Record number:
450
Adverse Occurrence type:
MPHO Type:
Time to detection:
16 days
Alerting signals, symptoms, evidence of occurrence:
16 year old female received a frozen irradiated patellar tendon, bone-tendon-bone allograft to replace a damaged anterier cruciate ligament. On day 16. swelling, redness and positive culture diagnosed septic arthritis. Knee fluid grew Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus faecalis. Tissue bank records showed irradiation took place.
Demonstration of imputability or root cause:
Unproven. Possible transmission but tissue bank had proof of terminal sterilization in final packaging by gamma irradiation. Two patellar tendon recipients developed pseudomonas infection and both allografts were from same donor. No procurement (preprocessing) or pre-implantation cultures done. No tissue bank contamination found. No other infections in recipients of allografts from same donor found. A tissue bank investigation showing absence of proof of allograft contamination of this donor was published in more detail in Eastlund T. Bacterial Infection Transmitted by Human Tissue Allograft Transplantation Cell and Tissue Banking 2006,7:147-166
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