Systematic Review| Volume 30, ISSUE 2, P236-244, February 2014

Management of the Contaminated Anterior Cruciate Ligament Graft


      This systematic review explores management strategies for intraoperative anterior cruciate ligament (ACL) graft contamination.


      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.


      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.


      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Oh Y.
        • Kreinbrink J.
        • Ashton-Miller J.
        • Wojtys E.
        Effect of ACL transection on internal tibial rotation in an in vitro simulated pivot.
        J Bone Joint Surg Am. 2011; 93: 372-380
        • Meyers A.B.
        • Haims A.H.
        • Menn K.
        • Moukaddam H.
        Imaging of anterior cruciate ligament repair and its complications.
        AJR Am J Roentgenol. 2010; 194: 476-484
      1. Wang C, Lee YH, Siebold R. Recommendations for the management of septic arthritis after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. September 6, 2013. [Epub ahead of print.]

        • Torres-Claramunt R.
        • Pelfort X.
        • Erquicia J.
        • et al.
        Knee joint infection after ACL reconstruction: Prevalence, management and functional outcomes.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 2844-2849
        • Hantes M.E.
        • Basdekis G.K.
        • Varitimidis S.E.
        • Giotikas D.
        • Petinaki E.
        • Malizos K.N.
        Autograft contamination during preparation for anterior cruciate ligament reconstruction.
        J Joint Bone Surg Am. 2008; 90: 760-764
        • Maletis G.B.
        • Inacio M.C.
        • Reynolds S.
        • Desmond J.L.
        • Maletis M.M.
        • Funahashi T.T.
        Incidence of postoperative anterior cruciate ligament reconstruction infections: Graft choice makes a difference.
        Am J Sports Med. 2013; 41: 1780-1785
        • Izquierdo Jr., R.
        • Cadet E.R.
        • Bauer R.
        • Stanwood W.
        • Levine W.N.
        • Ahmad C.S.
        A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts.
        Arthroscopy. 2005; 21: 1348-1353
        • Barrett G.R.
        • Luber K.
        • Replogle W.H.
        • Manley J.L.
        Allograft anterior cruciate ligament reconstruction in the young, active patient: Tegner activity level and failure rate.
        Arthroscopy. 2010; 26: 1593-1601
        • Kraeutler M.J.
        • Bravman J.T.
        • McCarty E.C.
        Bone-patellar tendon-bone autograft versus allograft in outcomes of anterior cruciate ligament reconstruction: A meta-analysis of 5182 patients.
        Am J Sports Med. 2013; 41: 2439-2448
        • Molina M.E.
        • Nonweiller D.E.
        • Evans J.A.
        • Delee J.C.
        Contaminated anterior cruciate ligament grafts: The efficacy of 3 sterilization agents.
        Arthroscopy. 2000; 16: 373-378
        • Plante M.J.
        • Li X.
        • Scully G.
        • Brown M.A.
        • Busconi B.D.
        • DeAngelis N.A.
        Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 696-701
        • Burd T.
        • Conroy B.P.
        • Meyer S.C.
        • Allen W.C.
        The effects of chlorhexidine irrigation solution on contaminated bone-tendon allografts.
        Am J Sports Med. 2000; 28: 241-244
        • Cooper D.E.
        • Arnoczky S.P.
        • Warren R.F.
        Contaminated patellar tendon grafts: Incidence of positive cultures and efficacy of an antibiotic solution soak—An in vitro study.
        Arthroscopy. 1991; 7: 272-274
        • Parker R.D.
        • Maschke S.D.
        Mechanical agitation and serial dilution.
        J Knee Surg. 2008; 21: 186-191
        • Stanford R.
        • Solomon M.
        • Levick M.
        • Kohan L.
        • Bell S.
        Sterilization of contaminated bone-tendon autografts using 10% povidone-iodine solution.
        Orthopedics. 1999; 22: 601-604
        • Slim K.
        • Nini E.
        • Forestier D.
        • Kwiatkowski F.
        • Panis Y.
        • Chipponi J.
        Methodological Index for Non-Randomized Studies (MINORS): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Wright J.G.
        • Swiontkowski M.F.
        Introducing a new journal section: Evidence-based orthopaedics.
        J Bone Joint Surg Am. 2000; 82 (editorial): 759-760
        • Bachner E.J.
        • Parker R.D.
        • Dul M.
        • et al.
        Management of contaminated bone-tendon grafts: Incidence of positive cultures and efficacy of three methods of decontamination of ACL grafts.
        Orthop Trans. 1993; 17: 1187-1188
        • Pasque C.B.
        • Geib T.M.
        Intraoperative anterior cruciate ligament graft contamination.
        Arthroscopy. 2007; 23: 329-331
        • Goebel M.E.
        • Drez Jr., D.
        • Heck S.B.
        • Stoma M.K.
        Contaminated rabbit patellar tendon grafts. In vivo analysis of disinfecting methods.
        Am J Sports Med. 1994; 22: 387-391
        • Alomar A.Z.
        • Gawri R.
        • Roughley P.J.
        • Haglund L.
        • Burman M.
        The effects of chlorhexidine graft decontamination on tendon graft collagen and cell viability.
        Am J Sports Med. 2012; 40: 1646-1653
        • Han Y.
        • Giannitsios D.
        • Duke K.
        • Steffen T.
        • Burman M.
        Biomechanical analysis of chlorhexidine power irrigation to disinfect contaminated anterior cruciate ligament grafts.
        Am J Sports Med. 2011; 39: 1528-1533