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68 (); 238-250
doi:
10.1016/j.jor.2025.07.025

Can contaminated musculoskeletal autografts and allografts be safely and effectively used in patients? A systematic review

, , , , ,
a Mizzou Joint Preservation Center, Missouri Orthopedic Institute, Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Ave, Columbia, MO, 65203, USA
b Creighton University School of Medicine, 2500 California Plaza, Omaha, NE, 68178, USA

⁎Corresponding author: James L. Cook. cookjl@health.missouri.edu

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

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.

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”.

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.

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.

Keywords

Decontamination
Musculoskeletal autografts
Musculoskeletal allografts
Chlorhexidine-based soaking protocols
Graft salvage
1

1 Introduction

Musculoskeletal autografts and allografts are used frequently in orthopaedics, with more than 300,000 ligament reconstruction, osteochondral allograft, and meniscus allograft surgeries performed each year in the United States alone.1 While strict aseptic protocols are followed for these surgical procedures, contamination of the grafts can occur intraoperatively or postoperatively through various mechanisms that are not uncommon, highlighting the importance of awareness and resolution of this potential complication. In fact, a survey sent to sports medicine specialists indicated that 25 % of respondents experienced at least 1 anterior cruciate ligament (ACL) graft contamination during their career.2 Additionally, this survey also reported that approximately one-third of respondents either did or would use a different graft when contamination was discovered.2 Harvesting a different autograft adds notable morbidity, increases risk for complications, and can prolong the recovery period. Using a different allograft, if even feasible, results in a waste of gifted tissues, increased costs, and the potential for inferior outcomes. But, the consequences of contaminated graft tissue can be severe for patients, including risk for surgical site infection (SSI), which can lead to prolonged antibiotic treatment, additional surgical interventions, and treatment failure.

The most common pathogens involved in these infections are Staphylococcus species, including Staphylococcus aureus and Staphylococcus epidermidis.3,5,6 In severe cases of SSI, mortality rates can be substantial, with studies indicating a 90-day mortality rate of 7.05 % in patients with septic arthritis of the knee.4 Thus, knowledge of effective decontamination protocols for commonly used grafts is paramount to mitigating patient, healthcare professional, healthcare institutional, and healthcare system burdens.

When intraoperative graft contamination is recognized, precious graft tissue can be salvaged for use and postoperative complications can be minimized when effective decontamination is implemented. While various tissue decontamination protocols are described in the literature, there are no definitive evidence-based guidelines for intraoperative salvage of the most common tissue forms used in orthopaedic surgeries. The purpose of this systematic review was to critically evaluate the safety and efficacy of reported decontamination protocols for tendon, meniscus, and osteochondral grafts in order to provide evidence-based guidelines for intraoperative graft salvage by addressing the following clinically relevant questions.1.What are the most common mechanisms for intraoperative contamination?2.Do decontamination protocols differ among tissue types?3.What decontamination protocols are most effective?4.What effects does decontamination have on outcomes?

2

2 Methods

2.1

2.1 Search strategy

Using Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines,7 a PubMed and Embase search was performed to include peer-reviewed articles from inception (1977) to 2025 to identify eligible studies for systematic review of tendon, osteochondral, and meniscal allograft decontamination protocols. Using the advanced search features, separate searches for tendon for ligament (tendon-ligament), osteochondral, and meniscal protocols were performed using keywords of (1) “operative”, (2) “dropped OR contamination OR sterilization”, and (3a) “tendon” or (3b) “ligament” or (3c) “osteochondral” or (3d) “meniscus”.

2.2

2.2 Inclusion and exclusion criteria

All titles and abstracts from the initial search were screened, eliminating articles irrelevant to this review. Following this, a full-text review of the remaining articles was performed by two independent reviewers (P.R. and B.W.R.) to determine eligibility for inclusion. Inclusion criteria required the controlled contamination of tendon, osteochondral, or meniscal allograft tissue and a defined protocol for decontamination. Exclusion criteria included studies performed on non-human tissue, inaccessibility to full-text literature, and studies unavailable in English. Eligible articles were further analyzed and underwent data extraction.

