Papineau technique

Three stages to this technique:

1.

2.

3.

Thorough debridement of all infected tissues,

repeated as necessary; stabilization of the
fracture with an external skeletal fixator
Cancellous autogenous bone grafting into a
defect lined with clean uninfected granulation
tissue
Skin coverage either by secondary
epithelialization or, in larger defects, by splitthickness 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 105 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.