Papineau technique

Three stages to this technique:

1. Thorough debridement of all infected tissues,

repeated as necessary; stabilization of the fracture
with an external skeletal fixator
2. Cancellous autogenous bone grafting into a defect
lined with clean uninfected granulation tissue
3. Skin 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.