2.3

2.3 Data extraction

Following a Population, Intervention, Comparison, and Outcome format, data extracted from eligible studies included.•Population: type of allograft tissue, size of allograft tissue, sample size•Intervention: mechanism of contamination•Comparisons: decontamination agent, volume, concentration, duration, mechanical component•Outcomes: positive culture rate, bacterial isolates, any other safety or efficacy outcomes

2.4

2.4 Quality assessment

Level of evidence (LOE) for included articles was based on the Center for Evidence-Based Medicine guidelines.8 Investigators (P.R. and B.W.R.) also independently assessed risk of bias (RoB) using the Cochrane Library ROBINS-I and the Risk of Bias tools.9,10 To evaluate the methodological quality of non-clinical studies, a modified version of the MINORS scale,11 adapted for laboratory-based research, was used based on the approach described by Khan et al.12 Similar to the original MINORS scale, the adapted version includes 12 core items. Each criterion is rated on a scale from 0 to 2, where 0 indicates the criterion is not reported, 1 signifies incomplete reporting, and 2 denotes adequate reporting, such that the maximum possible score is 24. Two independent reviewers conducted the quality assessment (P.R. and B.W.R.). Mean scores for the 2 reviewers are reported.

3

3 Results

The initial search yielded 920 tendon-ligament articles, 85 osteochondral articles, and 96 meniscal articles. A total of 16 studies (10 ex vivo, 2 case reports, 1 academic survey, 1 systematic review, 1 retrospective review, and 1 randomized controlled trial) using tendon-ligament grafts and 6 studies (5 ex vivo, 1 systematic review) using osteochondral grafts met inclusion criteria. No studies evaluating decontamination of meniscal tissue met inclusion criteria (Fig. 1). Included clinical studies involved only small case series such that LOE and RoB assessments were not highly relevant. As such, ex vivo laboratory studies served as the best available evidence for informing clinical practice regarding safety and efficacy of allograft decontamination protocols. Included tendon-ligament allograft decontamination articles are presented in Table 1; average modified MINORS score for quality was 17.4 (Table 2). Included articles regarding osteochondral tissue are presented in Table 3; average modified MINORS score was 19.4 (Table 4).

