoid uncontrollable bleeding during operation, reduce postoperative complications, and improve surgical outcomes. Key words: Cervical; Fractures, bone; Dislocation; Vertebral artery injury

Delayed infection after using bone wax in maxillofacial surgery: A rare complication after reduction mandibuloplasty

Abstract Background Although several studies have reported various adverse reactions associated with the use of bone wax in the clinical setting, the incidence of complications after using bone wax during maxillofacial surgery via a transoral approach remains unclear. We aimed to address this scarcity of data and describe the incidence and nature of postoperative infections associated with bone wax treatment during reduction mandibuloplasty. Materials and methods A retrospective chart-review study was conducted among patients who underwent reduction mandibuloplasty performed by the same surgeon between January 2010 and December 2014. Delayed postoperative infection was diagnosed based on clinical manifestations, associated treatment strategy (additional antibiotic treatment with or without revision surgery), and results of microbiological investigation. Patients were divided into 2 groups according to whether or not bone wax had been applied during the reduction mandibuloplasty procedure. Results A total of 355 patients (44 men; average age, 31.0 years; age range, 19–53 years) underwent reduction mandibuloplasty during the study period. Of these, 19 patients (1 men; age, 26.0 ± 6.62 years) were treated with bone wax applied to the cut surface of the mandibular cancellous bone for controlling bleeding. The infection rate among patients not treated with bone wax was 1.5% (5/336; acute infection), compared to 21.0% (4/19; delayed infection) among patients treated with bone wax. The use of bone wax contributed to an increased risk of developing infection (odds ratio, 14.87 [95% confidence interval, 3.22–68.70], P Conclusion This is the first report describing the incidence of infection associated with the use of bone wax for controlling bleeding from the cancellous bone during maxillofacial surgery via a transoral approach.

Costal cartilage transplantation for treatment of growth plate injury in a rabbit model.

ObjectivesThe purpose of this study is to evaluate the effects of allogenic costal cartilage transplantation on preventing bony bridge formation and angular deformities for the treatment of partial growth plate injury using a rabbit model.MethodsAn experimental model of partial growth injury was created by resecting the medial part of the proximal tibial growth plate in male six-week-old New Zealand White rabbits. The rabbits were divided into four groups: no surgery; no transplantation; bone wax transplantation; and allogenic costal cartilage transplantation. The angular deformities of the tibia and bony bridge were analysed using radiographs and microcomputed tomography, and the repair of the injured growth plate cartilage and bony bridge formation rate were histologically evaluated.ResultsOn radiographic evaluation, the varus deformities in the costal cartilage group were significantly improved compared with the no transplantation group at four and eight weeks after operation and with the bone wax group at eight weeks after operation. Micro-computed tomography showed that the bony bridge formation was prevented in the bone wax and costal cartilage groups. Histological findings showed that the bony bridge formation in the bone wax and costal cartilage group was decreased. In addition, the growth plate was continuous and stained with safranin O and immunohistochemically stained for type II collagen.ConclusionTransplantation of costal cartilage improved angular deformities and decreased bony bridge formation in the partial growth plate injury. Costal cartilage might be a suitable graft for the treatment of growth plate injury.

Bone Wax Is Effective in Reducing Blood Loss After Total Knee Arthroplasty

BackgroundTotal knee arthroplasty (TKA) is associated with major blood loss and blood transfusion is often required. This study aimed to evaluate the efficacy of bone wax in reducing blood loss and transfusion rates after TKA. MethodsA prospective randomized controlled study that included 100 patients undergoing primary unilateral TKA with cement was conducted in a tertiary center between March 2014 and June 2014. The bone wax group received 2.5 g of bone wax, applied onto the uncovered bone around the prostheses and the nail holes before the tourniquet was released, whereas the control group had hemostasis achieved using electrocautery only. Total blood loss was calculated using the hemoglobin balance method. ResultsThere were no demographic differences between the 2 groups. The preoperative serum hemoglobin levels were comparable between the 2 groups. The drop in serum hemoglobin levels at 24 h post-TKA was 1.6 ± 0.9 and 2.1 ± 1.1 g/dL in the bone wax and control groups respectively (P = .021), while the drop in serum hemoglobin levels at 72 h post-TKA was 2.7 ± 1.1 and 3.6 ± 1.2 g/dL respectively (P = .013). Total blood loss at 72 h post-TKA was 987.9 and 1183.5 mL for the bone wax and control groups respectively (P = .017). There was no adverse event associated with the use of bone wax at the 3-month follow-up. ConclusionThe application of bone wax in TKA was safe and effective for reducing total blood loss and maintaining higher hemoglobin levels.

