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Point-Counterpoint: Is Hydrosurgery More Efficacious Than Ultrasonic Debridement In The Diabetic Foot?

Point.

Dr. Eric Lullove

This author contends that hydrosurgery facilitates precise debridement while
preserving healthy adjacent tissue, allows for optimal wound bed preparation for skin grafting procedures and has reduced costs and complications in comparison
to other debridement techniques.

By Eric Lullove, DPM, CWS, FACCWS

Debridement is an essential component of wound management because the presence of devitalized tissue within the wound may mask or mimic signs of infection.1 Necrotic tissue may serve as a source of nutrients for bacteria, particularly anaerobes such as Bacteroides species and Clostridium perfringens.2 Devitalized tissue also acts as a physical barrier to healing and could prevent the effectiveness of topical antimicrobials, pain relief formulations and steroids. This barrier may subsequently impede normal matrix formation, angiogenesis, granulation tissue formation and epidermal resurfacing.3 This unhealthy tissue may also contribute to the production of inflammatory cytokines that can promote a septic response, and can also lead to the overproduction of matrix metalloproteases (MMPs).2, 3

The presence of necrotic tissue within the wound may not only impair healing and lead to an exaggerated inflammatory response, it may also prevent the clinician from gaining an accurate picture of the extent of tissue destruction. This in turn inhibits the clinician’s ability to assess the wound correctly.2-4 This phenomenon may be of particular significance in pressure wounds and diabetic foot ulcers (DFUs).

Therefore, there is a need to remove necrotic tissue as quickly and efficiently as possible to reduce bioburden, prevent infection, promote wound closure and assist with proper wound assessment.5,6 Hydrosurgical debridement can be a very efficient modality to accomplish these goals for traumatic wounds, pressure sores, burn wounds, and chronic non-healing wounds due to diabetes mellitus, venous insufficiency and peripheral vascular disease.

How Hydrosurgical Debridement Works

The hydrosurgery system console highly pressurizes saline, hypochlorous acid or any other sterile solution, and generates a jet of solution, which is emitted from the tip of the handheld instrument. When the jet of solution travels through the nozzle of the instrument, there is a Venturi effect, which increases the fluid’s velocity and decreases its static pressure due to passage through a constricted area. The high-pressure delivery of this solution clears non-viable tissue from a wound. The debrided tissue is subsequently removed via an evacuator port next to the tip of the instrument and into a collection canister.7,8

The single-use, handheld instrument is attached to a console and the surgeon activates the system with a foot pedal. The surgeon can adjust the velocity with which the fluid is delivered. This allows for precise depth of debridement, thus achieving accurate and complete removal of non-viable tissue with maximum preservation of healthy tissue.

Assessing The Benefits Of Hydrosurgery

The inability to remove hard eschar and debride bone are two known drawbacks of hydrosurgery. Even though hydrosurgery does not replace sharp techniques for dessicated eschar removal and bone debridement, it can be an efficient alternative as a cutting implement.

The use of hydrosurgical debridement provides the operator some choice and flexibility in the best application of the treatment. The closer the operating window is to parallel, the more aggressive the tissue excision one can perform. When one orients the operating window obliquely to the tissue, the primary actions become irrigation and vacuuming of the contaminated tissue.

Again, one can adjust the pressure and velocity of the hydrosurgery jet to regulate debridement. The faster the water, the more effective the cutting technique becomes.3

This single-device system combines lavage and sharp debridement instrumentation with single-handed operation. The device provides the control to hold targeted tissue during irrigation and excision. Importantly, the handpiece provides the ability to perform simultaneous debridement and removal of debris by aspiration. This helps keep the operative field cleaner and drier in comparison to conventional lavage techniques. The hydrosurgery system offers a highly selective form of tangential excision that enables surgeons to precisely target damaged and necrotic tissue and debris while sparing the viable adjacent tissues. In addition, when comparing the hydrosurgery system to sharp debridement, there is less bleeding, which can be especially important for patients on anticoagulant therapy.

In my clinical experience, the use of hydrosurgical debridement also leads to decreased operative and anesthesia times as well as fewer debridement encounters. It is the optimal procedure choice for planning split- and full-thickness skin grafting as hydrosurgical debridement allows for more optimal wound bed preparation. The hydrosurgery system allows the surgeon to work from inside the wound rather than from the outside. In most cases, one can precisely debride the wound of all unwanted tissue in a single operative sitting. This facilitates a more rapid progression to surgical closure or the application of effective topical therapy.

