SLR - April 2021 - Gavin G. Tsuchida

Contamination and Decontamination of Autologous Bone in the Operating Room: A Systematic Review

Reference: Mortazavi SMJ, Ghasemi MA, Khan FMY, Zarei M, Shahabinezhad A. Contamination and Decontamination of Autologous Bone in the Operating Room: A Systematic Review. J Orthop Trauma. 2021 Feb 1;35(2):65-70. 

Level of Evidence: Therapeutic Level IV

Scientific Literature Review

Reviewed By: Gavin G. Tsuchida, DPM
Residency Program: New York Presbyterian Queens – Flushing, NY

Podiatric Relevance: An unfortunate complication in podiatric surgery is accidently dropping a necessary bone fragment on the operating room floor. However, there does not appear to be a consensus on a protocol for decontamination. This systematic literature review focused on finding the rate of decontamination, microbial profile, and evaluate the effectiveness and residual cellular viability of different decontamination techniques. 

Methods: A systematic literature review was performed by the authors. Using PRISMA guidelines, articles studying the contamination of host bone fragments, rates of autologous bone contamination in the operating room, microbial analysis of contaminated bone autograft, and outcome of and cellular viability after decontamination were included. Studies including soft tissue contamination, bone allograft, commentaries/questionnaires, or non-English were excluded. This resulted in a total of six studies being included. The authors then analyzed each study with regards to rate of contamination, microbial profile, decontamination method, and cellular viability of the graft post decontamination.

Results:
1. Rate & Means of Contamination: The rate of bone graft contamination was found to be 0-70 percent, In five out of the six studies the bone fragment was contaminated by dropping it on the operating room floor. One study was done by creating a bacterial broth from cultures from the operating room floor.
2. Microbial Profile: Five out of six studies reported microbial profiles with the most common organism being S. epidermidis, Bacillus, E. coli. In one study all organisms were contaminated with S. epidermidis because it was found to be the most common organism on the operating room floor
3. Decontamination: Autoclave, chlorhexidine gluconate solution, mechanical scrubbing with saline irrigation, 10 percent povidone-iodine solution with or without saline irrigation were all 100 percent effective.
4. Cellular Viability: Two out of six studies had data on cellular viability after decontamination procedures. Out of the 100 percent effective methods, in order of most to least toxic:
a. Autoclave or Chlorhexidine Gluconate solution (0-3 percent cellular viability)
b. Mechanical Scrub with Saline (18 percent viability)
c. 10% povidone-iodine solution & let dry (21 percent viability) or irrigate with saline (51 percent viability)

Conclusions: In this review, the rate of contamination of host bone grafts dropped on the operating room floor was found to be 0-70 percent with the most common bacteria being S. epidermidis. Various decontamination procedures were evaluated, and it is suggested based on this review that a 5-10 min. bath in 10 percent povidone-iodine solution and then a one min. irrigation with normal saline was the optimal method since it was both effective and retained significant cellular viability of the host bone graft. A few limitations to the study include no correlation with clinical outcomes and the sparsity of data available. However, for a likely underreported complication, this review provides evidence for an effective decontamination protocol if such a situation were to occur. 

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