Technique of Papineau in the Management of Chronic Osteomyelitis in a Low Setting Area. A 12 Years’ Experience

http://dx.doi.org/10.22158/rhs.v5n2p19 Abstract Introduction: Chronic osteomyelitis, a bone infectious pathology is difficult to treat. The authors report their experience in a series of patients treated in a low-income country. Methods: We report a prospective study of 53 patients suffering of chronic osteomyelitis for a long time, covering our experience between January 1998 to December 2010 at the Kinshasa University Hospital in central Africa. We used the technique described by Papineau with success, until the consolidation of the bones and the drying up of the wounds. The following elements were analyzed and taken into account: age and sex of the patients, sites involved, germs, surgical technique, length of stay in the hospital and estimated cost of the treatment. Result: The majority of patients were between 26 and 35 years old with extremes between 15 and 80 years old, with 34 males and 19 females with a sex ratio of 1.7/1. Upper limb was involved with 7 humerus, 6 radius, 6 cubitus and the lower limb with 14 femurs and 20 tibias. Staphylococcus aureus was the germ most found in cultures from dead bone from high economic cost and it is absolutely useless to begin a Papineau treatment if the patients do not have enough money.


Lesion and a Sequestra Inside the Tibia
The patients were treated using the Papineau technique consisting of open wide resection of all the bone sequestra ( Figure 2).

Figure 2. Picture of Some Sequestra Removed from the Infectious Foci
It will leave a gap with margin viable bone, with the preservation of the posterior bone cortex, which is no longer mechanically stable. The immobilization of the affected limb is done (Stein & Lerner, 2001).
The cavity was then cleaned with Dakin's solution and saline serum. The dry cavity was packed with vaseline gauze, and covered with dry dressing applied in slight compression. We inspected the wound after 5 days. If the dressing became soiled, we changed it without disturbing the Vaseline gauze pack.
When this was removed, there was fresh bleeding and the bone surface was covered with granulations tissues. After this first step, we proceed to the second step. It is performed by cleaning the cavity and then completely filled with fragments of cancellous bone as seen in Figure 3. www.scholink.org/ojs/index.php/rhs Research in Health Science Vol. 5, No. 2, 2020 22 Published by SCHOLINK INC.

Limb Immobilized by Hoffman Fixators
Daily drip irrigation of the grafts started using 1 liter of saline for 2 hours a day, for 45 days until the grafts were incorporated within the granulation tissue. Skin cover will be achieved by spontaneous healing or by a third step consisting of skin grafting. Radiography was necessary to control cavity and to decide when the immobisation would be discarded and the limb might be allowed to bear weight.

Age and sex
Fifty three patients with a mean age of 18 years were included in the study. The majority of patients were between 26 and 35 years of age with extremes between 15 and 85 years, with 34 Males and 19 Females (Figures 4 and 5).

Bacteriology
Staphylococcus aureus was the germ most found in ours patients cultures from dead bone taken through open surgical biopsy.
We use 30 days of antibiotherapy against staphylococcus. Fifteen days after the sequestrectomy and for a similar period after bone grafting.
Length of stay in hospital was of an average around 17 weeks for upper limb and 28 weeks for treatment of lower limb injuries and the estimated cost was more than 700 to 800 dollars.

Discussion
The   (2004)  This protocol delivered low recurrence rates with few re-operations or complications over a one-to three-year follow-up period. Their initial experience shows that this offers a patient-friendly treatment which merits further study.
In our series, the percentage obtained after Papineau (99%), remains a solution for those chronically ill patients who find the joy of going to their business. An obvious consolidation of the treated bone is a satisfaction for us and especially for the patient and his family with good healing of bone and soft tissue ( Figure 6) escaped from amputation otherwise.
Concerning medical treatment, chronic osteomyelitis is a relatively common infection and is often a lifelong disease. Many protocol exist: three months for Bauer, 1 to 1.5 months for Mac Nally.
Traditionally, osteomyelitis has been treated with 4-6 weeks of parenteral antibiotics after definitive debridement surgery. There is no solid evidence in the medical literature to support the continuous use of long duration antibiotic treatment. The medical literature, including studies in animals and humans, was searched for evidence to support the use of short courses of antibiotics (Haidar, Der Boghossian, & Ayiyeh, 2010). In our experience, we use antibiotics for 4 weeks. The prognosis is depending of authors and technique used (Bauer, Litellier, Mamoudy, & Lortat-Job, n.d.). Anyway, in our series, the percentage obtained after Papineau (99%), remains a solution for those chronically sick patients who find the joy of walking like everyone else and going about their business.
An obvious consolidation of the treated bone is a satisfaction for us and especially for the patient and his family with good repair of bone and soft tissue ( Figure 6) otherwise amputation.

Figure 6. Picture of Skin Covering the Wound
More than 700 to 800 dollars for the treatment can't be afforded by a low income population such as in sub-Saharan Africa. And we deplore the high number of patients lost; the cost of the treatment added to the long stay in hospital seemed prohibitive. Therefore, many patients are pushed to find and to consult traditional physicians; unfortunately unqualified for the matter.
Limitations of the study. There are some limitations in this study. The first bias might be the small sample size of this monocentric study and the second, many factors may be associated with chronic osteomyelitis as diabetes mellitus, obesity, smoker, alcohol drinker were not taken into consideration in the study. Despite these limitations, this study carried out in low income country and based on local experience seems to be the first one as far as we are aware. It provides valuable information on the chronic osteomyelitis and its treatment by the technique of Papineau in austere environment.
For future study, each of these biases should be taken into consideration to demonstrate scientifically an estimate significance and robustness of the findings of this technique in a poor country. It may have an important clinical implication suggesting that even the evidence is not sufficiently robust to identify the most effective treatment of chronic osteomyelitis in low-income countries (Geurts, Hohnin, Vranken, & Moh, 2017), the technique of Papineau may be appropriate and effective.

Conclusion
For our 12 years' experience in the treatment of chronic osteomyelitis using Papineau technique, we can conclude that osteomyelitis is a chronic disease which is not easy to treat. The technique of