When considering which methods of wound debridement will be effective in their patients, clinicians have a wide range of choices at their disposal. These expert panelists discuss their preferences for sharp debridement, ultrasound debridement, non-surgical debridement and the use of maggots.
Kazu Suzuki, DPM, CWS, prefers using a 4 mm diameter disposable sharp curette by Miltex. It has a sharp edge that loops around and he says dermatologists often use the curette to remove small benign skin lesions. Dr. Suzuki finds the curette to be the “perfect tool” to debride most wounds. He notes that one can bend the blade tip by hand to turn it into various shapes (blunt or sharp) to match the size and shape of the wounds.
David G. Armstrong, DPM, MD, PhD, also finds that certain large curettes work well at debriding the central area of wounds. Desmond Bell, DPM, CWS, notes that curettes work very well to remove slough. He also says curettes can effectively debride areas of tunneling and undermining as well as remove biofilm from a relatively clean wound base.
Dr. Suzuki and Dr. Bell both use disposable #10 and #15 blades. Dr. Bell prefers to perform debridement with sharp surgical instruments since sharp debridement provides a highly selective manner to remove non-viable tissue. Additional benefits of surgical debridement include rapid conversion of the wound from chronic to acute and facilitating an immediate clinical assessment of perfusion, according to Dr. Bell. Dr. Bell prefers a #10 blade when he needs more extensive removal of necrotic tissue and a #15 blade when he needs to debride a smaller area or for finer removal of tissue.
In addition, Dr. Suzuki will use regular, non-disposable surgical instruments, forceps and scissors. He notes the non-disposable instruments are plastic surgery fine grade instruments that do not traumatize the skin edges. Dr. Suzuki says cheap disposable instruments can crush the skin’s edge.
All three panelists use the Versajet (Smith and Nephew). Dr. Suzuki uses the high-speed “water scalpel” in the operating room for debriding large wounds. As Dr. Bell explains, hydrosurgery utilizes the “Venturi effect,” which allows water to circulate in such a fashion that it produces a cutting effect on non-viable tissue. He says this method allows a suctioning effect as well and when one utilizes in it the OR setting, “the Versajet can dramatically reduce surgical time while performing its primary task exceptionally.” Dr. Suzuki concurs. Since Versajet combines debridement and saline irrigation in one hand-piece, Dr. Suzuki says it effectively cuts the OR time in half.
In his clinic, Dr. Armstrong has access to several ultrasonic debridement devices including the Qoustic Wound Therapy System (Arobella Medical) and SonicOne (Misonix). Although ultrasonic devices debride wounds more slowly than a curette or the Versajet, he says ultrasound may be more effective at breaking up biofilm.
Dr. Suzuki has also been using the Qoustic for more than three years. Similar to Versajet, ultrasound devices combine debridement and irrigation while delivering therapeutic ultrasound to the wound bed to fragment non-viable tissues and kill bacteria, according to Dr. Suzuki.
“I use the Qoustic system on almost every patient I see in our wound care center and I cannot imagine practicing wound care without it,” he says.
As for billing, since he does not yet have the specific CPT codes for ultrasound debridement and therapy, Dr. Suzuki just bills the services under sharp debridement codes (see the sidebar “What You Should Know About Debridement Coding Changes” on page 30 of the July 2011 issue).
Although Dr. Bell has not yet used ultrasound debridement in his practice, he expresses curiosity as ultrasound “appears to be an excellent clinical modality.”
Dr. Suzuki’s non-surgical debridement agent of choice is collagenase (Santyl ointment, Healthpoint Biotherapeutics).
“It is virtually painless and much more effective and consistent than simple autolytic debridement using occlusive dressings,” maintains Dr. Suzuki.
Since one will usually treat a few patients who cannot tolerate the pain of sharp debridement, Dr. Suzuki would prescribe such patients Santyl, which they would apply daily to the wounds between their office visits or during hospital stays. For these patients, he would also provide minimal sharp debridement and non-contact ultrasound debridement for their follow-up visits.
Although the modalities are not advertised as debridement tools, Dr. Suzuki believes medical-grade topical honey and topical cadexomer iodine products have some debriding properties besides their antimicrobial properties. Therefore, he may use Medihoney (Derma Sciences), Iodosorb and Iodoflex (Smith and Nephew) for debridement of infected wounds.
Although Dr. Armstrong says enzymatic therapy can be helpful in what his SALSA group calls “wound hospice” patients (when the primary goal may be to keep the wound clean but not necessarily to heal it), he says enzymatic therapy is not a substitute for surgical debridement.
Dr. Bell’s favorite non-surgical debridement tool is the Versajet as cited above.
Calling himself a “larvaphile,” Dr. Armstrong has used maggots for many years.
“Our non-human colleagues are quite adept at bridging the gap between surgical debridements and in assisting in wound hospice,” notes Dr. Armstrong.
Likewise, Dr. Suzuki thinks maggots are very useful for infected or non-infected wounds. Similar to collagenase, maggots are mostly painless so he will use maggot therapy for a few patients who absolutely cannot tolerate the wound debridement due to pain or their critical medical conditions (as in ICU patients). The only drawback is the cost, which Dr. Suzuki estimates at about $100 per vial of medical maggots, which will provide 48 hours of debridement.
Dr. Bell has not had the opportunity to use the larvae of Lucilia sericata (the green bottle fly). He notes this method of debridement is selective as the larvae only ingest necrotic tissue. Maggot debridement can be beneficial in a setting where debridement is needed yet severe underlying arterial compromise is a concern, according to Dr. Bell. He says maggot debridement also may be beneficial in settings where management of the wound is not under the care of a surgically trained provider.
As for other methods of debridement, Dr. Bell has extensively used enzymatic debridement and lavage debridement as well as primary dressings such as hydrogels and alginates to promote autolytic debridement. He advises considering a number of factors to determine what debridement modalities one will use.
Dr. Armstrong is a Professor of Surgery at the University of Arizona College of Medicine in Tucson, Ariz. He is the Director of the Southern Arizona Limb Salvage Alliance (SALSA).
Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.
Editor’s note: For a related article, see “Keys To Ensuring Optimal Wound Debridement” in the July 2011 issue of Podiatry Today. For other related articles, please visit the archives at www.podiatrytoday.com .