A Study of the Clinical Incidence of Infection in the Use of Banked Allograft Bone

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1981;63:244-248.J Bone Joint Surg Am.WW Tomford, RJ Starkweather and MH Goldman allograft boneA study of the clinical incidence of infection in the use of banked

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C opyrtgh l 981 by The Journa l o f Bone and Jo in t Surge ry. Incorpora ted

24 4 TH E JOURNAL OF BON E AND JO INT SURGERY

A S tudy o f th e C lin ica l In cid en ce o f In fect ionin th e U se o f B anked A llo gra ft B one*

BY W . W . TOM FORD , M .D .t, R . J . S TA RKW EATH ER , M .D 4 , AND M . H . GO LDMAN , M .D . BETH ESDA , M ARYLANDFro tn the C lin ica l In ves tiga tio n D ep ar tm en t. N a va l M ed ic-a l R e sea rch In stitu te , B ethesda , M ary lan d

ABSTRACT : To determ ine th e in cid ence of in fectionin grafting procedures u tiliz ing banked allo graft bone ,56 7 questionna ires w ere sen t to co llabo rating surgeon sw ho used Navy T issue B ank freeze-d r ied a llo graft bonefrom O ctober 1973 to O ctober 1976 . T hree hundredand three ques tionna ires w ere su fficien tly com p le ted tobe in c luded in th e study . Tw en ty-one pa tien ts w ere re -ported a s show ing ev id ence of in fection , o f w h ichtw e lve w ere con sid ered m inor and n in e w ere con sid -ered m a jor accord ing to th e effec t on th e pa tien tspos toperative course . In e lev en of th e tw en ty-one pa-tien ts th ere w ere posit ive cu ltu res as p roo f o f in fection ;in th e rem ain ing ten there w ere no t. A na lysis o f theproved in fec tion s show ed that th e a llogra ft w as prob -ab ly no t p rim arily respon sib le in m ost o f th e patien ts.B a sed on the data ob ta in ed in th is study , th e in cid enceo f in fec tion w ith th e u se of banked a llogenou s bone ap -pears to com pare favorab ly w ith in fection rates re -ported fo r orthopaed ic p rocedures u tiliz ing au togenou sbone .

O rth op aed ic dem and fo r a llog ra ft bon e h as beenstead ily inc rea sin g o ve r the past sev era l yea rs . T he N avyT issu e B ank , w h ich has a ttem p ted to m ee t th is dem and ,h as n o ted th at su rgeon s ap p licatio ns h ave broadened fromben ig n cystic le sions7 to frac tu re m a lun ions and non-un ions3 , la rg e segm en ta l de fec ts , and w ho le-bon ea llog ra f ts fo r tum or su rge ry 6 . Long -te rm ev alu atio n ofthese g raf ts has b een an im portan t pa rt o f the T issueB ank s ro le in the m ed ica l comm unity , and stud ies o f th ep hys ica l and chem ica l su itab ility o f the tissues h av e beenin itia ted in term itten tly 2 4 . H ow eve r , n o de te rm in a tion o fth e inc idence of in fec tion fo llow ing th e use o f p rocessedand s to red a llo g raf t bo ne has b een p erfo rm ed . F o r th isrea so n , a re tro spectiv e study of the re su lts o f g ra f ting p ro -cedure s us in g N avy T issu e B ank allo g raf t bon e w as ins ti-tu ted , an d th e fin d ing s a re repo rted he re .

* Th is w ork w as su ppo rte d by the N av al M edical R ese arch and D c -v elo pm ent C omm and , W ork Un it N o. M 0095 -PN .00 l.0 003 . T he o pin -ions or as ser tion s con tained he rein a re the p riva te one s o f the au th ors andare no t to b e cons trued as o ffic ia l o r reflect ing th e v iew s of the U .S . N avyD ep artm en t or the n ava l serv ice at la rge .

1 D ep artm en t of O rthop aed ic Su rge ry . M assa chu set ts G eneralH osp ita l, B os ton , M assa chu setts 0 2 1 14 .

W ena tch ee V a lley C lin ic , W enatch ee, W ash ing to n 98801 . D ivisio n o f T ransp lan t Su rge ry , U n ive rsity of V irg in ia M ed icalC en ter , R ichm ond , V ir g in ia 23298 .

