One of the earliest solutions of hemostasis in bone was developed by Horsley and Squire. Horsley published the composition of his"antiseptic wax"as: seven parts beeswax, one part almond oil, and 1% salicylic, sterilized by boiling (Horsley, V.

(1892), Brit Med J., 1 : 1165). First report of this agent's clinical use to control bleeding from bone was made by Parker (Parker, R. (1892), Brit Med J., 1 : 1076-7). Despite the great surgical advances of the century, current bone wax is remarkably similar to Horsley's composition: 88% refined beeswax and 12% isopropylpalmitate. (Baldauf, R. and I. Kanat (1986), J. Foot Surg., 25 : 456-458). Conventional bone wax has no inherent hemostatic quality; its effect is via tamponade of marrow spaces. The material is not resorbed by the adjacent bone or local surrounding tissues. Therefore, it can induce inflammatory response and inhibit bone regeneration. Furthermore, bone wax may lower the bacterial clearance in cancellous bone (Johnson, P. and Fromm, D.

(1981), Surgery, 89 (2) : 206-9), or result in wax embolization (Robicsek, F. et al. (1981), Ann Thorac Surg., 31 (4) : 357-9).

Although there have been some advances in the area of hemostatic agents for skeletal tissue, conventional bone wax continues to be the most commonly used hemostatic agent. Thus, the need exists for a composition that can easily be delivered to an osteotomy gap and that controls hemostasis of bone without delaying or inhibiting bone repair. There exists a need for an effective resorbable bone agent that has inherent hemostatic qualities, is easily delivered to the site, is compatible with osseous repair and is biodegradable.

Summary of the Invention: This invention provides a resorbable hemostatic agent that is easily applied to the site of solid tissue bleeding and, further, controls hemostasis without limiting or delaying the subsequent healing of the tissue. The invention features a delivery component that can exist in either a semi-solid form or liquid form at temperatures

ranging from 0°C to 45°C. The change in viscosity of the delivery component at varying temperatures allows for straightforward, uncomplicated application of the hemostatic agent to the wound. Once the composition is delivered to the wound in solid or semi- solid form, the increased temperature of the body causes the delivery component to become less viscous. This aids faster reabsorbtion into the adjacent bone and surrounding tissues. In a preferred embodiment, the delivery component is a water soluble delivery agent, such as polyethylene glycol.

In one aspect of the invention, the delivery component comprises about 65% to about 99% by weight of the resorbable hemostatic agent, preferably about 70% to about 99% by weight.

In another aspect of the present invention, the delivery component comprises a combination of a high molecular weight and a low molecular weight polyethylene glycol. Preferably, the resorbable hemostatic bone agent contains about 84% to about 89% high molecular weight polyethylene glycol and about 3% to about 15% low molecular weight polyethylene glycol. However, the proportions of high molecular weight and low molecular weight polyethylene glycols can be adjusted in order to provide easy application even when the temperature of the body being treated is elevated or reduced.

The resorbable hemostatic agent of this invention can further be used for treatment of defects to dense tissues other than bone. The hemostatic agent can also be used, for example, as a plug in bleeding muscle tissue.

The invention also features an active resorbable hemostatic component for controlling hemostasis at the wound site. This component performs an active role in coagulation, does not retard bone healing, and after delivery, it is slowly degraded and resorbed by surrounding tissue. In one embodiment, this component is in a fibrous form which adheres to the bone tissue pores and does not interfere with subsequent osseous repair. Active resorbable hemostatic components which are in fibrous form include collagen sponges, thrombin and microfibrillar collagen. In a preferred embodiment, the active hemostatic component is microfibrillar collagen (MFC). In another embodiment, the active resorbable hemostatic component is in a liquid form which fills bone tissue pores and does not interfere with subsequent osseous repair. Active resorbable hemostatic components which are in liquid form include fibrin, platelet-derived factors, and thrombin. The resorbable hemostatic agent can comprise about 1 % to about 25% by weight active hemostatic component, preferably 1% to 20% by weight active hemostatic component, more preferably about 1 % to 10% by weight active hemostatic agent, and most preferably about 6% to about 7% by weight active hemostatic component.

The present invention can also contain a biologically active healing adjunct or bone inducing or regenerating agent to further aid in the process of bone repair.

Brief Description of the Drawings Figure 1 illustrates the operative site, showing four 5 mm holes in frontal and parietal bones.