Bone wax versus oxidized regenerated cellulose in preventing sternal intramedullary bleeding in cardiac surgery

BackgroundBone wax (BW) or oxidized regenerated cellulose (ORC) concomitant with electrocoagulation is one of the preventive strategies in controlling sternal intramedullary bleeding post cardiac surgery. The aim of this study is to compare the difference between these two strategies in our patients. Methods50 of our patients who underwent conventional open heart surgery in our department were recruited in this study and were randomized into 2 groups; group I (25 patients) bone wax and concomitant electrocauterization were used, and group II (25 patients) oxidized regenerated cellulose and concomitant electrocauterization were used. The following parameters were compared: the amount of postoperative hemorrhage in the first 24 h, numbers of units of blood and its products used, rates of re-exploration for hemorrhage, wound complications in first 3 months follow-up and the difference in cost-effective ratio. ResultsPatient's Demographics and intraoperative variables were comparable in both groups. There was no statistically significant difference between the amounts of postoperative hemorrhage in both groups; however, there was only one case of superficial wound infection and one case with sternal dehiscence in the short term follow-up in group I. Bone wax is significantly cheaper than ORC. ConclusionBW concomitant with electrocauterization is effective as ORC concomitant with electrocauterization in preventing sternal intramedullary bleeding in cardiac surgery and is much cheaper.

Serum N-terminal telopeptide of type I collagen as an early marker of fracture nonunion in rabbits.

The aim of the present study was to establish an experimental animal model of fracture nonunion, and to investigate the changes in serum biomarker concentrations in fracture nonunion. A total of 20 purebred New Zealand rabbits were divided into two group: A bone defect group and a bone fracture group. In the bone defect group, a 15-mm section of bone (including the periosteum) was removed from the mid-radius, and the medullary cavities were closed with bone wax. In the bone fracture group, the mid-radius was fractured. X-rays were taken and blood samples were collected preoperatively and at 2, 3, 4, 5, 6, 7, 8, 10 and 12 weeks after the surgical procedure. The serum concentrations of osteocalcin (OC) and bone-specific alkaline phosphatase (BSAP) served as markers of bone formation, and those of C-terminal telopeptide of type I collagen (CTX), N-terminal telopeptide of type I collagen (NTX) and tartrate-resistant acid phosphatase 5b (TRACP 5b) served as markers of bone resorption. The concentration levels of the markers were measured using a biotin double-antibody sandwich enzyme-linked immunosorbent assay. In the bone defect group, bone callus was observed on X-ray at 2 weeks in three rabbits and the bone calluses stabilized at 5 weeks; however, none of the bones had healed at 8 weeks. In the bone fracture group, the fracture line was distorted at 2 weeks and bone calluses formed at 6–8 weeks. In the bone defect group, the serum BSAP and TRACP 5b concentrations increased following the surgical procedure, peaked at 4 weeks, began to decrease at 5 weeks and stabilized after 6 weeks. The serum OC concentrations did not change significantly following the surgical procedure. The serum CTX concentrations fluctuated during the first 4 weeks, peaked at 5 weeks, then decreased and stabilized after 6 weeks. The serum NTX concentrations fluctuated during the first 4 weeks, were significantly lower at 5 weeks compared with the other time points and stabilized after 6 weeks. These results suggested that a bone nonunion model can be established in New Zealand rabbits by resecting a 15-mm section of bone from the mid-radius prior to bone wax blocking. Measurement of the serum BSAP, CTX, NTX, and TRACP 5b concentrations may be useful for the early detection of bone nonunion. The serum NTX concentrations changed significantly in rabbits with bone nonunion. Further studies are required in order to determine the feasibility of using serum NTX concentrations for the early diagnosis of bone nonunion.

