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There is a variety of debridement options ranging from sharp debridement and mechanical debridement to enzymatic debridement. In recent years, physicians have also seen the emergence of ultrasound debridement and the use of a hydro scalpel. Accordingly, this author evaluates the various debridement methods and assesses their cost effectiveness.
Continuing Education Course #162 | -Jeff A. Hall
Executive Editor
Podiatry Today I am pleased to introduce the latest article, “Wound Debridement: Are Adjunct Therapies Cost Effective?” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
What is the best approach when it comes to debridement and converting chronic wound environments to acute wound environments and eventual closure? In order to answer this question, Leon R. Brill, DPM, CWS, offers a closer look at different debridement methods and assesses their cost effectiveness. He also reviews a case study that shows the use of different debridement techniques.
At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.
Sincerely,
Jeff A. Hall
Executive Editor
Podiatry Today
INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 70 and successfully answering the questions on pg. 74. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Brill has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: April 2008
EXPIRATION DATE: April 30, 2009
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• cite the goals of wound bed preparation;
• discuss the use of sharp debridement in converting chronic wounds to acute wounds;
• describe possible indications for enzymatic debridement;
• describe the use of ultrasonic debridement in wound care;
• review the potential benefits of hydro scalpel debridement; and
• analyze the cost effectiveness of standard and emerging debridement techniques.
Sponsored by the North American Center for Continuing Medical Education.
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Wound debridement has been in use for thousands of years. Wound bed preparation is a widely described set of principles and actions that attempt to identify and correct the wound microenvironment to help facilitate complete wound healing in a timely and orderly manner. These events are well described and follow a natural process from the original wound to hemostasis, inflammation, angiogenesis, the formation of granulation tissue, reepithelialization and finally, remodeling.1
In reality, these phases overlap each other rather than being distinctly clear phases. In each of these phases, specialized cells including platelets, neutrophils and fibroblasts are released into the wound. These cells, in turn, signal the release of a cascade of chemical mediators such as growth factors, proinflammatory cytokines and inhibitors of cytokines. These orderly events are at least partially dependent on the overall good health of the host. Conditions such as diabetes, vascular disease, cancer, infection and poor nutritional status may alter or eliminate all or some of these events.
Wound bed preparation is a multi-step process that can be defined as the global management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapies.2 The primary goals of wound bed preparation are to decrease bacterial load, remove necrotic tissue, stimulate the production of granulation tissue and manage exudates. Wound debridement is a critical and primary component of wound bed preparation.
Due to both internal and external events that are beyond the scope of this article, acute wounds may turn into chronic wounds that harbor bacteria, senescent cells, an abundance of metalloproteases, lower levels of growth factors and tissue inhibitors of proteases.3 The primary goal of wound debridement is to convert the chronic wound environment to an acute wound environment.
What You Should Know About The Various Debridement Methods
|  | | A 49-year-old male with diabetes presented with an ulcer on the medial side of his left foot. In this image, one can see osteomyelitis of the first metatarsal head. |
One may achieve wound debridement by sharp surgical debridement, mechanical debridement, autolytic debridement, enzymatic debridement and biologic debridement.
Sharp debridement. Sharp debridement of chronic wounds has been considered the gold standard in the treatment of wounds. One needs only to look at the work of Steed and associates to see the value of sharp debridement. In a multicenter, prospective double-blind, placebo-controlled study of rhPDGF versus placebo, there was a higher rate of healing in the treatment groups in which the number of debridements was higher irrespective of the treatment type.4 Properly performed sharp debridement achieves the goal of changing the chronic wound environment to an acute wound environment.
This stimulates the release of growth factors and cytokines as well as the reduction of wound bioburden. This ultimately results in enhancement of the wound environment and increased speed of wound healing. One may perform sharp debridement in a clinic, office or operating room setting. It may be conservative or radical depending on the type and amount of tissue one needs to remove.
Mechanical debridement. Mechanical debridement is a non-selective method that can create a healthy wound bed conducive to healing. The most commonly employed form of mechanical debridement is pulse lavage. One can achieve pulse lavage through high or low pressure with some form of irrigation solution such as normal saline or an antibiotic solution such as bacitracin, neomycin or gentamycin.
