Accidental peri- and intraoperative faecal contamination in clean Orthopaedic Surgeries: A scoping review and...

Infections associated with Orthopaedic implants, particularly periprosthetic joint infections and fracture-related infections, represent complications of extremely high morbidity, lethality, and cost. Massive contamination of the surgical field by accidental intraoperative faecal discharge is a catastrophic event from a microbiological standpoint - owing to the high burden of biofilm-forming pathogens such as Enterococcus spp. - yet it remains an underreported phenomenon without standardized management in the Orthopaedic literature. The objective was to map available evidence on the impact of peri- and intraoperative faecal discharge on surgical site infection (SSI) and to propose a risk classification algorithm and immediate management protocol to mitigate inoculation in clean Orthopaedic surgeries. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) criteria. The structured search was designed to encompass the period from anesthetic induction to procedure completion, and was performed in MEDLINE/PubMed, Embase, Scopus, and Cochrane Library databases. Given the scarcity of direct Orthopaedic data, studies from related surgical fields on intestinal spillage and intraoperative adverse events were included for translational extrapolation. Eighteen studies were included. The literature demonstrated that enteric content inoculation is independently associated with severe rates of therapeutic failure, lethality, and the need for reoperations. Current Orthopaedic guidelines focus on primary prevention and do not provide rescue protocols for dramatic aseptic breaches. A three-dimensional classification system is proposed based on the extent of the event (A0 to A3), stool consistency (B1 to B3), and the biological vulnerability of the procedure (C0 to C2), generating risk classes that guide redraping, instrument exchange, irrigation, reassessment of antibiotic therapy, and even procedure suspension. Peri- and intraoperative faecal discharge should be institutionally recognized as a formal "Intraoperative Adverse Event." The application of a pragmatic, multidimensional protocol standardizes actions, reduces team inertia, and minimizes the potential bacterial inoculum, thereby mitigating the biological catastrophe associated with biofilm formation.