New and Improved: Our Experience with the 22G Cook Fiducial Needle System

Traditionally fiducial markers have served as reference points and have been placed by Endoscopic ultrasound (EUS), intraoperatively, or percutaneously via ultrasound or CT. EUS guided placement has increased in popularity recently due to the ability of EUS to allow for close proximity to deeper abdominal structures not easily accessible via surgical or percutaneous routes. One limitation to the growth of this technique has been the need to individually back load and seal the fiducial using bone wax or recently described wet fill technique. The back loading procedure increases the time for the procedure, may increase risk to the operator if one is loading fiducials into dirty needles (when more than one fiducial is required), or increase cost if new FNA needles are used for each fiducial. The new 22G Cook Fiducial needle is preloaded with four gold fiducials, which solves many of the problems mentioned. Four patients underwent fiducial placement with the 22G Cook Fiducial Needle System. A 63 year old male with metastatic renal cell carcinoma to the stomach and proximal duodenum presented with melena. EGD showed a large ulcerated bleeding mass in the anterior wall of the stomach. Fiducials were placed to allow for selective embolization. A 52 year old male presented with progressive dysphagia and weight loss. EGD revealed a large partially obstructing lower esophageal mass. Pathology confirmed esophageal adenocarcinoma and he underwent fiducial placement to assist in intensity modulated neoadjuvant radiation therapy. A 68 year old male with rectal adenocarcinoma had a 10 mm mass in the left lobe of the liver. The patient was to undergo neo-adjuvant therapy followed by surgical resection of the primary tumor and wedge resection of the solitary liver lesion. Fiducial placement was requested prior to neoadjuvant therapy to mark the position of the mass for localization during the eventual wedge resection. A 57 year old male with abdominal pain had an EUS which showed an ill-defined mass in the pancreatic neck with background chronic pancreatitis. EUS FNA of the mass was positive for adenocarcinoma. Due to ill-defined nature of the mass, the presence of background chronic pancreatitis and for accurate surgical localization fiducial placement was requested. We have shown that this needle is easy and quick to use in a variety of settings with subsequent excellent visualization of the fiducial with no immediate or delayed complications.

Preparation and Administration of I-125 Labeled Seeds for Localization of Nonpalpable Breast Lesions.

Radioactive seed localization (RSL) is a new technique for surgical identification of non-palpable breast lesions. We describe the preparation of the needle with I-125 seeds for ultrasound-guided deposition in breast lesions. In a feasibility study we investigated the minimum activity amount needed for reliable gamma probe identification of the seeds and the levels of exposure to the staff. 11 patients received a seed, which was manually placed in an 18 gauge needle with bone wax occluding the tip, and the radiologist introduced it into the breast tissue guided by ultra-sound. The seed was located during the operation with a handheld gamma probe. The activity amount required was studied in a water bath. Radiation exposure to the fingertips of pathologists was measured by a thermoluminescent dosemeter. All seeds were successfully prepared, positioned in the breast lesion, and easily identified. The surgeon removed the seeds together with the breast lesions, and they were identified by the pathologist. There were no unexpected adverse drug reactions. Water bath studies suggest that 1-3 MBq I-125 was sufficient for precise identification, regardless of the presence of conventional Tc- 99m activity from sentinel node injection. The total finger dose exposure to the pathologists for the 8 procedures was below the detection limit of 0.1 mSv. I-125 seeds for ultrasound-guided deployment and surgical identification of breast lesions were successfully prepared and identified for this promising new radioguided surgical technique. The radiation exposure to staff involved is considerably below the permissible limits and almost negligible.

Cochlear Patency After Transmastoid Labyrinthectomy for Ménière's Syndrome.