M ater ia ls and M ethod sU nited S tate s N avy T issue B ank tissu es are p ro cu red

from dono rs w ho m ee t the stand ard c rite ria fo r tissue co l-lectio n rep orted p rev iou sly . Bon es co llected u nde r ste rileco nd itio ns a re cleaned of a ll so f t tissue . F o r c rushed org ro und bone , long itud in al sectio ns a re cu t from th e sha ftand then processed in to p ieces tw o to fou r cub ic m ilh im e-te rs in size. C o rtica l p la te s o r str ip s a re cu t in to fif te en -cen tim e te r leng th s. Lo ng bones a re le ft w ho le o r a re d i-v id ed a t m id -sh a ft. A ll tis sue is s to red in liqu id -n itrog enfreezers (- 196 d eg rees C e lsiu s) to aw a it re su lts fromae ro b ic and anae rob ic to uch cu ltu re s m ade o f all depositsd u rin g p ro cu rem en t and p ro cess in g . If cu ltu re s are n ega -tive , the tissu e is freeze -d ried to le ss than ten m icrom ete rso f vapo r p re ssu re an d s to red a t room tem peratu re inevacua ted bo ttle s .

A s m any as 10 per cen t o f cu ltu res o f a ll tissues p ro -cessed in the T is sue B ank a re p ositive a fte r b ein g h eld fo rtw en ty -one days. A ppro x im ate ly 90 per cen t o f th e pos i-tiv e cu ltu re s g row e ithe r Co rynebac te rium acnes orS ta ph ylo coc cus e p id erm id is. The rem ain ing 1 0 p er cen tgrow e ith er n on-hem o ly tic S trep to co ccu s, o r , rare ly ,S tap hy lococcus aureus ( les s than 2 pe r cen t). A ny tis suetha t has a po sitive cu ltu re is con side red con tam ina ted andis irrad ia ted . In th is s tu dy , few e r than 5 pe r cen t o f th ea llog ra fts requ ired irrad ia tion . T hese a llog ra f ts w ere cu l-tu red afte r ir rad iatio n and a ll cu ltu re s w ere nega tive .

Q u estio nna ires w ere sen t to 567 co llab o ra tin g su r-geon s w ho used N avy T is sue B ank bone d uring the p eriodO ctob er 1973 to O ctob er 1 976 . T he qu es tionna ire con-sis ted o f a h is to ry o f the p a tien ts g ra fting proced ure an dreq uested rem arks rega rd ing an y com p lica tion s tha t en -sued tha t po ssib ly w ere rela ted to in fec tion . O f the 567qu es tionn aire s m a iled , 31 3 (5 5 pe r cen t) w ere retu rn ed ,w ith 303 of the 3 1 3 com ple ted su ff ic ien tly to be used tocom pile d a ta. N o case w as in clu ded tha t d id no t have a tlea st an e igh teen -m on th fo llow -up . T he d iagn oses, p roce -du re s pe rfo rm ed , an d types o f g ra fts used in the 30 3 p a-tien ts a re lis ted in T ab le s I, II , and III, re spec tive ly .

ResultsTw enty -on e (6 .9 p er cen t) o f th e 303 com ple ted

question na ire s rep orted ev iden ce of in fec tion in the pa -tien ts pos to pera tiv e co urse ; the rem ain ing 2 82 reported no


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CLIN ICAL INCIDENCE OF INFECTION IN THE U SE OF BANKED ALLOGRAFT BONE 24 5

V O L . 63-A , N O . 2, FEBRUARY 1981

ev idence of this complication. O f necess ity , ev idence o finfec tion w as determ ined by the reporting surgeon becausethe patients could no t be personally evaluated by us. Casesrepo rted as infec tion inc luded complications o f w ound-healing such as erythema and delayed epithehializatio n(w ith o r w ithout w ound drainage ) , and w ound drainagealone . From information rece ived from the respondingsurg eons, the tw enty -one patients could be div ided intotw o groups on the bas is o f the effec t o f the complicatio n onthe postoperative course . Cases c lassified as show ing ev i-dence of m inor infectio n invo lv ed complications produc-ing little o r no e ffect on the patients reco very ; tho seclassif ied as show ing ev idence of majo r infec tion eitherrequired reoperation or inv o lved a chronic complication.These tw o g roups are listed in Table s IV and V and w ereanalyz ed se parate ly .

