Can contaminated musculoskeletal autografts and allografts Be safely and effectively used in Patients? A systematic review

Background

Musculoskeletal autografts and allografts are used frequently in orthopaedics, and contamination of the grafts can occur. When intraoperative contamination is recognized, the graft can be salvaged for use and postoperative complications minimized with effective decontamination. The purpose of this systematic review was to critically evaluate safety and efficacy of decontamination protocols for tendon, meniscus, and osteochondral grafts in order to provide evidence-based guidelines for graft salvage.

Methods

Using PRISMA guidelines, a literature search was performed to identify eligible studies for systematic review of tendon-ligament, osteochondral, and meniscal graft decontamination protocols. Separate searches for tendon, for ligament (tendon-ligament), osteochondral, and meniscal protocols were performed using keywords: (1) “operative”, (2) “dropped OR contamination OR sterilization”, and (3a) “tendon” or (3b) “ligament” or (3c) “osteochondral” or (3d) “meniscus”.

Results

A total of 16 studies for tendon-ligament and 6 studies for osteochondral grafts met inclusion criteria. For all graft types, dropping the tissue onto the operating room floor is the most commonly reported method of contamination. The most common decontaminants used were 10 % povidone-iodine and 4 % chlorhexidine with the typical soaking time being 10 min. For both tissue types, chlorhexidine-based protocols were most consistently effective at eradicating bacterial contaminants. Clinical outcome measures were limited to assessments of subsequent infections with none reported in the very few studies that provided outcome data.

Conclusion

The currently available evidence for intraoperative decontamination of musculoskeletal autografts and allografts supports the use of chlorhexidine-based soaking protocols for treatment of tendon autografts and allografts, as well as fresh (viable) osteochondral allografts, in order to most effectively prevent related infections. Additional data is required to determine optimal protocols with respect to disinfectant types and concentrations, inclusion of antibiotics, exposure durations, and use of “mechanical agitation” that sufficiently eradicate pathogens and preserve essential cell viability, material properties, and biocompatibility for each tissue type in order to prevent tissue waste, morbidity, complications, failures, and associated costs while promoting successful outcomes for patients.