Labyrinthectomy is considered the "gold standard" in the treatment of intractable vertigo attacks because of Ménière's Disease (MD) but sacrifices all residual hearing. Interest in auditory rehabilitation has lead to cochlear implantation in some patients. Concern remains that the cochlear lumen may fill with tissue or bone after surgery. This study sought to determine the incidence of obliteration of the cochlea after transmastoid labyrinthectomy. Retrospective observational study. Tertiary referral center. Eighteen patients with intractable vertigo from MD who underwent surgery. Transmastoid labyrinthectomy between 2008 and 2013. Cochleas were imaged with unenhanced, heavily T2-weighted magnetic resonance imaging (MRI). Presence of symmetrical cochlear fluid signals on MRI. There was no loss of fluid signal in the cochleas of operated ear compared with the contralateral, unoperated ear in any subject an average of 3 years (standard deviation [SD]: 1.2) after surgery. Five of 18 patients had the vestibule blocked with bone wax at the time of surgery. Blocking the vestibule with bone wax did not change the cochlear fluid signal. The risk of cochlear obstruction after labyrinthectomy for MD is very low. The significance of this finding is that patients with MD who undergo labyrinthectomy will likely remain candidates for cochlear implantation in the labyrinthectomized ear long after surgery if this becomes needed. Immediate cochlear implantation or placement of a cochlear lumen keeper during labyrinthectomy for MD is probably not necessary.

The Use of Cryo-Preserved Umbilical Cord Plus Amniotic Membrane Tissues in the Resection of Tarsal Coalition

Category: Hindfoot Introduction/Purpose: Tarsal coalition can be a common underlying cause of painful flatfoot deformity in adolescent and adult patient populations. When conservative options fail, surgical resection becomes the mainstay of treatment. Adequate resection leaves a void, often filled with bone wax, fat graft or adjacent muscle or tendon. Interposition grafting is designed to provide a physical barrier between the ends of the excised segment and deter recurrence or bony overgrowth. No definitive graft choice has been shown to be superior to another. The goal of this study was to evaluate the use commercially available umbilical cord plus amniotic membrane tissues as an interposition graft with functional and radiological outcomes at one year follow-up. Methods: Retrospective review was performed of patients who had resection of tarsal coalition at our institution. Patients who had interposition of umbilical cord plus amniotic membrane tissues (Amniox Medical, Atlanta GA) at the site of the resection were included in this review. Postoperative data collection included VAS scores, Foot Function index scores, and radiographic review. Radiographic review included postoperative CT scans in all patients. Assessment of hindfoot ROM was noted on physical examination at last follow up visit. Results: Fourteen patients (8 male and 6 female; median age 28.5 years at time of evaluation) were enrolled in the study. Of these patients, 7 were calcaneonavicular coalitions and 7 were talonavicular coalitions. Average follow up occurred at 18 months (range 9-32 months). Interposition of umbilical cord plus amniotic membrane tissues was performed at the site of the resection. Median improvement in pain visual analog score (VAS) was 89.75%, with no post-operative infection or wound complications. Post-operative CT scan review demonstrated evidence of osteoarthritis in two patients (one at talonavicular and one subtalar joint). Four of 14 patients (29%) were found to have recurrence at follow-up. The median post-operative Foot Function Index score was 46 (range 30-110) and 64% of patients had improvement in range of motion. Conclusion: Based on radiological and functional outcomes at an average 19 month follow up, the interposition of umbilical cord plus amniotic membrane tissues after tarsal coalition resection appears to be a viable option in treating these patients. No adverse reactions were found and recurrence rate was noted to be 29%.