The minor infections (Table IV ), in tw elve patients,

TABLE I

D I A G N O S E S

LesionNo . o fPatients

CystsU nicameral I 17Aneurysmal 19Si mp l e 6Mandibular 14Rheumato id 1

T u m o r sMalignant l6B e ni g n 4 8

F ibro us d ys plas ia 27Fracture 20Sp i n e f u s i o n 1 8M an di bu lar re co ns tru cti on 4Limb-leng th discrepancy 4C on ge ni ta l p se ud arth ro si s 3Realignment os teo tomy 2Osteonecrosis IOsteopetro sis 1I l i a c d ef e c t 1S te rile ab sc es s 1

o ccurred chief ly in benign cy sts or fusio ns. There w ereseven benign bone cy sts , tw o tumors (chondrosarcoma andg iant-ce ll tumor), one non-union after a lengthening of thetibia, o ne spine fusion for cong enital s cohios is , and onemax illary osteo tomy for max illary recons truc tio n. Thetypes o f bone graft used inc luded crushed or g round bone(Cases 1 through 8), a combinatio n of crushed or cance l-bus bone w ith cortical bone (Cases 9 , 1 1 , and 12), andcortical bone alone (Case 10) . Pro cedures in this groupconsisted mainly o f cure ttag e and packing o f the les ion(Cases 1 through 8 ). One procedure (Case 9 ) utiliz ed enbloc exc ision o f a larg e po rtio n of bone, and the remainingthree (Cases 10 , 1 1 , and 12 ) utiliz ed onlay grafts for fu-sion .

N o serious complications resulted in the first group ofpatients (Table IV ). Only one inc ision (Case 4) did not

heal prim arily . W ound drainage w as noted in three pa-tients (Cases 2 , 4 , and 9), but each o f these responded to ashort-term course o f o ral antibio tics . N o procedure in thisgroup produced chronic drainage , none required intrave-nous antibio tic therapy , none necess itated removal o f thegraft because o f infec tion, and none resulted in os-teomyel i t is .

The group of majo r infections (Table V ), in nine pa-tients, w as different in sev eral aspects from the firs t group.D iagnostically , mo st o f these patients had tumors (Cases14 through 17) or traumatic w ounds (Cases 18 , 19 , and20). The tumors inc luded tw o malignant les ions (os-teog enic sarcomas) and tw o potentially malignant les io ns(g iant-ce ll tumors of the prox imal end o f the tibia). Thethree fracture non-unions had been operated on at leasttw ice prev iously , and all three had been infec ted (os-teomyehitis) at som e time prior to implantation o f the

TA BLE IIP R O C E D U R E S

Pro cedure N o.

Cure ttage and pack 22 9O nlay g rafts 49Whole or partial bo ne replac em ent 25

TABLE I I I

ALLOGRAFTS

T y p e N o .

Crushed cortical 18 3G ro un d c anc ello us 15Cortical strips 26Ilium strips 1 7Combination 37Whole b o n e 25

allog raft. The tw o remaining patients had a unicameralbone cyst (Case 1 3) and a cong enital pseudarthro sis o f thetibia (Case 21) . The unicam eral bone cyst had not beenoperated on prev iously . The cong enital pseudarthrosis hadbeen g rafted once w ith auto genous bone , unsucces sfully ,nine months prior to the use of the allog raft.

Grafts used in the second group inc luded more corti-cal bone than in the firs t group. Each of the tumor resec-tions necessitated the use o f a large piece o f cortical boneand in three (Cases 14 , 15, and 17) this ty pe of graft w asused ex clusive ly . The operatio ns fo r fracture non-union(Cases 18 , 19 , and 20) as w e ll as fo r the cong enitalpseudarthros is (Case 2 1) also utilized co rtical bone . Theunicameral bone cyst (Case 13) w as grafted w ith crushedcortical and co rticocance llous bone .

The pro cedures performed in the second group in-vo lved more extensiv e surgery than in the firs t group.Three o f the tumor resections (Cases 14 , 15, and 17) re-quired extensiv e ex cis ion of both so ft tissue and bone . Thefrac ture non-unions (Cases 18 , 19 , and 20) required w ideexposure because of prev ious infec tio n. The tibialpseudarthro sis (Case 2 1 ) required ex tensive dissec tion to


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24 6 W. W . TOMFORD , R . J. STARKWEATHER, A ND M. H. GOLDMAN