While the use of the waterjet involves the added cost of the handpiece, one can eliminate the need for other surgical equipment (e.g., pulse irrigator, larger quantities of saline, large surgical trays). The major economic impact of the hydrosurgical technique parallels the improved wound healing. In one study assessing hydrosurgical debridement, patient outcomes improved and the hospital had decreased expenditures for patient care due to reducing the number of operative procedures required to prepare the wound bed.8 Hydrosurgery also shortens the average inpatient hospital stay by reducing the need for prolonged serial debridements.

In Conclusion

In my experience, hydrosurgery has been beneficial in a multitude of clinical scenarios. While there is the additional cost of the handpiece to consider, the benefits of hydrosurgical debridement outweigh the associated risks with standard sharp debridement in cases that require skin graft preparation, reduction of hyperplastic granulation tissue or the need to preserve as much tissue as possible. 

Dr. Lullove is in private practice in Coconut Creek, Fla. He is the Chief Medical Officer of the West Boca Center for Wound Healing. He is a Staff Physician at West Boca Medical Center in Boca Raton. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists.

Dr. Lullove has disclosed that he previously consulted for Smith and Nephew, Celleration and Misonix.

References

1. O’Brien M. Exploring methods of wound debridement. Br J Community Nurs. 2002;7(Supp3):10-18.

2. Leaper D. Sharp technique for wound debridement. World Wide Wounds. Available at: http://www.worldwidewounds.com/2002/december/Leaper/Sharp-Debridement.html. Published December 2002. Accessed July 15, 2019.

3. Weir D, Scarborough P, Niezgoda JA. Wound debridement. In: Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. HMP Communications, Malvern, PA; 2007:343-355.

4. Vowden P, Vowden K. The economic impact of hard-to-heal wounds: promoting practice change to address passivity in wound management. Wounds Int. 2016;7(2):10-15.

5. Ayello EA, Cuddigan JE. Debridement: controlling the necrotic/cellular burden. Adv Skin Wound Care. 2004;17(2):66-75.

6. Reid K, Morrison M. Towards a consensus: classification of pressure ulcers. J Wound Care. 1994;3(3):157-160.

7. The Debrisoft monofilament debridement pad for use in acute or chronic wounds. National Institute for Health and Care Excellence. Available at: https://www.nice.org.uk/guidance/mtg17. Published March 2014. Updated March 2019. Accessed July 15, 2019.

8. Sainsbury DC. Evaluation of the quality and cost-effectiveness of Versajet hydrosurgery. Int Wound J. 2009;6(1):24-29.

Counterpoint.

Dr. Christopher Winters

Sharing insights from his clinical experience as well as the literature,
this author maintains that ultrasonic debridement enables clinicians to safely
target necrotic tissue and facilitates improved wound healing.   

By Christopher L. Winters, DPM, CWS-P

Debridement is the cornerstone of wound bed preparation in diabetic foot ulcers (DFUs). Proper debridement techniques are needed in order to efficaciously heal wounds. With the advent of newer technologies such as ultrasound, we can better debride wounds and ultimately heal these wounds faster than other currently available methods. While surgeons may choose from a variety of debridement methods, I would argue that ultrasonic debridement has many advantages to help heal wounds in the diabetic foot more rapidly.

Ultrasonic debridement is a method of removing devitalized tissue. The technique uses normal saline solution as the contact medium for the ultrasound waves to travel from the handpiece into the tissues via direct contact. Another advantage of ultrasonic debridement is that it has several different types of applicator tips. It is advantageous to have different types of tips for different types of wounds. Some wounds that are deep and tunneling require a different tip than a standard full-thickness wound without tunneling.

The therapeutic effects of low-frequency ultrasound on wound bed preparation and healing are well-documented in the literature. The mechanism of action of this technique involves acoustic microstreaming and cavitation. Acoustic streaming reportedly changes cell membrane permeability, which may allow for increased protein synthesis and increased production of growth factors.1

While surgeons will always employ traditional sharp debridement when appropriate, having ultrasonic debridement in the surgeon’s toolbox is of great benefit and in my hands has provided much greater wound healing rates than standard or hydrosurgical techniques. This method is much gentler on the tissues, especially the vascular structures, than other more aggressive techniques. This is especially important in a patient with peripheral arterial disease as aggressive debridement can harm the tissue and ultimately cause tissue necrosis.