Pulse lavage aids in removing necrotic tissue and loose fibrin. Studies have shown that high pressure lavage is more effective than low pressure lavage. However, there is a higher incidence of bacterial seeding into the deeper tissues and some concern for architectural damage to cancellous bone during early healing.5
Autolytic debridement. One would achieve autolytic debridement by using semi-occlusive or occlusive wound dressings such as transparent films, hydrogels and hydrocolloids. These moisture retentive dressings trap wound fluids and use the natural proteolytic enzymes to soften and liquefy the necrotic tissue. Each dressing change gently removes the necrotic and devitalized tissue.6
Enzymatic debridement. Enzymatic debridement is an effective tool to use in a subset of patients for whom surgical debridement may be too risky or for those who are confined to long-term care facilities. There are several enzymatic debriding agents available and they include collegenases, fibrinolytics, trypsin and papain-urea combinations. However, these agents are deactivated by peroxide, alcohol and heavy metals such as silver.7
Biologic debridement. Maggot therapy involves the use of larvae of the blowfly (Lucilia sericata). Applying maggots directly to the wound releases proteolytic enzymes that cause the liquefaction and removal of necrotic tissue. The three distinct benefits of maggot therapy are selective debridement of tissue, disinfection and promotion of granulation tissue.8
Maggot therapy was widely used during the Civil War and slowly grew in popularity until over 300 hospitals used this form of therapy by 1934.8 As more advanced wound therapy and antibacterials became available, the use of maggot therapy declined. However, because of its relatively low cost, there has been some resurgence in its use over the last several years.
A Closer Look At Emerging Debridement Options
Ultrasound debridement. Ultrasound is defined as a mechanical vibration transmitted at a frequency above the upper limit of human hearing (> 20KHz).9 One achieves ultrasonic debridement of tissue by the process of cavitation. This is essentially the production and vibration of micron-sized bubbles within the coupling medium and fluids within the affected tissues. The combination of cavitation and microstreaming provides a mechanical energy capable of altering cell membrane activity.
A study by Ennis, et al., demonstrates an overall healing rate of 40.7 percent with saline mist ultrasound in comparison to 14.3 percent in the sham group. The group treated with saline mist ultrasound also demonstrated faster healing (9.12 weeks) in comparison to the sham group (11.74 weeks).9
Hydro scalpel. The hydro scalpel is a debriding system that generates up to 15,000 psi of pressure through the venturi effect. This creates a micro-thin stream of water that acts as a blade. This stream of water is 5/1000 inches in diameter and, at its highest pressure, travels at over 600 mph. The hydro scalpel is a highly effective tool that allows for precise and selective debridement of skin, soft tissue, capsule and tendon. In addition, it functions as a tangential debrider, which allows for very efficient separation of tissue planes. Assessing The Cost Effectiveness Of Debridement Methods
Although sharp surgical debridement remains the gold standard, we are fortunate to have alternative methods of debridement at our disposal. Are those methods cost effective? This is a difficult question to answer because there are so many variables. With the exception of the hydro scalpel, which is restricted to the operating room, healthcare professionals other than physicians can use ultrasound debridement, pulse lavage, enzymatic debridement and maggot therapy.
Utilizing these various modalities, physical therapists and wound/ostomy nurses routinely debride wounds at the bedside and in a clinic setting. Ultrasound kits and pulse lavage kits cost the institution approximately $30 to $40 per kit. While these costs are passed on to the patient, savings in operating room and anesthesia fees more than make up for the added cost.10
However, offsetting these savings is the fact that clinicians use these modalities on a daily or three-time per week basis, which actually adds to the cost of patient care. Surgeons also use pulse lavage but not as a stand-alone procedure. The reported cost of maggot therapy ranges between $300 and $500 per treatment but staff and patients generally do not accept it well.10
Physicians should not consider the hydro scalpel as an alternative debridement method but rather as a new type of sharp debridement tool. The cost of the hydro scalpel hand piece varies from $425 to $525 depending on contractual arrangements.11 It is designed for use in the operating room, not at bedside, so comparing this tool to other modalities would not be appropriate. Researchers have shown that the hydro scalpel system decreases the cost of wound care by decreasing the number of debridements per wound. Granick, et al., demonstrated a decrease in the number of debridements from 1.9 to 1.2 with an overall cost savings of $2,000.12,13
Alternative debridement methods have a valuable place in the treatment of complicated wounds. Patients may not be able to undergo surgical debridement due to critical limb ischemia, nutritional deficiency or cardiac or renal complications that make them poor surgical candidates. In addition, some patients may reside in a facility such as a nursing home or long-term care facility where surgical intervention is neither feasible nor available.
Alternative modalities allow for regular debridement of wounds without trips to the operating room, possibly reducing overall costs. While these modalities look promising in fostering faster healing, their impact will remain unclear until long-term data becomes available. Case Study: When A Diabetic Patient Presents With A Foul Smelling Ulcer
|  | | The aforementioned patient underwent debridement and the author applied an external fixator as shown in the above photo. |
A 49-year-old Caucasian male with a 15-year history of type 2 diabetes developed an ulcer on the medial side of his left foot. He developed the ulcer after wearing a pair of tight fitting boots with steel toes that are required for his work as a construction supervisor.