PRISMA flow diagram depicting the conducted systematic review of decontamination protocols by tissue type.
Fig. 1 PRISMA flow diagram depicting the conducted systematic review of decontamination protocols by tissue type.
Table 1 Included tendon-ligament allograft decontamination articles.
Publication Study Type Number of Grafts/Specimens Method of Contamination Primary Decontaminant Concentration Solution Amount Soaking time Additional Protocol Steps Outcome (% Positive Cultures) Organism Additional Info Bias
Bardan 2016 Hamstring autograft during ACLR, extra graft tissue used 60 Dropped on floor for 15 s 10 % povidone-iodine 10 % 1 L 3 min 9/60 (15 %) S. aureus, S. epi, Acenitobacter, pseudomonas 0 post op infections
4 % chlorhexidine 50,000U/1 L 1 L 3 min 0/60 (0 %)
4 % bacitracin 50,000U/1 L 1 L 3 min 2/60 (3.3 % S. epi, Acenitobacter
None (control- skin) – – – 10/60 (16.7 %) poly
None (control- contaminant) – – – 30/60 (50 %) poly
Barbier 2015 Hamstring autograft during ACLR, extra graft tissue used 25 Dropped on floor for 15 s 10 % povidone-iodine 10 % 15 min 1/25 (4 %) S capitis 0 post op infections
4 % chlorhexadine 4 % 15 min 2/25 (8 %) Aerococcus anguinicola, S aureus, S epi Cultures from the floor did not predict organisms grown on specimen
Sodium hypochlorite 0.5g/100 ml 15 min 4/25 (16 %) S hominis, S capitis, S warneri
Control – – – 3/25 (12 %) S hominis, S capitis, Candida parapilosis
Control contaminant – – – 10/25 (40 %)
Bentkowski 2024 Testing Vanc/Tobra efficacy on cadaveric gracilis tendon 1 Innoculation with Staph epi Tobra 0.1 mg/ML 5 mL 10 and 20 min Significantly effective
1 5 mL Undetectable
2.5 5 mL Undetectable
5 5 mL Undetectable
10 5 mL Undetectable
Vanc 0.1 5 mL Not Significantly Effective
1 5 mL Not Significantly Effective
2.5 5 mL Significantly effective
5 5 mL Significantly effective
10 5 mL Undetectable
Casalonga 1999 Case report actual contamination 4 (BTB) Dropped on the floor rifamycin 0.8 mg/ml 10 min Loading dose of cefamandole followed by 14 days PO augmentin 15 days 0 infections
gentamycin 0.6 mg/ml 10 min
Cooper 1991 Cadaver BTB harvest, irradiated, frozen, thawed, dropped in OR after THA 20 Dropped on floor for 3 min bacitracin and polymyxin B 33.33 U/mL and 333.33 mL 1500 mL 15 min Rinsed in saline 3 times 3/10 (30 %) S epi, Diphtheroides
Control contaminant – – – – 6/10 (60 %)
Izquierdo 2005 Survey of 337 academic sports med fellowship directors and graduates 49/196 (25 %) reported at least 1 contaminated graft 35/49 (71 %) cleansed the graft and 75 % of contaminated grafts used 10/57 (18 %) alternative autograft used; 4/57 (7 %) used allograft 13/43 (30 %) contaminated grafts cleaned with chlorhexidine for 90 s to 30 min 11/43 (26 %) abx solution only 8/43 (19 %) chlorhexidine and abx solution 6/43 (14 %) iodine solution, 2/43 (5 %) iodine and abx solution; 1 iodine and chlorhexidine; 1 dilutions only
Burd 2000 15 Achilles tendon/calc allografts (after using fascia lata to determine concentration) were innoculated with S aureus, S epi, Pseudomonas, Klebsiella 5 fascia lata samples Direct innoculation 0.05 % castile soap 1 and 3 L –
0.03 % benzalkonium chloride 1 and 3 L –
soap with benzalkonium 1 and 3 L –
triple antibiotic (gentamicin 0.1 %, clindamycin 0.1 %, and polymyxin 0.05 %) 1 and 3 L –
4 % chlorhexadine 1 and 3 L – No growth
4 % chlorhexadine with triple antibiotic 1 and 3 L – No growth
normal saline (control) 1 and 3 L –
Determination of minimum effective concentration Chlorhexadine 0.05 %, 0.1 %, 0.5 %, 1 %, 2 %, 4 % – only 2 % and 4 % had no growth
Part III 10 2 % chlorhexadine 3 L – 0/10 (0%)
5 normal saline (control) 3 L – 5/5 (100%)
Khan 2014 Systematic Review
Burd et al. See above