Migration of Bone Wax into the Sigmoid Sinus after Posterior Fossa Surgery

Bone wax is a hemostatic agent that has been reported in some instances to migrate into the sigmoid sinus following posterior fossa surgery. The purpose of this study was to characterize the CT and MR imaging findings of this entity. The study included 212 consecutive patients who underwent posterior fossa surgery and postoperative CT and contrast-enhanced MR imaging. The presence of sigmoid sinus bone wax migration was determined with the following criteria: sigmoid sinus filling defect showing low signal on all MR imaging pulse sequences; sigmoid sinus filling defect showing low CT attenuation, similar to fat attenuation; and clinical confirmation that bone wax was used intraoperatively. CT and MR imaging of an in vitro bone wax sample was also performed. We identified 6 cases of sigmoid sinus bone wax migration. In each case, a low-signal-intensity, low-attenuation filling defect was noted in the sigmoid sinus. The morphology was linear (n = 3) or globular (n = 3). In patients with serial imaging, the appearance of migrated bone wax remained stable over time. No adverse outcomes related to sigmoid sinus bone wax migration were encountered. In vitro imaging of bone wax confirmed low CT attenuation and low MR imaging signal intensity on T1WI and T2WI. Bone wax migration into the sigmoid sinus is a recognizable imaging finding after posterior fossa surgery that appears to have a benign clinical course. The finding should be distinguished from more serious complications, such as venous sinus thrombosis.

Reduction of transfusion requirements in pediatric craniosynostosis surgery by a new local hemostatic agent

Craniosynostosis surgery is often associated with severe perioperative bleeding especially due to venae emissariae, resulting in large transfusion amounts of packed red blood cells (PRBCs). Blood loss from venae emissariae is usually reduced by the usage of bone wax. SeraSeal is a new hemostatic agent which might help to reduce transfusion amounts if used additionally to bone wax. This study was designed with a retrospective control group (23 children), treated only with bone wax and a consecutive prospective verum group (12 children) treated additionally with SeraSeal. All children solely suffered from non-syndromic craniosynostosis, and were all treated by the same surgeons. Primary outcome variable was the volume of PRBC transfused during surgery. The numbers of PRBC transfusion was reduced significantly during the intraoperative period in the SeraSeal group (-44.5%, p<0.05) and also during the combination of the postoperative and intraoperative period (-59.3%, p<0.05). Our analysis suggests that SeraSeal has a strong potential to reduce transfusion requirements in pediatric craniosynostosis surgery. However, we acknowledge that due to small numbers our trial can only be seen as hypothesis generating pilot study. We suggest that the effect of SeraSeal should be assessed prospectively in other studies.

Treatment of the recanalization of maxillary and mandibular arteriovenous malformations in children

This study reviewed our experience in treating the recanalization of maxillary and mandibular arteriovenous malformations in children. Four patients with maxillary or mandibular arteriovenous malformations (AVMs) were included in this study. All the patients had undergone multidisciplinary treatment of AVM at least 26months before our review, including superselective intra-arterial embolization combined with bone wax packing. Computed tomographic angiography and digital subtraction angiography were performed to confirm the presence of recanalization. Superselective intra-arterial embolization combined with bone wax packing and tooth extractions were performed in the patients with recanalization. After confirmation of the recanalization of AVM by digital subtraction angiography, the patients were treated with superselective intra-arterial embolization combined with bone wax packing and tooth extractions (if necessary). All the patients were followed up for 5 to 14months, with an average of 9.5months. The outcome for all patients was good, and no patient complained of pulsatile sensation or hemorrhage after treatment. In the treatment for recanalization of maxillary and mandibular AVMs, reapplication of the superselective intra-arterial embolization, combined with bone wax packing, remains necessary.

Cadaveric Study of an Endoscopic Keyhole Middle Fossa Craniotomy Approach to the Superior Semicircular Canal.

Demonstrate that an endoscopic keyhole approach to the middle cranial fossa is technically feasible for repair of semicircular canal dehiscence. Cadaveric technical feasibility/methods development study. Tertiary care military medical center. Three fresh cadaveric heads (six sides). Endoscopic minimally invasive approach to the middle cranial fossa using the Medtronic Fusion Guidance system. Ability to identify the surgical landmarks of the middle cranial fossa and successfully identify and instrument the superior semicircular canal. In every attempt, the arcuate eminence was successfully identified under endoscopic visualization and with the assistance of surgical navigation. The superior semicircular canal was unroofed, and its location confirmed visually and with the navigation system. The opened canal was then plugged with bone wax, bone pate, and covered with fascia. The 15-mm burr hole craniotomy provided ample room for one working instrument and a 4-mm 0-degree endoscope. The endoscopic keyhole approach to superior semicircular canal dehiscence is technically feasible in a human cadaveric model. Further studies will determine 1) if this approach is possible and safe in vivo, 2) is associated with improved surgical outcomes, and 3) if surgical navigation aids in this approach.

