Current And Emerging Modalities In Wound Debridement

Thomas Belken, DPM, and Neal Mozen, DPM, FACFAS

Given the important role of debridement in facilitating successful wound healing, these authors discuss pertinent issues concerning the timing and degree of debridement, and offer their perspectives on debridement modalities ranging from enzymatic agents to ultrasonic debridement and hydrosurgery.

Debridement is often a key element in effective wound care. Recently, the wound healing community endeavored to create guidelines in an effort to help standardize debridement.1 There will always be a certain amount of artistry in sharp surgical debridement (as there is with surgery), but the question is, “Are we debriding too much?”

   The frequency and aggressiveness with which we debride varies greatly from practitioner to practitioner. Training of the clinician, available resources and fee for service can factor into how frequently we debride an ulcer. The fee-for-service model can potentially increase the frequency and extent of debridement. As healthcare moves from a fee for service model to a value-based paradigm, providing the most high quality, cost-effective treatment is all that matters. We must learn to heal wounds quicker and with lower cost. Improving our techniques and protocols for effective debridement will help us meet this challenge. Value-based medicine demands superior outcomes.

   As wound care has evolved, the treatments have improved through trial and error. Through careful observation, we better understand the underlying science of wound healing. Wound debridement has long been established to be necessary for enhancing wound healing. More recently, we have developed a better understanding of the reasons why.

   Before wound care specialists ever get out a curette or tissue nipper, there is critical information they need to obtain. One should determine the etiology of the wound. Debriding a pyoderma gangrenosum actually causes the ulcer to worsen due to stimulation of the inflammatory cascade. What are the comorbidities of the patient? One must evaluate the vascular status. Determining local perfusion is particularly important when debriding wounds on the distal aspect of the foot.2 Although offloading is not the focus of this discussion, it is imperative to offload plantar ulcers properly. Neither the most meticulous debridement nor the latest technology can overcome inadequate offloading.

   Additionally, the chronicity of the wound and amount of bioburden are factors that reduce normal wound healing. Chronic ulcers may have developed secondary to a myriad of etiologies including trauma, surgery, pressure, metabolic, venous and arterial etiologies, and diabetic neuropathy. Bioburden is like a wall that allows bacteria to be protected from the host’s defenses. Biofilms are often recalcitrant to routine surgical debridement.3

   The three most prevalent agents to reduce bioburden are iodine, silver and honey. Iodosorb (Smith and Nephew) is able to reduce bioburden, control exudate and provide a measure of debridement. The use of silver and honey products is well documented. Maggot therapy is another modality that can help reduce bioburden while also debriding the wound.

Key Benefits Of Debridement

So why is debridement so important? Debridement has the following purposes.4,5
• Debridement reduces bioburden to help control or reduce infection. Even if an ulcer is not “infected,” the bacterial bioburden causes increased local inflammation.
• Debridement allows more accurate visualization of the wound base and edges, which allows for more precise staging.
• Debridement removes necrotic/non-viable tissue, which impedes wound healing, causes protein loss and can be a nidus for infection.
• Debridement stimulates new circulation (angiogenesis) and allows adequate oxygen delivery to the wound.
• Debridement removes undermining and tunneling, and may help reduce abscess formation.
• Debridement releases healing growth factors at the edge of the wound.
• Debridement prepares the wound bed by leaving only tissues that are capable of regenerating.

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