So the subtitle is, oh shit, I'm going to kill the resident. So this is what I'll talk about in the next three to five minutes, disclosures, case examples, how I resolved this. I'll base this on a case example that I had. I think for this session, it's a great quote. Many of you already heard it, but for complication sessions by Jack Houston, good judgment is based on experience, and experience is based on bad judgment. My disclosures, no financial disclosures, I'm 67 years old and I stopped elective surgical practice in August, 35 years in academic medicine, educating, training many residents, fellows, and practicing orthopedists. I have had three drop graphs in my operative career and many close calls. How many people here have had a drop graph? Come on, that's up. How many had close calls? Okay. Here is my drop graph history. Yes, you read correctly, that says Gore-Tex. When I came back from my fellowship, I worked at the VA hospital. Gore-Tex worked great in the old vets, by the way, and the graph was dropped during graph passage. In 1998, at the University Hospital, BTB allograft was dropped on transfer. Now, there's a message, an important message that I want to leave you with there. And in 2003, at the University Hospital, hamstring autograft was dropped by the graph master during the graph transfer. Case one and two are not a problem, just get another graph. So this will be a case presentation of number three here. So 29-year-old male, ACL reconstruction with four-stranded hamstring autograph, or choose any graph you want, quad tendon, BTB, et cetera. The graph was prepped on a separate table and a button, number two, non-absorbable. There it is, a picture of it. And here it is. That's me attending, and you can see the resident. Graph is dropped during transfer to the patient. And so what are the intraoperative decisions and management that we go through? So I'll take you through that. Here are the options. If you drop an autograft, harvest another graph, use allograft, or retain the current autograph, and take it through a decontamination, I put sterilization in quotes because it's never truly sterilized unless you put it in an autoclave, and we all know what happened then. So it's a decontamination process. So you can autoclave it, not going to work, right? Kills everything, including the collagen. Antibiotic rinse protocol is what I chose to do, and this is actually what's been supported in the literature. Rick Parker was where I first learned this in the late 1990s. Most common bacteria staff, aureus, and then bacilli is second, and if you look in the literature, there's been a lot of studies on this. And again, the current literature does support serial rinsing and antibiotic rinsing of the graft. The antibiotic solutions do vary. I'll have a few comments on that, but you must weigh with the solution you choose both the decontamination as well as the cytotoxicity. Some of these things kill everything. So the steps taken, the first thing I did was break scrub and talk to the family. This is what happened. This is what I would recommend, and we proceed from there. On the original graft table, obtain cultures, both swab and some tissue, send that off. Rinse with antibiotic solution. I prefer vancomycin and polymyxin, and I'll explain a couple of why, and remove all foreign graft material from whatever graft you have on the original prep table. Set up a new graft table. Go through mechanical agitation and serial washes and sterile basins, and it's usually about five of those. And here's what I choose. I can't, we aren't going to have time to talk about all the different rinses, but I like vancomycin, gram-positive, polymyxin, gram-negative. Both have low cytotoxicity, not only to the graft and the graft cells, but also to articular cartilage, synovium, et cetera. Chlorhexidine and iodine kill everything, but they're highly toxic, so I would not recommend using those. And that's in the literature, but the cytotoxicity and the clinical outcomes isn't quite as clear. So I prefer polymyxin and vancomycin. On the final graft reprep, prepare on a separate table. Suture and fixation materials placed, and as you go to pass the graft, consider different fixation devices. You may need that. Interference screws may not work. I don't use those, but I would choose here, with this hamstring, a post-fixation, suspensuous fixation with an endobutton and an AL screw. Postoperative management, consult infectious disease right away for postoperative antibiotic management. I would recommend at least two weeks of a broad-spectrum antibiotic, again, recommended by infectious disease. Check the cultures. You can consider using lab studies of CRP and SED rate, but they can be very deceiving. Even in normal needs for the first month, you can have elevated CRP and ESR. Follow the patient more closely. I think this is really important. Follow that patient every week. Don't see him at a week and then at a month and three months. Follow him much more closely, because these can be very subtle findings that are early infections. Go more slowly on your post-op rehab. Remember, this is not a normal graft. To protect the graft for longer, because from higher forces earlier, remember, ligamentization of a human graft is somewhere between six and nine months. It may be delayed in this case, so consider slowing your rehab down. Clinical signs of infection are the most important thing to me, and that's usually these three. Loss of motion, they don't get their motion. They're slow. They have persistent swelling and persistent pain. Redness, fever, and even drainage can be deceiving. Don't use those as your primary clinical markers. Continue to have ID follow you, with you. Have a high degree of suspicion that there is an infection post-op, and always err on the side of over-aggressive treatment. And finally, retaining the graft, if clinical signs of infection, develop plan on removing the graft and not retaining. When I have a primary graft infection, which I got about every other year, I would often do serial INDs and keep the graft. I wouldn't do it here. I would just take the graft out. And what did I learn since 2003? I learned I always have an assistant, usually me, hold both hands under the graft during the transfer. My line is, just assume the graft will be dropped, and you are there to catch it. Thank you, and kudos to the program committee for having this session on complications. Thank you.

surgeon

dropping grafts

managing dropped autografts

antibiotic solutions

postoperative follow-up