Approximately 2 million people in the United States are living with limb loss, and this figure is expected to double by 2050. Lower-limb amputation accounts for the vast majority of all amputations, and diabetes—specifically, diabetic foot ulcers (DFUs)—is the leading cause of nontraumatic...
By Michel H.E. Hermans, MD
There are a number of general rules in surgery. Among these: dead space has to be avoided. interestingly enough, there is virtually no real scientific documentation about this topic but everybody knows this to be true (in ulcers this, of course, applies to fistulae, crevices, etc.).
Another general rule is that dead tissue and foreign bodies have to be removed since they are dangerous to the body. Dead tissue (necrosis and slough) is a breeding ground for bacteria, leading to infection (and sepsis) and releases toxins into circulation. As an example: a regular-size adult with a 50% total body area full-thickness burn has 5 kilos (approximately 11 pounds) of dead tissue, and the absorbed toxins rapidly lead to burn disease, a systemic phenomenon. Similarly, in patients with necrotizing fasciitis, an infection that starts as a localized one but very rapidly expands, the mortality is very high when excision is not performed quickly and radically. Both are examples of why debridement is necessary. So why, then, is debridement performed less frequently on many chronic wounds?
The Role of Debridement in Wound Treatment
In patients with ulcers, sepsis rarely occurs which may be one of the reasons why debridement, getting rid of dead tissue with the associated bacteria (and biofilm), is not performed as often as it should be. When I did a photographic review of a number of clinical cases of patients who had been treated for sometimes years without significant signs of progress, it became rapidly clear that many of the ulcers, covered with slough and necrosis, had been treated with more or less sophisticated dressings but without frequent debridement.
It often surprises me at chronic wound care conferences that debridement per se still needs to be discussed: with few exceptions it is not an option but should be an integral part of wound care (as the TIME acronym indicates). Unfortunately, it often is not. Its importance cannot be stressed enough. It is probably even fair to say that, without proper and frequent debridement, even the most sophisticated dressings and treatment mechanisms fail to do their job properly or optimally.
Barriers to Success for Different Debridement Techniques
In looking at the various techniques available for wound debridement, we may also look at some of the barriers each method presents, perhaps lending reason to the frequency of performance. Autolytic debridement works somewhat but is slow. Certain enzymes have shown to be effective but not all of them are and if they work they are also slow. Wet to dry technique does work well but is painful and harms the wound surface since it is indiscriminate. Biomechanical debridement (with maggots) is very effective but the psychological impact of having crawling creatures in one's wound should not be underestimated. Surgical debridement is by far the quickest way but has to be performed carefully to avoid damage to the tissues and may only be used by specifically trained health care providers. And then, of course and as always, reimbursement issues may play a significant role.
Still, whatever debridement methodology is chosen: it should always be at the top of the list of wound care interventions and not an afterthought. Following the general rule, careful consideration should be given to all wounds that may benefit from having debridement performed to optimize the effectiveness of the overall treatment regimen.
About the Author
Michel H.E. Hermans, MD, is an expert in wound care and related topics, trained in general surgery, trauma care and burn care in the Netherlands. He has more than 25 years of senior management experience in the wound care industry. He has conducted a large number of clinical trials relating to devices and drugs aimed at wound care and related indications and diseases. Dr. Hermans speaks internationally and has authored many published works relating to wound management.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.