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A Comparison of Five Treatment Protocols for Contaminated Bone Grafts in Reference to Sterility and Cell Viability
Jennifer Bauer, BS1; Raymond W. Liu, MD1; Thomas J. Kean, PhD2; James E. Dennis, PhD2; William Petersilge, MD2; Allison Gilmore, MD1
1 Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, 11100 Euclid Avenue, RBC6081, Cleveland, OH 44106
2 Department of Orthopaedics, Case Western Reserve University, 2109 Adelbert Road, Cleveland, OH 44106
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at University Hospital, Case Western Reserve University, Cleveland, Ohio

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Mar 02;93(5):439-444. doi: 10.2106/JBJS.J.00418
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Occasionally, a bone graft or comminuted fracture fragment is dropped on the operating-room floor and becomes contaminated. The purpose of this study was to determine an optimal method for sterilizing this bone with the minimum sacrifice of cell viability.


A set of discarded bone samples was taken from a series of twenty total knee arthroplasty operations. The bone samples were uniformly contaminated with use of a bacterial broth prepared from culture samples taken from the operating-room floor. The bone samples in each set underwent five different decontamination procedures. Specifically, one sample in each set was autoclaved and four other samples underwent mechanical agitation in normal saline solution, 2% chlorhexidine gluconate, or 10% povidone-iodine (which was either left wet or was dried). Positive and negative controls were used for comparison. Ten sets were then cultured to determine sterility, and ten underwent live/dead trypan blue staining to determine cell viability.


Autoclaving, chlorhexidine gluconate, and dry povidone-iodine sterilized all samples; wet povidone-iodine decontaminated four (40%) of ten samples; and saline solution sterilized none. While all decontamination methods reduced the cell count to some extent, autoclaving and chlorhexidine gluconate left no viable cells. When the cell counts were expressed as a percentage of the control value, dry povidone-iodine sterilization maintained significantly fewer live cells than controls (21%; p < 0.01), whereas saline solution and wet povidone-iodine were not significantly different from controls (77% and 66%; p = 0.40 and p = 0.22, respectively).


Of the easily accessible protocols studied, mechanical agitation and serial washes of bone graft in povidone-iodine that is allowed to dry offers the best balance between complete sterilization of contaminated bone and maintenance of tissue viability.

Clinical Relevance: 

This study provides a recommended practice in the unexpected circumstance of bone contamination. A protocol consisting of five serial fifteen-second soaks with mechanical agitation in 10% povidone-iodine, followed by a fifteen-minute drying period and a saline solution wash, offers effective sterilization while preserving some cell viability. Importantly, the povidone-iodine solution must be allowed to dry to ensure sufficient sterilization.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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