While advanced modalities receive a fair amount of hype, proper debridement remains a fundamental cornerstone of wound care and closure. Accordingly, these expert panelists discuss sharp debridement, share their thoughts on device-assisted debridement methods and take a closer look at non-surgical options for debridement.
What are your favorite sharp debridement tools of choice and why?
As Paul Kim, DPM, MS, points out, there is a difference between surgical sharp debridement (excisional debridement) and sharp debridement one performs in the clinic. As he says, surgeons cannot be as aggressive in the clinic as they can be in the OR. While there are a variety of sharp debridement methods including the use of a hydrosurgical scalpel and ultrasound, Dr. Kim calls the scalpel, curette, scissors and rongeur “tried and true methods for excision debridement.”
Suhad Hadi, DPM, FACFAS, also prefers to use a curette and/or a scalpel when sharply debriding a wound. She says those instruments provide “the best approach to both the level of depth and extent of debridement I need to do not only to the wound bed but to the surrounding skin margins.”
“We are very aggressive with how we debride wounds,” says David G. Armstrong, DPM, MD, PhD. “We believe very strongly that in order to reboot these wounds, they need to be figuratively reset.”
For Dr. Armstrong, the go-to sharp surgical tools are good quality curettes and good quality Parker blades. He will use #10 and #15 scalpels. Dr. Hadi says a curette works well in debriding the fibrous slough on the wound surface while a scalpel such as a #15 blade allows one to excise a thin layer of the leading skin edges. As she notes, sometimes debriding a wound only at the level of the wound bed itself, and not the surrounding skin margins, may at times delay overall epithelialization.
“Creating a debris-free wound bed and healthy bleeding skin margins take the wound from a chronic state to a more acute state that further signals and facilitates the healing process,” maintains Dr. Hadi. “This overall process will promote proliferation and epithelialization to ultimately allow progression to wound closure.”
Kazu Suzuki, DPM, CWS, prefers using 4 mm dermal curettes from Miltex. With these curettes, he says he can perform the most precise sharp debridement of ulcers as well as debride any hypergranulation or hyperkeratosis that come his way.
Dr. Suzuki offers one tip of the trade for debridement: pinch and shape the tip of curettes to flatten or sharpen the edge of curette shapes. He also uses a lot of the #10 disposable blade and employs the #15 and #11 blades less often. In the operating room, he uses a conventional blade holder and #10, #15 and #11 blades. Dr. Suzuki notes the #10 blade is meant for the initial incision and creating skin and muscle flaps while he uses a #15 blade for anything else around the bones and joints. As he points out, a #10 blade is much thinner and can snap in half if one is not careful around the joints.
Do you use any device-assisted debridement methods in your practice?
For debridement assistance devices, Dr. Armstrong says there has been a “flowering” of tools that have been helpful over the last several years. He notes ultrasound debridement devices have gotten much more robust with debridement of tissue and that ultrasound debridement has been very helpful. In addition, Dr. Armstrong cites other high energy tools, such as plasma debridement and hydrodebridement, that may show promise in selective debridement of tissue.
Dr. Suzuki has also used ultrasound-assisted wound debridement tools for many years. He cites numerous benefits to ultrasound debridement, especially in terms of pain reduction for the patient. However, Dr. Suzuki notes that justifying the cost of the ultrasound device through reimbursement has been an issue. He says the same goes for a high-speed water jet-assisted debridement tool like Versajet (Smith and Nephew), adding that the cost of disposal units can be substantial. For Dr. Armstrong, the Versajet is a “staple” in his unit.
In the OR, Dr. Kim uses a hydrosurgical scalpel to assist in a thorough debridement. He notes the best method to assess whether one has performed a sufficient debridement is by using your senses: color, bleeding, feel and odor.
What are your favorite non-surgical wound debridement methods?
At one time, Dr. Hadi was of the thought that using one debridement product at a time was the best approach in order to really evaluate which product yields the best result in the least amount of time. However, with complex wounds, chronicity, vascularity, pain and other associated comorbidities, she has found combination therapy to be more favorable and effective in her practice. Ideally, Dr. Hadi notes one should debride while achieving and maintaining a stable wound environment.
As Dr. Kim says, collagenase can work for small wounds on an outpatient basis whereas enzymatic debridement takes a long time. He notes there are very few instances in which one cannot perform sharp debridement.“There is no method as effective as sharp debridement,” asserts Dr. Kim.
Enzymatic debriding agents have been Dr. Hadi’s go-to modalities and she often uses collagenase for wounds with heavy eschar or fibrous tissue.
Dr. Suzuki also uses a lot of medical honey products, such as Medihoney (Derma Sciences), in his institution for osmotic debridement. He also uses various water-based wound gels for autolytic debridement. Dr. Hadi will use Medihoney for wounds with a thinner fibrous slough layer. She couples Medihoney and collegenase with either an alginate or preferably Promogran Prisma (Acelity), adding that Promogran Prisma helps wick exudate while maintaining a moist wound environment.
“These combinations work well together if sharp debridement is not warranted or possible,” notes Dr. Hadi.
For non-surgical debridement, Dr. Armstrong suggests taking the back of a Bovie scratch pad (Bovie Medical) and roughening up the surface of the wound. He notes this method offers quality debridement. Before virtually all of his skin grafts, Dr. Armstrong will take a chlorhexidine surgical scrub and roughen up the surface of the wound prior to debridement or lavage.
Dr. Suzuki suggests maggot-based debridement is a good option for minimally invasive and minimally painful wound debridement. However, he cautions maggot debridement is generally difficult to implement because of the cost (about $100 per treatment, repeating treatment every three days) and patient acceptance of the maggot treatment.
Dr. Armstrong is a Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
Dr. Hadi is currently a full-time faculty member at the Louis Stokes Veterans Administration Medical Center in Cleveland and the Akron Community-Based Outpatient Clinic. She served as a past Preservation Amputation for Veterans Everywhere (PAVE) Program Director with the Veterans Administration Puget Sound Health Care System in Puget Sound, Wash.
Dr. Kim is a Professor in Plastic Surgery and Orthopedic Surgery at the University of Texas Southwestern in Dallas. He is the Medical Director of the Wound Program at the William P. Clements, Jr. University Hospital in Dallas. Dr. Kim is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Suzuki is the Medical Director of the ICM Wound Care Clinic in Beverly Hills, CA. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles CA. He can be reached at Kazu.Suzuki@cshs.org.