A Closer Look At Two Ultrasonic Debridement Tools

Low-frequency ultrasound SonicOne® O.R. (Misonix®) generates ultrasound waves with a 22.5 kHz frequency. A distinguishing feature of this device is that is provides aspiration while debriding. This allows bacteria from the wound that is being selectively debrided to be suctioned away instead of simply remaining in the surgical field.1 Additionally, it lyses bacteria and biofilm. There is also significantly less spray dispersion using this technique.2 This technique allows clinicians to selectively target nonviable tissue in comparison to viable tissue and facilitates very minimal blood loss.Another advantage of this technique is that one can debride bone as well as soft tissue.

The mechanism of action involves acoustic cavitation. Utilizing low-frequency, high-intensity ultrasound, the titanium tips vibrate at 22.5 kHz. The modality transfers mechanical energy to the tissue, causing molecules to oscillate. Microsized gas bubbles created in tissue and surrounding fluids create bubbles that collapse (implode), which results in destruction of necrotic tissue close to the bubbles. The membranes of healthy tissue simply move with the oscillation. The turbulence created by the imploding gas bubbles may be one mechanism by which destruction of bacteria and biofilm occurs.3 One can utilize this technique for patients with diabetes.

Another type of ultrasonic debridement involves non-contact low-frequency ultrasound. The commercially available unit is MIST® Therapy (Celularity). This method does not create thermal energy and one can employ this modality for debridement in the diabetic foot. This is a low power form of ultrasonic debridement. The value of this type of ultrasound is that clinicians can use it more frequently and it does not typically require anesthesia, nor that one performs the procedure in the operating room.  Any trained health care professional can perform this procedure. Reimbursement is favorable for this single-use probe in an office or wound care clinic setting.

What The Literature Tells Us About Ultrasonic Debridement

In regard to non-contact, low-frequency ultrasound, Ennis and colleagues in 2005 conducted a randomized, double-blinded, sham-controlled, multicenter study in hospital-based and private wound care clinics.4 Patients received standard wound care, which included products that provide a moist wound environment, offloading diabetic shoes and socks, and sharp or ultrasonic debridement versus sham, which delivered mist without ultrasound. Treatment was either active 40 KHz ultrasound delivered by a saline mist or a “sham device,” which delivered a saline mist without the use of ultrasound. After 12 weeks of care, the proportion of wounds healed (defined as complete epithelialization without drainage) in the active ultrasound therapy device group was significantly higher than that in the sham control group.

Kavros and colleagues also reported faster wound healing rates using a non-contact, low frequency device.5

In a 2017 randomized, controlled trial, Murphy and coworkers assessed the use of low-frequency contact ultrasonic debridement in patients with vasculopathy and lower extremity wounds of mixed etiology.6 In the study, which involved 68 patients, 33 patients received low-frequency contact ultrasonic debridement (LFCUD) plus standard wound care and 37 patients received standard wound care alone at four weekly visits. The study researchers followed patients for up to 12 weeks.

After four weekly treatments, patients in the group who received low-frequency contact ultrasonic debridement had significantly better wound appearance and reduction in the wound surface area in comparison to the control group.6 Patients who received low-frequency contact ultrasonic debridement also had a greater number of healed wounds and fewer instances of wound deterioration. The authors concluded that weekly low-frequency contact ultrasonic debridement application for patients with significant vasculopathy resulted in superior healing outcomes in comparison to current usual wound care practice.

A 2016 abstract by Betesh and colleagues reported increased skin graft take rates using ultrasonic debridement in comparison to standard debridement.7 While this study had a small number of patients, nine out of 10 patients had greater than 90 percent closure after routine six month follow-up. In comparison, other authors have reported a 78 percent success rate at achieving 90 percent closure with split thickness skin grafts after traditional wound bed preparation.7

Employing hypochlorous acid for irrigation during treatment, Grannick and colleagues demonstrated in a 2017 article that direct-contact low-frequency ultrasound is effective at eradicating biofilms on metallic implants.2

There are also favorable economic benefits as more effective ultrasonic debridement means higher cost savings per patient in comparison to sharp debridement. The SonicOne O.R. reportedly reduced the number of debridements needed by 39 percent over a twelve-week period.8 This is modestly better than hydrosurgery, which shows a reported encounter reduction of 36 percent in comparison to sharp debridements.9

In Conclusion

The use of ultrasonic debridement has shown great promise in treating DFUs. It is versatile in that one can use it both in the clinic as a non-contact option or in the operating room using direct contact. Numerous studies have shown that ultrasonic debridement is more effective than standard debridement techniques and it is less aggressive than the hydrosurgical technique in that it is selective for necrotic tissue and preserves healthy tissue. Ultrasonic debridement is easy to use, provides aspiration and rapidly decreases the bacterial counts in the wound bed, thus allowing the wound to heal more rapidly, or, if indicated, accept a skin graft or biologic product.

