Assessing Debridement Options For Diabetic Wounds

By Eric H. Espensen, DPM

      Diabetic wounds are a common occurrence in wound care centers and private practice. With the escalating rate of diabetes, more and more patients are developing wounds that require care. Wound care for diabetic wounds routinely includes debridement. The term debridement comes from the French desbrider, meaning “to unbridle,” and was probably first used as a medical term by surgeons working in war zones. The medical personnel and surgeons likely recognized that contaminated wounds had a better chance of healing if one surgically removed the damaged tissue to reveal a healthy, bleeding wound surface.       The modern definition of debridement is the removal of dead or necrotic tissue and foreign material from and around the wound with a sterile scalpel, scissors or other methods to expose healthy tissue. Surgical debridement involving extensive and aggressive removal of tissue with or without general or local anesthesia would take place in the operating room. Podiatric physicians may utilize more conservative (sharp) debridement, involving repeated minor tissue sparing debridement, at the bedside or in a procedure room.       Other methods of debridement include mechanical, biological, chemical, enzymatic or autolytic debridement. In 1962, Winter offered one of the earlier profound observations in wound care when he noted that moist wounds heal better in comparison to desiccated wounds.1 Proper debridement allows for exposure of the moist tissues and subsequently allows the practitioner to maintain a proper wound environment.

Underscoring The Importance Of Proper Debridement

      The clinician cannot properly assess or document the status of a diabetic wound until he or she has removed all necrotic, hyperkeratotic and devitalized tissue. Dead tissue acts as a medium for bacterial growth. Dead spaces within the tissue allow for abscess formation which can, in turn, allow for anaerobic bacterial growth such as Bacteroides species or Clostridium perfringens.       The presence of necrotic or foreign material provokes an inflammatory response, which adds to the systemic release of cytokines such as tumor necrosis factor and interleukins, which promote a septic response.       Necrotic tissues can retard wound contraction, the principle contribution to wound closure, when wounds are left to heal by secondary intention.       Diabetic wounds are often covered by scab, eschar or hyperkeratosis. Accordingly, it can sometimes be difficult to determine whether the tissue covering a wound is physiological or pathological. Indeed, podiatric physicians need to remove gangrenous, necrotic, ischemic and devitalized tissue by some method of debridement. Failure to debride diabetic wounds appropriately when necessary could be considered failure to render proper treatment.       It is a widely accepted premise that wound debridement is necessary for optimal wound healing. Surgical or sharp debridement has long been viewed as the “gold standard” for debridement. Unfortunately, the evidence for the effectiveness of different methods of debridement from randomized controlled trials is lacking and an evidence-based treatment algorithm has yet to be established. Oftentimes, the treating practitioner chooses the method of debridement based on his or her individual experience and level of comfort with the chosen method instead of an established treatment algorithm or other evidence-based rationale.

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