Parker et al.
Stanford et al. (1999) 33 Innoculation with S aureus 10 % iodine at room temp 0/6 sterile
10 % iodine at 36C 1/6 sterile
Innoculation with P aeruginosa 10 % iodine at room temp 0/6 sterile
10 % iodine at 36C 1/6 sterile
Innoculation with S aureus Serial washing with 10 % povidone-iodine and agitation (5 min at 3 cycles/s with 3-cm amplitude 5) 1/9 sterile
Molina et al.
Plante et al.
Cooper et al.
Luceri 2020
Lucanio 2020 25 tissue donors 125 (25 x 5) Placed on OR floor for 1 min 0.5 % chlorhexadine 0.50 % 100 mL 10 min 0/25 (0%)
0.9 % saline 0.90 % 100 mL 10 min 14/25 (56%) unknown
0.55 % ortho-phthalaldehyde 0.55 % 100 mL 10 min 2/25 (8%)
no decontamination 16/25 (64%)
no contamination 0/25 (0%)
Molina 2000 50 ACL specimens from TKA 200 (50 x 4) Dropped on floor for 15 s Antibiotic solution a 1-mL vial containing 40 mg of neomycin sulfate and 200,000 U of polymyxin B sulfate 1000 mL 90 s 3/50 (6%) Clostridium, bacillus
Providone-iodine 10 % 90 s 12/50 (24%) Staph sp, bacillus
Chlorhexadine 4 % 90 s 1/50 (2%) gram negative rod
Control – – – 29/50 (58%)
Parker 2010 12 donor specimen BTBs 40 (4x10) 15 s contamination in bacterial suspension Control CFUs: 33.1; 10.5; 31; 6.2; 63.1; 16.7 Staph sp, bacillus (bone, tendon, both)
Antibiotic soak polymyxin B (166.66 units/cc) and bacitracin (16.66 units/cc) 100 cc 15 s CFUs: 7.6; 1.3; 7.3; 1.2; 14.9; 2.5
Pulsatile lavage polymyxin B (166.66 units/cc) and bacitracin (16.66 units/cc) 1000 cc CFUs: 0.2; 0 0.3; 0.1; 0.5; 0.1
Mechanical agitation and serial dilution polymyxin B (166.66 units/cc) and bacitracin (16.66 units/cc) 1000 cc shaken for 15 s, 100 cc repeated x 10 CFUs: 0; 0; 0; 0; 0; 0
Pasque 2007 Case Report 3 (3 Cases) BTB Case 1: Scrub tech threw blood tinged sponge in kick bucket Chlorhexadine followed by triple antibiotic Unknown Unknown 15 min each Remove suture material, saline rinse after abx soak 0 post op infections Recommended six weeks close clinical follow up
Case 2: Hemostats were placed on suture ends of graft, one hemostat knocked and dragged graft onto floor Ancef 1 g q 8 24 h followed by Keflex 500 q6h ×10 days
Case 3: Graft holding device came loose and flung graft against the wall and onto the floor
Perez 2018 Prospective, actual ACLR 50: 29 BTB and 21 hamstring No intentional contamination Vanc 5 mg/mL (500 mg) 100 10–15 min Sample 1: Right after harvest 5/50 (10%)
Sample 2: Remaining after graft prep 2/50 (4%) Coag neg staph, P acnes
Sample 3: Soaked in vanc after graft prep 0/50 (0%)
Plante 2013 Excess hamstring tendon from ACL 180 (30 x 6) Dropped on the floor Control – 7/30 (23.3%)
Dropped 5 s – 10/30 (33.3)
Dropped 15 s – 7/30 (23.3%)
15 then saline 3 min 9/30 (30%)
15 then bacitracin 50,000 U per 1 L 3 min 1/30 (3.3% Coag neg staph
15 then chlorhexadine 4 % 3 min 1/30 (3.3%) bacillus
Shen 2021 Systematic Review 173 (5 studies) 4 % chlorhexadine 4/173 (2.3 %) Pooled rate of positive cultures from dropping was 44.9 % (92/205) ∗MINORS index?
Molina et al. 158 (5 studies) antibiotic solution 17/158 (10.8 %)
Plante 143 (4 studies) 10 % iodine 30/143 (21 %)
Badran
Parker
Cooper
Barbier
Goebel
Vertullo 2012 Retrospective cohort 285 4/285 (1.4 %) coag neg staph (3), culture negative (1)
870 pre soaked vanc 5 mg/mL 100 mL unknown 0/870 (0%)
Table 2 Ligament bias scores.
Bias Category Bardan 2016 Barbier 2015 Bentkowski 2024 Cooper 1991 Burd 2000 (?) Luciano 2020 Molina 2000 Parker 2010 Perez 2018∗No contamination Plante 2013
1. Clearly stated purpose 2 2 2 2 2 0 2 2 2 2
2. Adequete control groups 2 2 1 2 2 2 1 1 2 2
3. Graft type description 2 2 2 2 2 2 2 2 2 2
4. Power analysis 0 2 0 0 0 0 0 0 0 0
5. Appropriate statistical analysis 2 2 2 2 2 2 0 2 2 2