Surgeons should consider adding this form of debridement to their practice as the evidence has proven that it is safe, cost-effective and allows for more rapid wound healing to occur. 

Dr. Winters is affiliated with the American Health Network in the Indianapolis area and many hospitals in Indiana. He is board-certified in wound care by the Council for Medical Education and Testing, board-certified in the prevention and treatment of diabetic foot wounds by the American Board of Multiple Specialties in Podiatry, and is a Certified Wound Specialist Physician by the American Board of Wound Management.

References

1. Abolghasemi D, Szymanski KD, Baruch M, Zuberi J. Surgical debridement with SonicOne; an initial look at the bacterial load pre-and post-low frequency direct contact ultrasound. Presented at The Diabetic Limb Salvage Meeting, March 31-April 2, 2016. Washington, DC. Available at http://misonix.com/wp-content/uploads/2016/03/00443-MIS-Abstract-SonicOne-OR-spreads-v5.pdf. Accessed July 16, 2019.

2. Granick M, Rubinsky L, Parthiban C, Shanmugam M, Ramasubbu N. Dispersion risk associated with surgical debridement devices. Wounds. 2017;29(10):E88-E91.

3. Granick MS, Baruch M, Caputo W, Glat P. The clinical implications of a new wound debridement device that combines low frequency direct contact ultrasound and vacuum aspiration. Presented at The Diabetic Limb Salvage Meeting, March 31-April 2, 2016, Washington, DC. Available at: http://misonix.com/wp-content/uploads/2016/03/00443-MIS-Abstract-SonicOne-OR-spreads-v5.pdf. Accessed July 16, 2019.

4. Ennis WJ, Foremann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Manage. 2005;51(8):24-39.

5. Kavros SJ, Liedl DA, Boon AJ, Miller JL, Hobbs JA, Andrews KL. Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis. Adv Skin Wound Care. 2008;21(9):416-423.

6. Murphy CA, Houghton P, Brandys T, Rose G, Bryant D. The effect of 22.5 kHz low-frequency contact ultrasound debridement (LFCUD) on lower extremity wound healing for a vascular surgery population: a randomised controlled trial. Int Wound J. 2018;15(3):460-472.

7. Betesh SM, Gazes MI, Blume P. Split thickness skin graft incorporation  after ultrasonic debridement for wound bed preparation in diabetic  foot wounds. Presented at The Diabetic Limb Salvage Meeting, March 31-April 2, 2016, Washington, DC. Available at:  http://misonix.com/wp-content/uploads/2016/03/00443-MIS-Abstract-SonicOne-OR-spreads-v5.pdf. Accessed July 16, 2019.

8. Wendeken ME, Markowitz L, Alvarez OM. A closer look at ultrasonic debridement. Podiatry Today. 2010;23(8):42-48.

9. Granick MS, Posnett J, Jacoby M, Noruthun S, Ganchi PA, Datiashvili RO. Efficacy and cost-effectiveness of a high-powered parallel waterjet for wound debridement. Wound Repair Regen. 2006;14(4):394-397.

Additional References

10. Al-Mahfoudh R, Qattan E, Ellenbogen JR, Wilby M, Barrett C, Pigott T. Applications of the ultrasonic bone cutter in spinal surgery - our preliminary experience. Br J Neurosurg. 2014;28(1):56-60.

11. Bowlby M, Blume P. Can ultrasound debridement facilitate biofilm removal from diabetic foot ulcers? Podiatry Today. 2014;27(8): 20-24.

12. Donegan RJ, Schmidt BM, Blume PA. An overview of factors maximizing successful split-thickness skin grafting in diabetic wounds. Diabet Foot Ankle. 2014;5(1). Published October 24, 2014. Accessed July 16, 2019.

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By Eric Lullove, DPM, CWS, FACCWS and Christopher L. Winters, DPM, CWS-P
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