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We describe 2 confirmed episodes of surgeon-to-patient hepatitis B virus (HBV) transmission through large-joint arthroplasty without recognized breaches in infection control practices. The investigation supports the 2010 Society for Healthcare Epidemiology of America guidelines and 2012 Centers for Disease Control and Prevention recommendations for management of healthcare workers with chronic HBV infection.Background. During the evaluation of a needle-stick injury, an orthopedic surgeon was found to be unknowingly infected with hepatitis B virus (HBV) (viral load >17.9 million IU/mL). He had previously completed two 3-dose series of hepatitis B vaccine without achieving a protective level of surface antibody. We investigated whether any surgical patients had acquired HBV infection while under his care.Methods. A retrospective cohort study of all patients who underwent surgery by the surgeon was conducted. Patients were notified of their potential exposure and need for testing, and samples with positive HBV loads underwent DNA sequencing. Characteristics of the surgical procedures for the cohort were evaluated.Results. A total of 232 (70.7%) of potentially exposed patients consented to testing; 2 were found to have acute infection and 6 had possible transmission (evidence of past exposure without risk factors). Genome sequence analysis of HBV DNA from the infected surgeon and patients with acute infection revealed genetically related virus (>99.9% nucleotide identity). Only age was found to be statistically different between those with confirmed or possible HBV transmission and those who remained susceptible to HBV.Conclusions. We documented HBV transmission during orthopedic surgery to 2 patients from a surgeon with HBV. This investigation highlights the importance of evaluating individuals who do not respond to 2 series of HBV vaccination, the increased risk of HBV transmission from providers with high viral loads, and the need to evaluate the clinical practice of providers with HBV and implement appropriate procedure-based practice restrictions. [ABSTRACT FROM PUBLISHER]