Figure 2 demonstrates the average percentage of bone growth, measured as percent fill of original defects, in conventional bone wax and PEG/MFC agent treated defects versus open control defects, at Day 29.

Figure 3 illustrates bone growth over the 85 day study for conventional bone wax and PEG/MFC agent treated defects and unfilled defects.

Figure 4 provides a histologic view of bony defects filled with PEG/MFC agent at Days 0.33,7,14,29,55, and 85 (4a-4f, respectively). Residual MFC remains in lower left corner of defect at 8 hr. (4a). By day 7, bone growth from margins of defect is evident and residual MFC remains in upper right corner of defect (4b). At day 14, fibrous union achieved as spongy bone growth increases, some MFC present at the base of the defect (4c). At day 29, bony islands have formed and MFC has been resorbed (4d). At day 55, fat cells fill upper portion of defect, bone remodeling evident and no MFC observed (4e).

Figure 5 demonstrates the location of macrophages after treatment with conventional bone wax. Macrophage-filled fibrous granulation tissue lines the margin of bone wax filled defect which shows no sign of osteoporosis at Day 29.

Detailed Description of the Invention This invention features a resorbable hemostatic agent comprising a delivery component, that aids in the ease of delivery to the wound site, and an active hemostatic component that controls bleeding in solid tissue by activating factors involved in coagulation and that does not delay or interfere with healing. When used for the treatment of bony defects, it does not interfere with subsequent bone repair. The delivery component can exist in semi-solid or liquid form at temperatures ranging from 0°C to 45°C. As used herein, the term"semi-solid"is intended to encompass viscous states ranging from a liquid to a stiff paste. The ability of the delivery component to change viscosity at varying temperatures allows for uncomplicated application of the resorbable bone agent in a malleable, semi-solid form to an osseous defect. Upon application to the wound site, the resorbable agent is subjected to elevated body temperature which causes the delivery component to become less viscous. In less viscous form, the delivery component is quickly reabsorbed into adjacent bone and

surrounding body tissue. Thus, the delivery component's limited presence at the wound site, unlike conventional bone wax, does not inhibit bony union.

Polyethylene glycol (PEG) is particularly useful as the delivery component due to its water solubility, biocompatability, and ability to change from solid to liquid form at increased temperatures. As described in the following Examples, it has been found that polyethylene glycol is reabsorbed within several hours after the application of the hemostatic agent of the invention to bleeding bone. Since the polyethylene glycol is rapidly removed, the resorbable hemostatic agent allows for fresh blood and macrophages to infiltrate the wound site. The resorbable hemostatic bone agent can comprise about 65% to about 99% by weight of the delivery component, preferably, about 70% to about 99% by weight.

In a preferred embodiment, high molecular weight and low molecular weight polyethylene glycols are combined to form the delivery component. By combining low molecular weight polyethylene glycol, which is in liquid form at room temperature, with high molecular weight polyethylene glycol, which is a solid at room temperature, the delivery component takes on a malleable consistency. Preferably, the resorbable hemostatic composition comprises about 84% to about 89% by weight high molecular weight polyethylene glycol and about 3% to about 15% by weight low molecular weight polyethylene glycol. However, the consistency of the resorbable hemostatic bone agent can be adjusted by varying the percentages of high molecular weight and low molecular weight polyethylene glycol. The percentages of high molecular weight polyethylene glycol in the resorbable hemostatic agent can range from about 70% to about 90% by weight. The low molecular weight polyethylene glycol can comprise about 10% to about 30% by weight of the resorbable agent.

The resorbable hemostatic agent of this invention can further be used as a plug for the treatment of wounds in other dense tissues, such as muscle. For example, bleeding from puncture wounds in skeletal muscle can be stopped by filling the wound with the resorbable hemostatic agent. In addition, the viscosity of the resorbable hemostatic agent can be adjusted for treatments in which the body is exposed to elevated or reduced temperatures. For example, during cardiopulmonary bypass surgery, the body temperature is lowered to reduce the heart rate. By increasing the proportion of low molecular weight polyethylene glycol and reducing the proportion of high molecular weight polyethylene glycol, a less viscous hemostatic"plug"can be easily applied to the cold tissue. After the procedure, as the body temperature returns to normal, the polyethylene glycol is rapidly reabsorbed by the surrounding tissue.