6. Unbiased assessment of outcome 1 1 2 1 1 1 1 2 1 1
7. Contaminant identity 1 1 2 1 2 0 1 2 2 1
8. Infection risk 1 1 2 1 2 1 1 2 0∗No contamination 1
9. Culture method 2 2 2 2 2 0 2 2 2 0
10. Culture time 1 2Tryptic soy for 3d, thioglycolate for 7d 1 2 1 0 2Tryptic soy for 3d, thioglycolate for 7d 2 2 0
11. Cleansing agent 1∗Missing volume 1∗Missing volume 2 1∗Missing volume 2 2 1∗Missing volume 2 2 1∗Don't identitfy antibiotic solution∗Missing volume
12. Cleansing method 2 2 2 2 2 2 2 2 2 2
13. Biomechanical properties(Not included) 0 0 0 0 0 0 0 0 0 0
14. Cytocompatibility(Not included) 0 0 0 0 0 0 0 0 0 0
Total 17 20 20 17 20 12 15 21 19 14
Table 3 Included articles regarding osteochondral tissue.
Publication Study Type Number of Grafts/Specimens Method of Contamination Primary Decontaminant Concentration Solution Amount Soaking time Additional Protocol Steps Outcome (% Positive Cultures) Organism Additional Info Bias
Altinayak et al. 30 specimen from TKA 30 patients, 9 specimen each Dropped on the floor Control – – 15 min 19/30 (63.3%)
10 % iodine 15 min 0/30 (0%)
4 % chlorhexadine 15 min 5/30 (16.7%) Coag neg staph (4), Kleb (1)
sodium hypochlorite 0.5g 100 15 min 10/30 (33.3%) Coag neg staph (8), Kleb (1), pseudomonas (1)
Bruce et al. Phase II- controlled contamination 140 coag neg staph (28 each) Controlled innoculation 10 % iodine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
4 % chlorhexadine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
70 % alcohol/2 % chlorhexadine 20 mL 5 min 4/7 (rinse); 0/7 (scrub)
10 min 2/7 (rinse); 0/7 (scrub)
Control 5 min 7/7 (rinse); 0/7 (scrub)
10 min 7/7 (rinse); 0/7 (scrub)
100 bacillus (20 each) Controlled innoculation 10 % iodine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
4 % chlorhexadine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
70 % alcohol/2 % chlorhexadine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
Control 20 mL 5 min 1/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
100 Corynebacterium (20 each) Controlled innoculation 10 % iodine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
4 % chlorhexadine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
70 % alcohol/2 % chlorhexadine 20 mL 5 min 0/7 (rinse); 0/7 (scrub)
10 min 0/7 (rinse); 0/7 (scrub)
Control 20 mL 0/7 (rinse); 0/7 (scrub)
0/7 (rinse); 0/7 (scrub)
Campbell et al. Controlled lab study 12 MRSA immersion for 1 min No wash 290000000 MRSA Cell death increasing over time with even 0.05 % concentration
1.40E+05 Pulse lavage with saline 1 L 1 min 33000000
Pulse lavage with saline and 0.002 % CHG 0.002 % 1 L 1 min 0
Mortazavi et al. Systematic Review
Bauer et al. 20x3 (10 for efficacy, 10 viability) bacterial broth innoculation Control 10/10
Autoclave 0/10
saline 15 s then 2 min soak 10/10
2 % chlorhexadine 15 s then 2 min soak 0/10
10 % iodine 15 s then 2 min soak 6/10
dry iodine 15 s then 2 min soak 0/10
Bruce et al.
Yazdi et al- rabbit
Utkan et al. Samples from THA 48x3 Dropped on floor Control 28/48 (58.3 %)
Saline 1 min 19/48 (39.6 %)
Iodine then saline 10 % 1 min 5/48 (10.4 %)
Table 4 Osteochondral bias scores.
Bias Category Altinayak et al. Bruce et al. Campbell et al. Bauer et al. Utkan et al.
1. Clearly stated purpose 2 2 2 2 2
2. Adequate control groups 2 1 1 2 1
3. Graft type description 2 2 2 2 2
4. Power analysis 0 0 0 0 0
5. Appropriate statistical analysis 2 2 2 2 2
6. Unbiased assessment of outcome 1 1 2 2 1
7. Contaminant identity 1 2 2 2 1
8. Infection risk 1 2 2 2 2
9. Culture method 2 2 2 2 2
10. Culture time 1 2 2 2 1
11. Cleansing agent 1 2 2 2 1
12. Cleansing method 2 2 2 2 2
13. Biomechanical properties∗Not included
14. Cytocompatibility∗Not included
Total 17 20 21 22 17
4

