Modern Papineau Technique With Vacuum-Assisted Closure:

Modern Papineau Technique With Vacuum-Assisted Closure:

The Papineau technique involves open cancellous bone grafting on a granulated tissue base with delayed soft tissue coverage by skin grafting or healing by secondary intent. The process can be used to treat problematic osseous defects, including those that may arise from chronic osteomyelitis or tibial nonunions. In 1973, Papineau et al originally described results of the technique involving 37 cases of infected tibial nonunions. A follow-up article in 1979 presented the results of 180 patients treated with the technique for chronic osteomyelitis. As technology and free-tissue transfer methods have evolved, the technique has been abandoned or adapted to modern wound care techniques, including the application of external fixators to stabilize bony deficits while using the Papineau technique. Archdeacon and Messerschmitt described in 2006 a contemporary modification of the Papineau technique by implementing a vacuum assisted closure (V.A.C.) device in lieu of wet-to-dry dressing changes.

The patient is brought to the operating room and the affected limb is draped, sterile, and free. The first stage is excisional debridement of necrotic, infected bone, and soft tissue. A complete excisional debridement is performed by using a combination of osteotomes, rongeurs, and a highspeed burr. Bone is de´brided to the point where the ‘‘paprika sign’’ (active bleeding from small bony channels) is identified. A complete soft-tissue resection is performed to obtain a healthy vascular bed. Once adequate debridement is obtained, the limb is dressed with a vacuum-assisted closure device (V.A.C.; Kinetic Concepts, Inc., San Antonio, TX) sponge. Operative cultures are obtained at the time of bone excision, and broad spectrum, parenteral antibiotics are initiated. This regimen generally includes intravenous vancomycin, ciprofloxacin, and rifampin. The antibiotics regimen is modified as definitive cultures demonstrate appropriate sensitivities. The route and duration of antibiotics is determined by a surgical infectious disease consultant; however, intravenous antibiotics are commonly continued until normalization of inflammatory markers (Erythrocyte Sedimentation Rate and C-reactive protein.) If the clinical wound and radiographs demonstrate healing with no further evidence of infection, antibiotics are changed to sensitivity-appropriate oral antibiotics, which are continued for 6 months. Repeat bony excision and de´bridements are performed with V.A.C.sponge application at 48-to 96-hour intervals until a healthy tissue bed is obtained. Once a clean wound bed is obtained, an open cancellous bone grafting in performed. Donor sites include the iliac crest or the proximal tibia. If needed, autologous graft can be expanded with cadaver allograft cancellous chips. The composite bone graft is packed into the bony deficit created by the previous excisional debridements. The deficit is fully packed to the subcutaneous tissue level, and the open bone graft is then dressed with a petroleum jelly impregnated gauze (Adaptic, Smith and Nephew Richards, Largo, FL) and a V.A.C.sponge. The V.A.C.sponge is changed at 72-to 96-hour intervals to allow for wound granulation. At that point, the wound can be covered definitively with a split-thickness skin graft or allowed to heal by secondary intent with epithelization.