Various low molecular weight polyethylene glycols and various high molecular weight polyethylene glycols can be used to vary the consistency of the resorbable bone

wax. Low molecular weight polyethylene glycols can include, for example, polyethylene glycol with an average molecular weight ranging from about 300 to about 600. The high molecular weight polyethylene glycols can include polyethylene glycol with an average molecular weight ranging from about 1000 to about 1500. Preferably, PEG 400 and PEG 1450 are used in combination.

The active hemostatic component of the resorbable hemostatic agent provides an efficient mechanism for controlling bleeding at the wound site. As used herein, the term "active hemostatic component"refers to a hemostatic component which performs a role in activating coagulation factors and chemical substances which are involved in the coagulation pathway. In one embodiment, the active hemostatic component stimulates or induces production of factors or chemical substances involved in coagulation. In another embodiment, the active hemostatic component accelerates the series of coagulation reactions. By performing an active role in the coagulation pathway, the hemostatic components of the present invention enhance the rate at which a clot is formed and hemostasis occurs at the wound site. Active hemostatic components include microfibrillar collagen (MFC), thrombin, collagen sponge, fibrin and platelet-derived factors.

Moreover, the fibrous or liquid quality of the active hemostatic component has been found to permit easy combination with the delivery component. The liquid quality is also beneficial since the liquid nature of the hemostatic component allows it to fill the pores of bleeding bone and integrate into the fiber bundles of wounded muscle tissue.

The ability of the hemostatic component to flow into the pores of bleeding bone an in between fiber bundles enhances the area of wounded tissue exposed to the hemostatic component. Examples of hemostatic components which can exist in liquid form include thrombin, fibrin and platelet-derived factors.

The fibrous quality of certain hemostatic components of the present invention is also beneficial since the fibrous nature allows for the hemostatic component to catch in the pores of the bleeding bone and in between the fiber bundles of wounded muscle tissue. In addition, the fibrous quality of the hemostatic agent provides a higher surface to volume ratio with the wounded tissue. Examples of fibrous hemostatic components include collagen sponge, thrombin and MFC.

Another feature of the active hemostatic component is that it is slowly reabsorbed by the body during the healing process. Thus, the active hemostatic components of the present invention effectively stop bleeding in bone and then are slowly degraded and reabsorbed into surrounding tissue. This reabsorption period allows for bleeding to be controlled without having the hemostatic component interfering with subsequent osteogenesis. Preferably, the reabsorption period of the

active hemostatic component is between about three weeks and four months, more preferably between about one month and three months, and most preferably about two months from application of the resorbable hemostatic agent. For example, collagen sponge and MFC are slwoly degraded and reabsorbed by surrounding tissue over approximately a two month period.

In a preferred embodiment, MFC is the active hemostatic agent. MFC has been discovered to be effective at stopping bleeding from bone while eliciting minimal inflammatory response. In addition, MFC is easily embedded into cancellous bone when polyethylene glycol is the delivery agent. Once in place, MFC does not interfere with osteogenesis. Furthermore, MFC has been shown to be slowly removed from the wound site by natural healing processes over approximately a two month period..

In another aspect of the invention, the resorbable hemostatic bone agent can also comprise a biologically active healing adjunct or bone inducing or regenerating substance to further aid in the process of bone repair. The term"healing adjunct", as used herein, refers to biologically active substances, such as antibiotics and anti inflammatory drugs, that can aid in preventing infection or inflammatory response.

Antibiotics can include, for example, streptomycin, tetracycline, penicillin and ampicillin. Anti-inflammatory drugs can include, for example, indomethacin. The term "bone inducing substance"or"bone regenerating substance", as used herein, refers to substances that can be used to aid in the process of bone repair. For example, calcium phosphate and/or hydroxyapatite can be used as bone inducing substances.

This invention is further illustrated by the following Example which should not be construed as limiting.

Example I : Treatment of Bone Defects With A Polyethylene Glycol/MFC Hemostatic Agent We blended PEG with microfibrillar collagen (84% polyethylene glycol 1450 and 9.3% polyethylene glycol 400 and 6.7% microfibrillar collagen by weight) and compared it to commercial bone wax in full-thickness cranial defects in New Zealand white rabbits.

Preparation of Polyethylene Glycol/MFC Hemostatic Agent Preparation of the composite was done by sterilizing the PEG in an autoclave, while still in a liquid state it was added to MFC (Collastato) using sterile technique under a laboratory hood.

