Papineau technique

Three stages to this technique:

Thorough debridement of all infected tissues, repeated as necessary; stabilization of the fracture with an external skeletal fixatorCancellous autogenous bone grafting into a defect lined with clean uninfected granulation tissueSkin coverage either by secondary epithelialization or, in larger defects, by split-thickness skin grafting

1. Debridement & Stabilization

Debride all infected soft tissue and sequestra, and debride all necrotic bone to bleeding osseous tissue. Perform stabilization using an external skeletal fixator.

2. Bone grafting When exposed surfaces are covered with clean granulation tissue, pack finely morcelized autogenous cancellous bone into the defect created by the bone debridement or previous bone loss. The diameter of the graft should be slightly larger than the diameter of the bone being replaced, since the graft will tend to contract. Rhinelander recommends that the maximum graft thickness be 1.5 cm from the nearest granulation surface

3. Skin coverage Dress the wound with gauze and keep it moist with a physiologic irrigating solution such as Ringer's lactate, either by intermittent soaking of the dressings or by a slow intravenous drip. The dressing, which should be changed daily, is to be soaked with physiologic solution until the wound is covered by epithelialization or, in some cases, by secondary split-thickness skin grafting

HINTS AND TRICKS

Make sure all necrotic soft tissue and bone are debrided.Stabilize the fracture.There must be a clean granulating base before autogenous cancellous bone grafting is performed. Do a quantitative tissue culture and Gram stain. If the quantitative tissue culture yield is greater than 10-5 organisms, or if the Gram stain is positive (implying the presence of more than 10-5 organisms), do not perform the cancellous bone grafting. A count greater than 10-5 organisms is consistent with infection, in which case redebridement is necessary.

A: Lateral radiograph of the tibia and fibula in a 37-year-old woman with loss of the tibia following an infection that developed after the patient sustained a type III open fracture.

B: Anteroposterior photograph shows the soft-tissue and bone loss and exposed tibial shaft.

C: Photograph taken at the time of autogenous cancellous bone grafting of the dead space.

D,E: Anteroposterior and lateral radiographs, taken after the grafts had consolidated, show healing of the fracture.

F: Lateral photograph, taken 3 years after the procedure, shows knee flexion and the appearance of the leg. The patient has been free of infection.