THE JOURNAL OF B O N E A N D JO IN T S U R G E R Y

T A B L E I VP A T I E N T S W IT H E V IDE N C E O F M IN O R IN FE C T IO N

Case Diagnosis Procedure A llog raft Complicatio n Cultured Result Organism Treatment ResultI Mandibular cyst Cure ttag e and pack Ground cancel lous Lo calized wound

erythemaYes Po s. N o t l isted 10 days of oral antibiot. W ound healed

primarily2 N on.ossify ing Cure ttag e and pack Crushed co rtical D rainage at 4th day Yes Po s. N o t l isted 10 days of oral antibiot. W ound healed

fibroma primarily3 U nicameral Curettage and pack Crushed cortical Localized wound No - - - W ound healedbone cyst erythema primarily4 Mandibular cy st Cure ttage and pack Ground cancel lous D rainage at 5 th day Yes Po s. N o t l isted W ound incised and drained;

10 day s o f o ral anti bio t.W ound healed

secondarily5 S imple bone Cure ttag e and pack Crushed co rtical Lo calized w ound N o - - - Wound healed

cyst erythema primarily6 Mandibular cy st Cure ttage and pack Ground cancello us Localized wound

erythemaNo - - - W ou n d h ea led

primarily7 U nicameral Cure ttage and pack Crushed cortical Lo calized wound No - - - W ou n d h ea led

bone cyst erythema primarily8 G ia n t -c ell tumor Curettage and pack Crushed cortical Lo calized wound


primarily9 Chondrosarcoma Partial bone

replacementF em oral c on dy le Drainage at 4 th day Yes Po s. Enterobacte r

species1 0 day s of oral antibio t. W ound healed

primarily10 N on-union of limb- Onlay graft Cortical strip Lo calized wound No - - - W ou n d h ea led

leng thening ery thema primarilyI I Congen. sco lio sis Onlay g raft Rib matchsticks ,

c ru sh ed c on ic alLocaliz ed w ound


primarily12 Crouzons syndrome Onlay g raft Rib segment.ilium strip

Localiz ed w ounderythema

Yes Po s. N o t l isted 10 days of oral antibiot. W ound healedprimarily

allow placement of the nine-centimeter fibular-shaftailograft.

A ll nine patients in the second g roup had w ounddrainage po stoperativ e ly , and each had a culture . Thecharac ter o f the drainag e w as no t described by any of thereporting surgeons. O f nine cultures, three (Cases 14 , 17 ,and 19 ) show ed no grow th. The remaining six culturesw ere po sitive . The organisms w ere no t nam ed in three o fthese (Cases 16 , 1 8 , and 20), but the o ther three greweither Staphylococcus epidermidis (Case 1 3) orStaphylococcus auerus (Case 21) , o r bo th (Case 15) . A n-tibio tics w ere used in the treatment o f f ive patients (Cases15, 16 , 1 8 , 20 , and 21).

Complicatio ns ensued in all patients show ing ev i-dence o f major infectio n that w ere not no ted in patientsshow ing ev idence o f m inor infectio n. The unicameralbone cy st (Case 13 ) drained for s ix months and thenc leared w ithout antibio tic therapy . In each of the patientsw ith tumors , drainage deve loped during the pos toperativ ecourse . One patient (Case 14) had drainag e fo r six monthsand union w as delayed. One patient (Case 17) beg an tohave drainage at one w eek po stoperativ ely ; the w oundseparated at tw o w eeks , and the g raft w as removed at threew eeks. The graft w as removed in another patient w ith atumor (Case 16 ) after one w eek, and in another (Case 15)drainage dev e loped eight months postoperative ly , after apro longed course o f irradiation and chemo therapy beforeand after surgery . O f the three frac ture non-unions , oneallograft (Case 1 8) w as removed at tw o w eeks and one , atfo ur months (Case 2 0) , bo th secondary to re infectio n. Thethird frac ture non-union (Case 1 9) drained minimally forseveral m onths and then the infectio n c leared w ithout an-tibio tic s . In the patient w ith a cong enital pseudarthro sis(Case 2 1 ), drainag e began sho rtly after surgery , but cul-

tures w ere negative until s ix months postoperative ly w hena culture w as positive for Staphylococcus aureus.A lthough the g raft reso rbed and there w as no ev idence ofhealing o f the pseudarthro sis , the infectio n c leared w ithantibio tic therapy .