He initially treated himself with an over-the-counter antibiotic cream for several days but his foot continued to swell and the redness that initially was around the great toe joint extended onto the dorsum of his foot. He started to notice a foul smelling discharge, which is what drove him to seek medical care.
The patient’s past medical history is significant for type 2 diabetes, hypertension and cardiovascular disease. The physical examination revealed a University of Texas grade 3B ulcer. A probe to bone test was positive. There was foul smelling purulent exudate with the wound. There was also an oblique sinus tract leading to the plantar surface under the first metatarsal head. Radiographs demonstrated a bunion deformity with a minimal hallux valgus. There was a lucent defect on the medial side of the metatarsal head. The vascular examination was within normal limits but the patient’s neurologic examination demonstrated peripheral sensorimotor neuropathy with loss of protective sensation.
|  | | Here one can see the 49-year-old patient’s healed wound. Physicians utilized saline mist ultrasound debridement as well as negative pressure wound therapy. |
The patient was admitted to our hospital for aggressive wound care management and surgical debridement. Upon admission to our service, the patient’s MRI showed a well circumscribed, subcortical marrow defect with a sinus tract extending to the adjacent skin surface consistent with osteomyelitis. His laboratory values demonstrated leukocytosis with a white blood cell count of 12,500. The patient had a sedimentation rate of 50 and a C reactive protein of 6.0. The diagnosis was an abscess with cellulitis and osteomyelitis.
In the operating room, we performed a debridement of bone and soft tissue. We excised the first metatarsal head using the hydro scalpel in addition to standard surgical instrumentation.
Intraoperative cultures revealed oxacillin sensitive Staph aureus and Bacteroides fragilis. The patient received piperacillin/tazobactam and levofloxacin, and had a good response. We left the surgical wound open after debridement and stabilized it with a small bone external fixator. We started initial wound care with daily saline mist ultrasound debridement and the subsequent use of a matrix dressing for 72 hours.
When the wound was clean and free of necrotic tissue and fibrin, we discontinued ultrasound debridement and applied a negative pressure dressing, which the patient changed three times per week until wound closure. This was five weeks after the initial debridement. Dr. Brill practices at the Limb Salvage Center at the BrillStone Building and is President of the BrillStone Corporation in Dallas. He is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Brill is also an attending staff member at Presbyterian Hospital in Dallas. References 1. Monaco JL, Lawrence TL. Acute Wound Healing; An Overview. Clinics in Plastic Surgery. 30: 1-12, 2005.
2. Falanga V. Wound Bed Preparation and the Role of Enzymes: A Case for Multiple Actions of the Therapeutic Agents. Wounds 14: 47-57, 2002.
3. Sibbald, RG, et al: Best Practice Recommendations for Preparing the Wound Bed. Update 2006 Skin and Wound Care 20(7), July 2007.
4. Sherman RA. Maggot Debridement in Modern Medicine. Infect Med 15 (9): 651-656, 1998.
5. Fletcher N, Sofianos D, Berkes MB, Obremskey WT. Prevention of Perioperative Infection. J Bone Joint Surg Am 89:1605-1618, 2007.
6. Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. Lippincott Williams and Wilkins 2004, 117-116.
7. Ayello E, Cuddigan J. Debridement: Controlling the Necrotic/Cellular Burden. Advances in Skin and Wound Care 17(2), March 2004.
8. Personal Communication: Department of Physical Therapy Presbyterian Hospital of Dallas, Dallas Texas.
9. Ennis WJ, et al. Ultrasound Therapy for Recalcitrant Diabetic Foot Ulcers: Results of a Randomized Double Blind Controlled Multicenter Study: Ostomy/Wound Management 51(8):24-39, 2005.
10. Steed DL, Donohoe D, Webster MW, Lindsley L, and the Diabetic Ulcer Study Group: Effect of Extensive Debridement and Treatment on the Healing of Diabetic Foot Ulcers. J Am Coll Surg 183:61-64,1996.
11. Wysocki AB, Staiano-Coico L, Grinell F. Wound Fluid from Leg Ulcers Contain Elevated levels of Metalloproteinase MMP-2 and MMP-9. J Invest Dermatology 101:64-8, 1993.
12. Granick M, Boykin J, Gamelli R, Schultz G. Toward a Common Language: Surgical Wound Bed Preparation and Debridement. Wound Rep. Reg 14 S-1-S10, 2006.
13. Granick M, Posnett J, Jacoby M, Norvthun S, Ganchi P, Datiashvili RO. Efficacy and cost – effective of a High Powered Parallel Waterjet for Wound Debridement: Wound Rep Reg 14: 394-397, 2006. For further reading, see “Assessing Debridement Options For Diabetic Wounds” in the March 2007 issue of Podiatry Today. Also check out the archives at www.podiatrytoday.com. |
