Management of the contaminated anterior cruciate ligament graft.
OBJECTIVE
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.


METHODS
Level IV, systematic review of basic science studies.
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Moin
M
Khan
Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.
Benjamin B
BB
Rothrauff
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Fahim
F
Merali
Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A.
Volker
V
Musahl
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Devin
D
Peterson
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. Electronic address: ayenif@mcmaster.ca.
Olufemi R
OR
Ayeni
D016118:Anterior Cruciate Ligament / Q000601:surgery*; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods*; D000900:Anti-Bacterial Agents; D004866:Equipment Contamination / Q000517:prevention & control; D006801:Humans; D013242:Sterilization / Q000379:methods*; D013710:Tendons / Q000382:microbiology / Q000637:transplantation*; D014182:Transplantation, Autologous
D000900:Anti-Bacterial Agents