Discus s i onTw enty-one patients w ith ev idence of infec tion out of

303 surg ical pro cedures emplo y ing banked bone ahlo graftsis a 6 .9 per cent inc idence o f infec tio n. N o o ther studies o fthe inc idence o f clinical infec tion fo llow ing the use o fbanked bone hav e been reported. Cruse reported an infec -tion rate o f 2 .7 per cent in 372 patients after bone biopsyand exc isio n of a le sion, and a 3 .9 per cent incidence ofinfection in the donor site in 98 6 patients w ho had auto-grafting

The 6 .9 per cent infectio n rate in our study , comparedw ith C ruses report, implies that the risk of infec tio n w iththe use o f allog raft bone is approx imate ly double that w ithautog raft bone . How ever, many o f the complications re -ported by the responding surgeons as ev idence of infec tio n- ery thema, de layed epithe lialization, and drainage -are no t necessarily pro of o f infec tion. These phenomenao ccur in the presence of devascularized tis sue w ithoutbac terial contam ination. There fo re , the inc idence based onall repo rted infec tio ns may not accurately reflect the truerisk of infectio n. The ev idence in each case must be ex am -med to determ ine if an infectio n proved by bac terial con-tam inatio n occurred, and if the allo graft can be implicatedas the source of the contam inatio n.

Elev en patients had a po sitive culture: five w ith ev i-dence of a m ino r infec tion and six w ith ev idence of amajo r infec tion. Fo r four of the fiv e w ith positive culturesin the fo rmer g roup (Cases I , 2 , 4 , and 12 ) the org anism


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CLIN ICAL INCIDENCE OF INFECTION IN THE U SE OF BANKED ALLOGRAFT BONE 24 7

VOL. 63 -A , NO . 2 . FEBRUARY 1981

T ABLE VPATIEN TS W ITH E v I D E N C E O F M A J OR I NF E c rI oN

Case D iagnosis Procedure A llog raft Complicatio n Cultured Result Organism Treatment Result

13 U nicameralbone cyst

Curettage and pack Ilium strip,c ru sh ed c on ic al

Drainage at 4 th day Y es P os . Staph.epidermidis

Dry dressing , no antibiot. D rained for 6 mos.,th en c le are d

14 Giant-cell tumor Who le bone Prox. end o f tib iainc luding 10 cmo f s haf t

D rainag e at 5 th day Yes N eg. N o g row th D ry dres sing , no antibio t. D rained fo r 6 m os .,th en c le are d;de lay ed uni on

15 Osteo genicsarcoma

Who le bone D istal end o f femurincluding 12 cmo f s haf t

D rainage at 8 mos. Y es Pos . Stap h. aur e-u s. St ap h.epidermidis

Dry dressing . lo ng-term oral antibiot. D rainage continuedat 1 8 mos.;de lay ed uni on

16 Giant-cel l tumor Curettage and pack C orti cal p late ,crushed conica l

Drainage a t 4 t h day Yes Pos. N o t lis ted Graft remov ed at 1 w k.; 10 day s o fI V /o ra l a nti bi ot.

Wound healedsecondarily

17 Osteo genics a r c om a

Whole bone Mid-femoral shaft D rainag e at 7 th day ;w ou nd sep ar at ion

Yes N eg. N o grow th Graft remov ed at 3 w ks. ; n o a nt ib io t. W ound healeds e conda r i l y

18 Fracturenon-union

Onlay graft Fibular shaft,crushed cortical

D rainage at 5th day Yes Pos . Not listed Graft remov ed at 2 wks.; 10 day s ofo ra l a nt ib io t.

W ound healedsecondarily

19 Frac turen o n - u n i o n

Onlay graft Conical plate D rainag e at 1 0 th day Y es N eg . N o g row th D ry dress ing , no antibio t. Spot drained fo rseve r al m on th s,t h en c l ea r e d

20 Frac turenon-union

Onlay graft Conical plate D rainage at 4 mos. Y e s Po s. N ot listed Graft removed at 4 mos. ; 6 wks. of IVantibiot.

Wound healedsecondarily

21 C on gen . tibialpseudarthrosis

Onlay graft Fibular shaft D rainag e at 7 th day Y es Po s. St ap h. a ur eu s 10 days o f oral antibiot. A sep tic d ra in agefo r 6 mo s. , thencultured Staph.aureus

w as no t listed; each of these four patients w as treated w ithantibio tic s . For the fifth patient (Case 9 ) the o rg anism w aslisted and the patient required inc ision and drainage asw ell as antibio tic treatment. For three of the six patientsw ith positive cultures from the group w ith ev idence of amajor infec tio n (Cases 16 , 18 , and 20), the organism w asnot listed, but in each o f the three the g raft w as removedand antibio tic treatment w as used. For the remaining threepatients in this group (Cases 13 , 15, and 21), the o rg anismw as listed.

