Open Bone Grafting

Papineau technique

Overview
Described by Papineau et al. to treat chronic osteomyelitis in 1979 Panda et al. reported an 89% success rate with the Papineau technique for the treatment of 41 patients with chronic osteomyelitis. Beals and Bryant reported good results in seven of eight patients treated with the Papineau technique. They stressed the importance of bony stabilization through the use of circular external fixation techniques.

principles
1. granulation tissue markedly resists infection, 2. autogenous cancellous bone grafts are rapidly revascularized and are resistant to infection, 3. the infected area is completely excised, 4. adequate drainage is provided, 5. adequate immobilization is provided 6. antibiotics are used for prolonged periods

Operation stages
1. excision of infected tissue without or with stabilization using an external fixator or an intramedullary rod, 2. cancellous autografting, 3. skin closure.

STAGE I: DBRIDEMENT
1. 2. 3. completely excise the sinus tracks and sequestra, and saucerize the areas of devitalized bone. May need to resect the diaphysis in segments, such as in cases of infected nonunion. If the demarcation between healthy and infected tissues is difficult to recognize, repeat this stage at intervals of 5 to 7 days. Between the operations, pack the wound open with dressings soaked in antibiotic, or use an antibiotic pouch technique (described later) Stabilized using ext. fix (or nail as described by papineau himself) After 4 or 5 days, begin dressing the wound daily; excise infected tissue as necessary, and delay the next stage until signs of infection are absent, and healthy-appearing granulation tissue is present throughout.

4.
5. 6.

STAGE II: GRAFTING

1. 2. 3. 4. 5. 6. autogenous cancellous bone grafting, preferably from the posterior iliac crest. (graft in strips 3 to 4 cm long) Place the grafts in concentric and overlapping layers, and fill the cavity completely. In the area of resection recreate the shape of the diaphysis. Pack the wound open with dressings soaked in antibiotics. Change the first dressing between the third and fifth days, and replace any grafts that adhere to the dressing. Change the dressings until the grafts stabilize. If indicated, use local muscle pedicle grafts to enhance the blood supply to the grafts, and leave the overlying skin and subcutaneous tissue open. Especially in subcutaneous bones such as the tibia, excise the lips of the wound if the skin tends to cover the granulation tissue before it completely covers the graft.

7.

STAGE III: WOUND COVERAGE

1. In some cases, spontaneous epithelialization results in adequate wound coverage; 2. May need skin graft or various types of flap. to obtain adequate coverage