Polyethylene glycol was supplied by Sigma Chemical Company; the specifications for molecular weights used in the composite are listed below: Specifications (Sigma Chemical Company) Polyethylene Average Freezing Point pH at 25°C, 5% Viscosity at Glycols,Molecular °C Aqueous 210°F, Carbowax0 Weight Solution Centistokes 400 380 to 420 4. 5 to 7.5 1450 1300 to 1600 43. 0 to 46.0 4.5 to 7.5 25 to 32 Preparation of Drill Hole Models Twenty-one white New Zealand rabbits (2.8-5.0 Kg) were kept in a facility, accredited by the American Association for the Accreditation of Laboratory Animal Care, and provided food pellets and water ad libitum. An intramuscular injection of 3.0- 5.0 cc of Atropine (0.08 mg/ml) Xylazine (6 mg/ml), and Ketamine (50 mg/ml was administered. The scalp hair was removed with electric clippers and the skin was prepped with 70% ethanol. A midline incision extending from parietal to nasal region was made and the scalp and periosteum was retracted laterally to expose the calvaria. A #6 round bur on a cordless low-speed drill (Dremel) run at 10,000 RPM was used to create four 5 mm diameter holes in the left and right frontal and parietal bones (Figure 1). During drilling, the site was irrigated with 0.9% NaCl solution to reduce thermal damage. The defects were obtained by angling the bit to cut through the inner cortical plate at the circumference of the hole and removing the remaining button of cortical plate with a discoid/cleoid instrument. The quality of the defect and condition of the animal was noted as"good hole","dura tear", or"bone bleed". Care was taken to avoid trauma to the dura.

Treatment of Bone Defects with Polyethylene Glycol/MFC composition The four defects were copiously irrigated prior to treatment. The defects were filled with equal volumes of one of two treatments, or left empty as a control. The two treatments included commercial bone wax (Ethicon@) and the PEG/MFC composite prepared as previously described. The volume of treatment used was that which could be compressed into a #4 amalgam carrier. This volume, when properly shaped, completely filled the bony defect.

The defects were evaluated at intervals ranging from 8 hours to 85 days. After the allotted healing time had expired, animals were again anesthetized and then euthanized with thiopental via intracardiac injection. The cranial bones were exposed and photographed. A separating disc was used to harvest a block of skull including all four defects, which was subsequently split into four individual samples each containing one defect.

Bone specimens were fixed for at least 3 days in 2% paraformaldehyde, 0.1 M cacodylic buffer, pH 7.4 on a rotating table at 4°C. Specimens were decalcified in 7.5% EDTA in 0.1 M cacodylic buffer, pH 7.4, at 4°C. Samples were placed on a shaker and the solution was changed daily for approximately 3 weeks. Samples were infiltrated with vacuum with catalyzed JB-4 Solution A according to manufacturer's directions (Polysciences, Inc.). Infiltrating solution was changed every day for three days, and then samples remained in the fourth solution for approximately 3 weeks. Samples were embedded in glycol methacrylate (JB-4, Polysciences, Inc.) at a ratio of 1.0 ml Solution B (N, N-dimethylaniline) to 30 ml Solution A (acrylic monomer, n-butoxyethanol).

Serial sections, 4 pm thick, were cut transversally in the midportion of the treated defect and stained for 8 minutes with Toluidine Blue 0, pH 4.0.

An observer, masked to the type of treatment, analyzed the samples and used computer planimetry to determine the extent of new bone growth. Bone growth was estimated as percent fill, measuring the area of new bone compared to the original size of the defect. Values are expressed as mean standard deviation.

Results Gross Appearance: This formulation of PEG/MFC agent was initially harder than conventional bone wax but with brief kneading became softer and more malleable than bone wax. The strands of microfibrillar collagen were easily embedded into the lattice of trabeculae of cancellous bone. Both PEG/MFC and conventional bone wax effectively stopped bony bleeding caused by drilling. All animals survived to sacrifice, with no evidence of infection or hematoma.

Analysis of the defects showed that the polyethylene glycol composite was completely resorbed at time of the earliest biopsy, taken at 8 hours (n=2). Defects sampled on or before two weeks (n=12) contained a visible amount of MFC. The residual MFC was surrounded by fresh blood, mesenchymal tissue, and macrophages.

Little or no MFC was observed in wounds sampled between two weeks and 55 days (n=26) and no MFC was present in specimens examined after day 55 (n=4).