The remaining ten patients did no t have positive cul-tures. Seven patients (Cases 3 , 5 through 8 , 10 , and 1 1)w ere no ted to have w ound ery thema w ithout drainage . N oculture w as grow n and no antibio tic s w ere used in any ofthese patients . A ll w ounds healed primarily . The three re -maining patients (Cases 14 , 1 7 , and 19) had negative cul-tures. Each of these had drainage from the w ound, butnone w ere treated w ih antibio tics . In Cases 14 and 19 ,drainage continued for several m onths and then c leared.The drainage fluid w as cultured periodically but nev ergrew an o rganism . In Case 17 , the w ound separated sev-eral day s postoperative ly and the graft w as removed butnot cultured. M aterial from the w ound w as negative onculture , and the w ound healed w ithout further comphica-tions and w ithout the use o f antibio tic s .

A positive w ound culture do es not prov ide ev idenceof the source of the infectio n. Fac to rs apart from allograftimplantation - such as ex tensive surg ical dissectio n, ex -cessiv e operative time , or contam inated instruments orpersonnel - may produce o r contribute to bacterial con-tam inatio n. One method o f ev aluating the ro le o f theallograft in the ev ent of a po stoperative w ound infec tion isto culture the allograft prio r to implantatio n. In the pro-cessing of tissues at the N avy Tissue B ank, touch culturesare grow n just prio r to freeze-dry ing and vacuum-packing

the tissue. In addition, as a final check on the sterility o fthe tissue , the N avy Tissue Bank recommends that the co l-labo rating surg eon culture the allograft immediate ly priort o impl an ta ti o n.

Of e leven patients w ith po sitive postoperative cul-tures , o nly one (Case 1 3) w as reported to show a sim ilarorg anism on culture preoperative ly and po stoperative ly .Culture o f the tissue used in that patient w as negative prio rto shipment from the N avy Tissue Bank, and the tissuew as not irradiated. The contam inating organism may havebeen missed by the final touch culture at the Tissue Bank,or the tissue may have been contam inated at the time ofremoval from the g lass storag e container. The results o fthe preoperative culture (o r even if one w as performed)w ere not reported fo r any of the ten remaining patientsw ith pos itiv e cultures.

Of the five patients show ing ev idence of m inor infec -tio n w ho had a po sitive culture , three (C ases 2 , 4 , and 9)had postoperative drainage . The surg ical inc is ions healedprimarily , how ever, and there w as no ev idence of os-teomyelitis at any time in the pos toperativ e course . For theother tw o patients in this g roup (Cases 1 and 12), w ounderythema w as lis ted as the ev idence for infec tion. In eachof these f ive patients , the repo rted info rmation suggested asuperfic ial infec tion that w as unlike ly to be due to a con-tam inated graft, although this cannot be proved.

Ofthe patients (o ther than Case 1 3) show ing ev idenceof major infec tion w ho had pos itive cultures , tw o (Cases18 and 20) w ere know n to have had a prev ious infec tion.The graft may have been respons ible fo r the re infec tion,but it is more like ly thatthe orig inal infection recurred. Intw o patients, infec tions occurred only at several monthsafter the surg ical pro cedure . In one o f them (Case 15) aninfec ted draining sinus deve loped after e ig ht months o fchemotherapy . The graft cannot be e lim inated as a source


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24 8 W . W . TOMFORD , R . J. STARKWEATHER, A ND M. H. GOLDMAN

THE JOURNAL OF BONE AND JOIN T SURGERY

of infec tion in that patient, but the suppres sive e ffec t o fchemotherapy on the immune sys tem should be consideredas a fac to r in the e tio log y of the infec ted drainag e . Thesecond patient (Case 2 1 ) had aseptic drainag e from thesurg ical site for six months be fo re the cultures becamepos itiv e . A lthough impossible to prove , this sugg es ts thatthe drainage became infec ted from an exogenous sourcerather than from the g raft. In the remaining patient in thisgroup (Case 1 6) , the allog raft w as remov ed at one w eek,the patient w as treated w ith antibio tic s , and the w oundhealed satis fac torily . N o repo rt w as available on a cultureo f the allog raft be fore o r after surg ery .