Effects of hydrogen-rich water on the expression of aquaporin 1 in the cerebral cortex of rat with traumatic brain injury

To investigate the effect of hydrogen-rich water on cerebral edema and aquaporin 1 (AQP1) expression in rats with traumatic brain injury (TBI). Ninety male Sprague-Dawley (SD) rats were randomly divided into sham operation group, TBI model group, hydrogen-rich water treatment group (H group),with 30 rats in each group. TBI model was reproduced by weight dropping method. The skulls of rats in sham operation group underwent only craniotomy without direct hit and with bone wax sealed suture.5 mL/kg of hydrogen-rich water injection was given intraperitoneally after model reproduction in H group, and equal amount of normal saline was given in sham and TBI groups, once a day for both groups for 5 days. Six rats from each group were sacrificed at 6,12,24,48 hours and 5 days after evaluating neurological severity scores (NSS).The cerebral cortex was harvested, and the pathological changes in morphology of brain tissue were observed with light microscope. The positive expression of AQP1 in cerebral cortex was observed with immunohistochemistry by light microscopy, the AQP1 mRNA expression in cerebral cortex was determined by real-time fluorescent quantization reverse transcription-polymerase chain reaction (RT-PCR),and the AQP1 protein expression in cerebral cortex was determined by Western Blot. ① All rats in sham operation group had a NSS of zero at each time point. NSS of TBI group was obviously raised with time prolongation, and peaked at 24 hours followed by a lower tendency, while the score in H group was significantly lower than that of TBI group, and the difference was the most obvious at 24 hours as compared with TBI group (9.83 ± 2.78 vs.13.50± 2.42,P ＜ 0.05).② It was shown by light microscope that in the TBI group there were pathological changes in cerebral cortex, including obvious irregular arrangement of nerve cells, cerebral edema, obvious bleeding, especially at 24 hours, then the cerebral edema became vanished gradually; and the positive expression of AQP1 in the pia mater at all the time points in the TBI group was significantly increased, and it was most obvious at 24 hours. Compared with TBI group, the pathological changes at time points of 12 hours to 5 days in H group was significantly lessened, and the positive expression of AQP1 in the cerebral pia mater was reduced obviously.③ Compared with sham operation group, the mRNA and protein expressions of AQP1 in cerebral cortex in TBI group were significantly elevated, peaked at 24 hours [AQP1 mRNA (2-△△Ct):7.50±0.26 vs.1,AQP1 protein (gray value):1.986±0.110 vs.0.336±0.034, both P ＜ 0.05], then they gradually declined. The mRNA and protein expressions of AQP1 in cerebral cortex were significantly decreased after hydrogen-rich water treatment [24-hour AQP1 mRNA (2-△△Ct):5.40±0.21 vs.7.50±0.26, 24-hour AQP1 protein (gray value): 1.246±0.137 vs.1.986±0.110, both P ＜ 0.05]. The up-regulation of AQP1 mRNA and protein in rats' cerebral cortex after TBI perhaps participates in edema formation which might be involved in the pathophysiology of cerebral edema in TBI. Early treatment with an intraperitoneally injection of hydrogen-rich water is capable of attenuating the extent of TBI-induced up-regulation of AQP1 mRNA and protein, alleviating cerebral edema, and achieving its protective effects.

