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Published on: April 30, 2014
Management of the contaminated anterior cruciate ligament graft
Moin Khan1, Benjamin B Rothrauff2, Fahim Merali1
1Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Purpose:
This systematic review explores management strategies for intraoperative anterior cruciate ligament (ACL) graft contamination.
Methods:
Two databases (Medline and EMBASE) were screened for studies involving ACL graft contamination published between 1946 and April 2013. We included studies evaluating the management of a contaminated graft and excluded small case-series studies. We conducted a full-text review of eligible studies, and the references were searched for additional eligible studies. Inclusion and exclusion criteria were applied to the searched studies.
Results:
Our search yielded 6 laboratory investigations with a total of 495 graft samples used. These samples were contaminated and cleansed by various methods. The most successful sterilization protocols used chlorhexidine or mechanical agitation with a polymyxin B-bacitracin solution to achieve sterility in 100% of their respective experimental graft tissues. A chlorhexidine soak and plain bacitracin soak were also effective, at 97.5% and 97%, respectively. Povidone-iodine and an antibiotic soak of polymyxin-bacitracin were the least effective, with sterility rates of 48% and 57%, respectively.
Conclusions:
The results of this review suggest that the optimal agent for sterilizing a dropped graft is chlorhexidine. A protocol of mechanical agitation and serial dilution with a polymyxin B-bacitracin solution was also highly effective; however, the sample size was too small to realistically recommend its use. Bacitracin alone was also found to be an effective sterilization agent, as was a combined solution of neomycin and polymyxin B. Pooled results showed that normal saline solution, povidone-iodine, and a polymyxin B-bacitracin solution all yielded suboptimal sterilization. The available evidence, however, is laboratory based and may not accurately reflect clinical conditions; moreover, there is a lack of biomechanical studies evaluating sterilized grafts. As a result, the findings should be interpreted with caution.
Level Of Evidence:
Level IV, systematic review of basic science studies.
Insights
Chlorhexidine is the best agent for sterilizing a dropped anterior cruciate ligament (ACL) graft. Mechanical agitation with polymyxin B-bacitracin and bacitracin alone were also effective, but results are lab-based.
Area of Science:
- Orthopedic Surgery
- Microbiology
- Biomaterials Science
Background:
- Intraoperative graft contamination is a risk during anterior cruciate ligament (ACL) reconstruction.
- Effective sterilization methods are crucial to prevent infection and ensure graft viability.
- Limited evidence exists on optimal management strategies for contaminated ACL grafts.
Purpose of the Study:
- To systematically review laboratory investigations on management strategies for intraoperative ACL graft contamination.
- To identify effective agents and protocols for sterilizing contaminated ACL grafts.
Main Methods:
- Systematic review of Medline and EMBASE databases (1946-April 2013).
- Inclusion of laboratory investigations evaluating ACL graft sterilization.
- Exclusion of small case-series studies.
Main Results:
- Chlorhexidine and mechanical agitation with polymyxin B-bacitracin achieved 100% sterility.
- Chlorhexidine soak (97.5%) and bacitracin soak (97%) were highly effective.
- Povidone-iodine (48%) and polymyxin-bacitracin soak (57%) showed suboptimal sterilization rates.
Conclusions:
- Chlorhexidine is the optimal agent for sterilizing a dropped ACL graft.
- Bacitracin alone and a neomycin/polymyxin B combination were also effective.
- Findings are laboratory-based and require cautious interpretation due to lack of clinical and biomechanical data.