Of all the cases analyzed, the g raft appears to be astrong candidate for the source o f infec tion in only one pa-tient (Case 13 ). In one additional patient (Case 16 ) thegraft w as a possible source , although reports o f culturesbe fore surgery w ere not av ailable. Info rmation prov idedfo r the other nine patients sugg ested that the allog raft m aynot have been a primary fac to r in the infec tion. Thisanalysis cannot be interpreted as prov ing the innocence o fthe grafts , but it does emphas ize the necessity fo r care fulsurg ical techniques and prophy lac tic measures w hen em-plo y ing an ahlograft. The use of preoperative antibio tic s ,fo r example , w hich w as not examined in this study , m ightbe a valuable adjunct. Many of these procedures inv o lveex tensiv e dissec tion fo r tumors, or d#{ 233 } bridement w ith pre-

v io usly infected fractures, and these facto rs are importantin the deve lopment o f infec tion in any patient undergo ingsurgery . W hen combined w ith the implantation of a largepiece o f dead bone, prev entive measures w ould seem to beparticularly im portant.

In this analysis o f the tw enty -one patients reported ashav ing an infec tion, the incidence o f infec tion varies ac -cording to w hich cases are included and which are no t. Ifo nly patients in w hom the ahlograft cultured positiv ely be -fore and after the pro cedure are included, the inc idence isle ss than I per cent. If o nly patients w ith prov ed po st-o perative infec tion are inc luded, the inc idence is 3 .6 percent. If all patients w ho w ere repo rted to have an infec tionare inc luded, the inc idence is 6 .9 per cent. Perhaps thebest interpretation of the data is that the inc idence does no tappear to be greater than 7 per cent and probably is low er.The advantages o f the use o f a banked allog raft - de -creased operative time and avo idance o f po stoperative painand complications such as bleeding or infec tion as soc iatedw ith a second operativ e site - still are w orthy o f consid-eration. The indiv idual surgeon tog e ther w ith the patientmust dec ide if the risk of using allog raft bone is accept-able . W e hope that this study w ill m ake that dec isio neasier.

NoTE: T h e a u t h o r s w ish t o t h a n k M r . V er n o n G am bt t l fo r h is v a lu ab le asst st an ce in t h estudy.

Re f e r e n c e sI. B R IG H T . R . W .: D ecis ion M ak in g in T issu e Pr ocu r em en t . T r an sp l. P r o c., S ( S u p p l em en t 1): 17 3-179 , 1976 .2. B R IG H T . R . W ., a n d B UR S T E I N . A . H .: M ech an ica l Pr op e r t ies o f P r e se r v ed C or t ica l B on e . T r an s . O r t h op . R e s. Soc. , 3: 21 1 . 1978 .3. C R U S E . P. J. E.: lncidence of W ound Infection on the S urg ical Se rv ic es. Surg . Clin. N orth America. 5 5: 1 269 -12 75 . 197 5 .4. F R I E D L A E N D E R . G. E.; S T R O N G , D . M .; and SELL, K. W .: S tudie s on the A ntigenicity ofB one. I. Freez e-D ried and D eep-Fro zen Bone A llografts

in Rabbits. J. B one and Jo int S u r g . , 58-A: 854-85 8, Sept. 1 976 .5. M CM A S T E R , P . E .. an d H O H L , M A S O N : T ib io f ib u lar C r oss-P eg G r a f t in g . J. B one and Joint Surg ., 57 -A : 720-721 , J u ly 19 75 .6. M A N K I N . H. J.; FOGELSON, R. S .; T H R A S H E R . A . Z .; an d J A F FE R . FA R OO Q : Massiv e Resection and A llo graft Transplantatio n in the Treatment o f

M alignant B one Tumors. N ew England J. Med., 29 4: 12 47-1255 , 1 976 .7 . SPENCE. K . F.. J R .; S E L L. K. W .; and B R O W N , R. H.: Treatment o f Unicameral B one Cyst w ith Freez e-D ried Cance llo us B one A llog raft. I n

Pro ceedings o f The American A cademy of Orthopaedic Surgeons. J. B one and Joint Surg .. 50 -A : 841 -84 2 . June 1968 .

A Study of the Clinical Incidence of Infection in the Use of Banked Allograft Bone

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