Novel bone wax based on poly(ethylene glycol)–calcium phosphate cement mixtures

Classic bone wax is associated with drawbacks such as the risk of infection, inflammation and hindered osteogenesis. Here, we developed a novel self-setting bone wax on the basis of hydrophilic poly(ethylene glycol) (PEG) and hydroxyapatite (HA) forming calcium phosphate cement (CPC), to overcome the problems that are linked to the use of conventional beeswax systems. Amounts of up to 10wt.% of pregelatinized starch were additionally supplemented as hemostatic agent. After exposure to a humid environment, the PEG phase dissolved and was exchanged by penetrating water that interacted with the HA precursor (tetracalcium phosphate (TTCP)/monetite) to form highly porous, nanocrystalline HA via a dissolution/precipitation reaction. Simultaneously, pregelatinized starch could gel and supply the bone wax with liquid sealing features. The novel bone wax formulation was found to be cohesive, malleable and after hardening under aqueous conditions, it had a mechanical performance (∼2.5MPa compressive strength) that is comparable to that of cancellous bone. It withstood systolic blood pressure conditions for several days and showed antibacterial properties for almost one week, even though 60% of the incorporated drug vancomycin hydrochloride was already released after 8h of deposition by diffusion controlled processes. Statement of SignificanceThe study investigated the development of alternative bone waxes on the basis of a hydroxyapatite (HA) forming calcium phosphate cement (CPC) system. Conventional bone waxes are composed of non-biodegradable beeswax/vaseline mixtures that are often linked to infection, inflammation and hindered osteogenesis. We combined the usage of bioresorbable polymers, the supplementation with hemostatic agents and the incorporation of a mineral component to overcome those drawbacks. Self-setting CPC precursors (tetracalcium phosphate (TTCP), monetite) were embedded in a resorbable matrix of poly(ethylene glycol) (PEG) and supplemented with pregelatinized starch. This formulation was found to be malleable and cohesive underwater. While immersion in an aqueous environment, CPC precursors formed highly porous, nanocrystalline HA via dissolution/precipitation reaction as water penetrated the novel wax formulation and PEG molecules simultaneously dissolved. The bone wax further withstood blood pressure conditions. After hardening, mechanical performance was comparable to that of cancellous bone and we also successfully provided the bone wax with antibacterial properties.In our opinion, the described bone wax formulation outmatches conventional bone waxes, as it circumvents the detriments being associated with the term “bone wax”. Our wax has a novel composition and would broaden the application of CPC and besides, the general interest in bone waxes will increase, as they were long considered as a “first-line treatment” to avoid.

Syringe-pressurised bone wax to stop bleeding from vertebral body pin sites during anterior cervical discectomy and fusion (ACDF).

Anterior cervical discectomy and fusion (ACDF) is a common spinal procedure, with over 500,000 cases performed between 1990 and 1999 in the USA alone. ACDF is well-established for the management of patients with radiculopathy and/or myelopathy secondary to degenerative disc disease and/or spondylosis. In 2007, Fountas et al reported a postoperative haematoma rate of 5.6% (n=57) in a series of 1015 ACDFs, with emergent surgical evacuation of a haematoma required in 2.4% (n=24) of cases. No patients who developed haematomas had a bleeding diathesis and, at the time of evacuation, no active bleeding points were seen. Many surgeons place distraction pins in the vertebrae above and below the disc to facilitate the procedure (Figure 1). In our experience, removal of these pins towards the end of the procedure can lead to bleeding from the resultant holes that can be hard to control (Figure 2). We present a technique to stop bleeding from the vertebral body pin sites via the use of syringe-pressurised bone wax.

Giant bilateral cavernous-carotid aneurysms complicated by epistaxis

IntroductionEpistaxis secondary to a ruptured cavernous-carotid aneurysm that has eroded into the sphenoid sinus is a life-threatening condition. When it is unilateral, balloon or coil embolization of the parent vessel should be considered. When bilateral, coiling the aneurysm to gain hemostasis followed by stent insertion after anticoagulation has been shown to be successful in achieving stabilization of the aneurysm wall whilst maintaining flow through the artery. Case reportWe present a case of epistaxis secondary to giant bilateral cavernous-carotid aneurysm. Despite successfully excluding the left-sided aneurysm from the circulation, using coils, recurrent right-sided epistaxis proved extremely difficult to control and ultimately led to the death of our patient. DiscussionIn recurrent life-threatening episodes of epistaxis resistant to endovascular hemorrhage control, the sphenoid sinus should be packed with bone wax, in order to prevent further episodes of potentially fatal epistaxis, awaiting definitive neuro-radiological intervention.