During the anterior cruciate ligament reconstruction, my hanstring graft (STG) has fell on the floor accidently twice. I did not have option of the allograft. I only had the options of either harvesting the same side BTB or contralateral hamstring or using the same graft after cleansing it. I exercised the last option of washing the graft with 500 ml saline, soaking it in cidex for 30 minutes and again washing it with saline. I was fortunate enough that in both the patients there was no infection. Both the patients have completed 2 years and 5 years follow up and the KT assessment as well as functional assessment is good.
But is it the right way to go in this situation or we should always harvest another new graft?
How was this happened twice in your practice? I'm pretty surprised this has ever happened at all.
dear ravi
its surprising and I think you are too lucky in this way.
best regards
Dear Ravi
Below comments from Bernard R. Bach, MD, - What Do You Do If You Drop the Graft on the Floor? Healio Orthopedics.
Great care must be taken to avoid contamination during harvest and or preparation of the graft for anterior cruciate ligament (ACL) reconstruction. Our protocol emphasizes that the surgeon who harvests the graft personally walks the tissue to the back table to reduce the risk of dropping the graft. Handing off of a freshly harvested graft to other members of the surgical team for preparation simply increases the likelihood dropping the graft. With this protocol, the senior author has not dropped any grafts in over 20 years of practice, including more than 1700 knee ligament procedures. Careful attention must be paid during preparation on the back table as well. The fully prepared graft is placed in a marked kidney basin. All operative personnel are informed to prevent the graft from being inadvertently passed off the sterile field
When the graft is brought to the operative field for graft placement, if it is wrapped in a laparotomy sponge, theoretically the only contaminated portion would be the sutures extending beyond the sponge if the graft were dropped.
If the graft is dropped, the salvage falls into one of several possible categories, namely cleaning the graft, using an alternative graft (auto or allograft), or stopping the procedure and completing the surgery at another time with a different graft.
One study showed a 58% rate of positive culture when the graft was dropped and left on the operating room floor for 15 s. Molina et al have shown that a 90-s soak in chlorhexadine gluconate is the most effective method to resterilize the graft
Another report found that a 30-min soak in 4% chlorhexadine followed by a 30-min soak in triple antibiotic solution (gentamicin, clindamycin, polymixin), followed by sterile saline wash was 100% effective in sterilizing contaminated rabbit patellar tendon grafts. In that same study, 10% povidone-iodine was 100% ineffective, as was triple antibiotic soak used in isolation.
A survey of sports medicine specialists found that most would choose cleansing the graft to manage the problem of a dropped graft. Forty-three surveyed surgeons reported having cleansed a contaminated graft and none reported postoperative infections.3
Another option is choosing an alternative graft. This requires preoperative consent from the patient or intraoperative consent from a family member and may be problematic for a patient who expects one graft type but ends up with another. Some surgeons routinely consent their patients for the use of an allograft should the autograph become contaminated or otherwise compromised. Again, if this option is selected, preoperative discussion with the patient is best because cultural or religious beliefs may preclude the use of cadaveric tissue.
Our preference would be cleansing the graft using a 30-min soak in 4% chlorhexadine gluconate followed by lavage with sterile saline, then another 30-min soak in triple antibiotic solution (0.1% gentamicin, 0.1% clindamicin, 0.05% polymyxin) and another sterile saline wash. Washing the chlorhexadine is crucial because chlorhexadine-induced chondrolysis has been reported.4 While this protocol is time consuming, it has solid scientific backing and would allow one to proceed with the same graft as planned preoperatively. One could consider a course of postoperative antibiotics, although we would refrain from this as it would likely only mask an underlying infection, delaying its definitive treatment. In addition, we recommend full disclosure to the patient regarding the incident and the low likelihood of any residual difficulties.
References
1. Molina ME, Nonweiller DE, Evans JA, DeLee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000;16:373-378.
2. Goebel ME, Drez D Jr, Heck SB, Stoma MK. Contaminated rabbit patellar tendon grafts: in vivo analysis of disinfecting methods. Am J Sports Med. 1994;22:387-391.
3. Izquierdo R Jr, Cadet ER, Bauer R, Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21:1348-1353.
4. Van Huyssteen AL, Bracey DJ. Chlorhexadine and chondrolysis in the knee. J Bone Joint Surg Br. 1999;81-B:995-996.
Dr Elias,
In addition to all the measures elaborated by you to prevent the graft from falling, the other protocols which we recommend now is that the surgeon, after harvesting the graft, places it in the basin and then hands over the basin to the scrub nurse on the back trolley, who will then prepare the graft on the back trolley. If one transfers the graft from surgeon's hand directly into the hand of the scrub nurse, the literature shows that the chances of dropping the graft in the space between the operating table and the back trolley are high.
Dear Ezequiel
I think its necessary interrupt ischaemia and keeping a compression in the operative approach associated with copious irrigation with saline solution.
Regards
I wonder how often this unpleasant "accident" occurs in the discussion above. It has never occured to me for 42 years practice. Rapid resterilization with chlorhexadine solution seems to be reasonable option. In similar cases with dropped bone grafts we apply soak in water iodine solutios for a short time. In any case if the one insertion is preserved (which techniques I still prefer) the prepared graft can not fall down on the flour.
That Dr Gupta was a very important question and every surgeons nightmare. In the absence of readily available allograft alternatives, is it wise to take consent for a alternative autograft also? I understand the excellent solutions described above described would take a toll on operative time. So is there a heightened risk of operative complications in the time taken to prepare and resterilise the graft. IS there an option to gamma irradiate or something?
I face this fear every time i remove the femoral head out in a hip where an impaction or structural graft is planned, a veritable nightmare.
Gamma sterilization is not available in many facilities, so I think it would take a lot of time. Chlorhexadine or providone-iodine solutions would be efficient enough.
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