4 Discussion

4.1

4.1 What are the most common mechanisms for intraoperative contamination?

For all graft types, dropping the tissue onto the operating room floor is the most commonly reported method of contamination.13,14 However, indirect or direct contamination during aseptic recovery, processing, and/or preparation of autografts and allografts has also been reported.15,16 As such, the included studies implemented methods of decontamination that included intentionally dropping the tissue onto the floor,13,17–22 direct inoculation with bacteria,18,20,24–27 and accidental contamination of grafts initially intended for clinical use.13,14,16,28 Tendon-ligament studies most commonly used an “intentional dropping on the floor” contamination protocol, while osteochondral studies must common used a “direct inoculation” contamination protocol.

4.2

4.2 Do decontamination protocols differ among tissue types?

The primary components of decontaminant solution types and exposure (soaking) times were similar among included studies for both tissue types. The most common decontaminants used were 10 % povidone-iodine and 4 % chlorhexidine with the typical soaking time being 10 min. However, notable differences among protocols included the use of vancomycin predominating in tendon-ligament studies and “mechanical agitation” steps predominating in osteochondral studies.

4.3

4.3 What decontamination protocols are most effective?

For tendon-ligament studies, 4 % chlorhexidine solutions consistently yielded more effective decontamination (92–100 % efficacy) than 10 % povidone-iodine solutions (76–100 % efficacy)12,17–20,29–31 and bacitracin and polymyxin solutions (70–96.7 % efficacy).17,20,30,32,33 Soaking the tissue in vancomycin was also extremely effective with no culture growth reported in any study that used this protocol.16,28,34 No studies had any direct comparison between vancomycin and the decontaminant solutions.

For osteochondral studies, efficacy results varied widely with chlorhexidine-based protocols associated with more consistently effective decontamination compared to iodine-based protocols (83–100 % versus 40–100 %).16,21,24–27 Importantly, alcohol/chlorhexidine solutions were associated with superior decontamination efficacy when directly compared with chlorhexidine alone in all bacterial strain inoculations tested.21,24,25 A “mechanical agitation” component in the decontamination protocol in the form of scrubbing or pulsatile lavage also improved efficacy when compared to non-agitated groups.25,33 However, it is critically important to note that mechanical agitation was associated with decreases in chondrocyte viability in these tissues, which has been well established to have direct impacts on osteochondral allograft transplantation outcomes.25,35,36

The most common organisms demonstrating growth despite decontamination interventions were S. aureus and S. epidermidis.13,14,16–20,23,28–34

4.4

4.4 What effects does decontamination have on outcomes?

Clinical outcome measures following decontamination have been limited to assessments of infections with no studies discovered via systematic review evaluating related treatment revisions or failures, return-to-sport, or patient-reported outcome measures (PROMs). For the included case reports, no infections following contamination of tendon-ligament autografts were reported when using a 15-min chlorhexidine soak followed by a 10-min rifampin/gentamycin soak and 10–14 days of oral antibiotics.13,14,16,28 Similarly, in a survey of surgeons reporting instances of tendon-ligament contamination, no resultant infections were recognized when chlorhexidine- and/or antibiotic-based solutions were used for decontamination. In terms of tissue effects, no evidence of detrimental structural consequences on anterior cruciate ligament grafts treated with 4 % chlorhexidine were noted.37 However, chlorhexidine, of all the decontamination solutions evaluated, have the potential to be cytotoxic, which may have profound ramifications for autografts as well as for fresh (viable) allografts.24,38–40

4.4.1

4.4.1 Limitations

With limitations related to the relative paucity and quality of data available for this systematic review, caution should be used when interpreting and applying these results to clinical practice. Given the variability of study designs and reporting methods, definitive conclusions regarding optimal decontamination protocols cannot be made, nor can the results of the systematic review be generalizable. No eligible studies including decontamination of meniscus allografts were found, and tendon-ligament and osteochondral decontamination studies lacked clinical outcome measures for toxicity, revisions, failures, return-to-sport, or PROMs. As such, well-designed clinical studies are needed to accomplish the goal of providing definitive evidence-based guidelines for decontamination protocols for contaminated tendon, meniscus, and osteochondral grafts for intraoperative graft salvage.

5

5 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, 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 to prevent tissue waste, morbidity, complications, failures, and associated costs while promoting successful outcomes for patients.

CRediT authorship contribution statement

Patrick Ryan: Conceptualization, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Bryce W. Rigden: Conceptualization, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Clayton W. Nuelle: Conceptualization, Investigation, Resources, Writing – review & editing. James P. Stannard: Conceptualization, Investigation, Resources, Supervision, Writing – review & editing. Steven F. DeFroda: Conceptualization, Investigation, Resources, Writing – review & editing. James L. Cook: Conceptualization, Formal analysis, Investigation, Resources, Supervision, Writing – original draft, Writing – review & editing.

Ethical statement

Institutional Review Board approval was not needed to conduct this study.

Funding

This study was conducted and completed with no funding from an external source.

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