The conventional bone wax was grossly present in all defects in which it was placed (n=10). However, wax was not directly observed in histological sections due to melting that occurred during slide processing. Defects treated with bone wax evidenced very little bony regeneration (Figure 2). Biopsies taken on Day 29 showed no new bone growth (n=6). Infiltration was limited to a moderate number of macrophages in granulation tissue lining the border of the defect. Granulation tissue was evident throughout the 85-day study.

Both PEG/MFC (n=2) and unfilled specimens (n=2) demonstrated rapid osteoblastic activity with periosteal proliferation beginning by Day 3 and the formation of woven bone and bony islands by Day 7 (n=2,2, respectively). Fibrous tissue crossed most defects by two weeks. In PEG and untreated wounds, the percent of new bone increased to day 29, after which time there was no significant difference in the amount of bony growth between the PEG/MFC treated defects, 43 13% (n=18), and the untreated defects, 47 19% (n=12) (Figure 3). Between days 29-85, new bone filled from 41 21%-44 7% of the defect area for PEG/MFC defects (n=30) and 44 28%-60 0% for untreated defects (n=20). During this time frame, 2 of 30 PEG/MFC treated defects achieved complete bony union and 5 of 20 control defects reached bony union (Figure 4). None of the ten bone wax treated defects evidenced bony union.

There were no gross or histologic signs of infection in any of the wounds during the study period. No giant cells were observed in PEG/MFC or control defects and very few were observed in bone wax treated sites.

These data demonstrate the compatibility of the PEG/MFC composite with bony ingrowth and repair. Bony union can also be inhibited by foreign material such as conventional bone wax. PEG is water soluble and was shown to be resorbed within 8 hours, whereas microfibrillar collagen (MFC) was slowly removed over a two-month period. None of the defects filled with conventional bone wax showed any evidence of healing.

Example II : A Polyethylene Glycol/Collagen Sponge Hemostatic Agent We blended PEG with hemostatic collagen sponge (84-89% polyethylene glycol 1450 and 9-15% polyethylene glycol 400 and 1-2% collagen sponge by weight).

Preparation of Hemostatic Collagen Sponge.

The hemostatic collagen sponge was prepared from 1.5% bovine achilles tendon collagen (Sigma, St. Louis, MO). The bovine collagen was blended in sterile water (pH 5) to a final volume of 0.26 ml/cm3 at 10°C for 30 minutes. This suspension was frozen

and placed in a freeze dryer with a shelf temperature of-35°C for 2 hours. A vacuum of 200 m Torr was applied and the shelf temperature was increased to 0°C. This resulted in a highly porous structure with a thickness of approximately 2 mm.

Preparation of Polyethylene Glycol/Collagen Sponge Hemostatic Agent Preparation of the composite was done by sterilizing the PEG (Sigma) in an autoclave, while still in a liquid state it was added to the collagen sponge using sterile technique under a laboratory hood. The specifications for molecular weights used in this composite are listed above in Example I.

Treatment of Bone Defects with Polyethylene Glycol/Collagen Spouse composition Using New Zealand rabbits, drill hole models can be prepared and comparisons of treatment of bony defects can be performed as described above in Example I.

Example III : A Polyethylene Glycol/Thrombin Hemostatic Agent PEG is blended with thrombin (84-87% polyethylene glycol 1450 and 3-11% polyethylene glycol 400 and 5-10% thrombin by weight). Thrombin is commercially available from Sigma Chemical Co. (St. Louis, MO).

Preparation of Polyethylene Glycol/Thrombin Hemostatic Agent Preparation of the composite is done by sterilizing the PEG (Sigma) in an autoclave, while still in a liquid state it is added to the thrombin using sterile technique under a laboratory hood. The specifications for molecular weights which can be used in this composite are listed above in Example I.

Example IV: A Polyethylene Glycol/Fibrin Hemostatic Agent PEG is blended with fibrin (84-87% polyethylene glycol 1450 and 3-11% polyethylene glycol 400 and 5-10% thrombin by weight). Fibrin is commercially available from Sigma Chemical Co. (St. Louis, MO).

Preparation of Polyethylene Glycol/Fibrin Hemostatic Agent Preparation of the composite is done by sterilizing the PEG (Sigma) in an autoclave, while still in a liquid state it is added to the fibrin using sterile technique under a laboratory hood. The specifications for molecular weights which can be used in this composite are listed above in Example I.