Toward a common language: surgical wound bed preparation and debridement

Wound management encompasses a number of disciplines. As new concepts and innovative technologies develop within this exciting field, it is important to share them in spite of the divergence of clinical perspectives between the expert disciplines. One such divergence exists between surgeons and nonsurgical wound specialists. As a result, there is a need to develop a common language between these two groups. How can we develop a common language that unites surgical expertise within medical wound management? One route may be through the principles of wound bed preparation, which we believe have great potential for the communication of effective surgical techniques. Another is through sharing our concepts of surgical debridement as it is applied to different wounds by a variety of surgical disciplines. In this monograph, we try to bring these two themes together. We discuss how wound bed preparation has added to our understanding of the pathophysiology of the nonhealing wound and has provided us with some general clinical concepts. We discuss what role debridement, and then specifically surgical debridement, has to play within wound bed preparation, before analyzing the importance of surgical debridement in tissue preservation and the control of infection. We finally look at ongoing work that examines the cost of various surgical debridement techniques. We will also review a new hydrosurgery system (VERSAJET^®, Smith and Nephew, Hull, UK), which we believe has an important role to play in the surgical preparation of the wound. We also expect that this paper will remind our medical colleagues about the critical role played by surgery in wound management.     

Wound bed preparation: a systematic approach to wound management

The healing process in acute wounds has been extensively studied and the knowledge derived from these studies has often been extrapolated to the care of chronic wounds, on the assumption that nonhealing chronic wounds were simply aberrations of the normal tissue repair process. However, this approach is less than satisfactory, as the chronic wound healing process differs in many important respects from that seen in acute wounds. In chronic wounds, the orderly sequence of events seen in acute wounds becomes disrupted or “stuck” at one or more of the different stages of wound healing. For the normal repair process to resume, the barrier to healing must be identified and removed through application of the correct techniques. It is important, therefore, to understand the molecular events that are involved in the wound healing process in order to select the most appropriate intervention. Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. Experts in wound management consider that wound bed preparation is an important concept with significant potential as an educational tool in wound management. This article was developed after a meeting of wound healing experts in June 2002 and is intended to provide an overview of the current status, role, and key elements of wound bed preparation. Readers will be able to examine the following issues; ? the current status of wound bed preparation; ? an analysis of the acute and chronic wound environments; ? how wound healing can take place in these environments; ? the role of wound bed preparation in the clinic; ? the clinical and cellular components of the wound bed preparation concept; ? a detailed analysis of the components of wound bed preparation. (WOUND REP REG 2003;11:1–28)     

Wound bed preparation: a systematic approach to wound management

The healing process in acute wounds has been extensively studied and the knowledge derived from these studies has often been extrapolated to the care of chronic wounds, on the assumption that nonhealing chronic wounds were simply aberrations of the normal tissue repair process. However, this approach is less than satisfactory, as the chronic wound healing process differs in many important respects from that seen in acute wounds. In chronic wounds, the orderly sequence of events seen in acute wounds becomes disrupted or "stuck" at one or more of the different stages of wound healing. For the normal repair process to resume, the barrier to healing must be identified and removed through application of the correct techniques. It is important, therefore, to understand the molecular events that are involved in the wound healing process in order to select the most appropriate intervention. Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. Experts in wound management consider that wound bed preparation is an important concept with significant potential as an educational tool in wound management.
This article was developed after a meeting of wound healing experts in June 2002 and is intended to provide an overview of the current status, role, and key elements of wound bed preparation. Readers will be able to examine the following issues;
• the current status of wound bed preparation;
• an analysis of the acute and chronic wound environments;
• how wound healing can take place in these environments;
• the role of wound bed preparation in the clinic;
• the clinical and cellular components of the wound bed preparation concept;
• a detailed analysis of the components of wound bed preparation.
(WOUND REP REG 2003;11:1–28)     

Using wound bed preparation to heal a malignant fungating wound: a single case study

Full healing was achieved within eight weeks in a malignant fungating wound using the principles of the TIME paradigm. This concept appears to provide a structured and systematic approach for managing such non-healing wounds.     

Fatal iodine toxicity following surgical debridement of a hip wound: case report

This report presents the case of a patient who expired 10 hours following and emergent hip-wound debridement where Betadine, a povidone iodine solution, was used to provide continuous postoperative wound irrigation. Toxic manifestations of systemic iodine absorption appeared to cause her demise.     

The science of wound bed preparation

The concept of wound bed preparation (WBP) heralded a new era in terms of how we treat wounds. It emphasized the difference between acute and chronic wounds, and it cemented the idea that the processes involved in the healing of acute wounds do not apply completely to the healing of chronic wounds. The arbitrary division of the normal healing process into the phases of hemostasis, inflammation, proliferation, and maturation addresses the events in acute wound healing. We have realized that the impediments to healing in chronic wounds lead to a failure to progress through these phases and are independent factors that make the chronic wound a much more complex condition. A major advance in resolving or addressing the chronic wound has been the concept of WBP. WBP allows us to address the problems of wound healing individually-the presence of necrotic tissue, hypoxia, high bacterial burden, corrupt matrix, and senescent cells within the wound bed. In WBP we can optimize our therapeutic agents to accelerate endogenous healing or to increase the effectiveness of advanced therapies.     

Reviewing the evidence for wound bed preparation

This paper explores the nature of evidence and how it has evolved in recent years, and sets out a process for assembling and assessing the evidence to support wound bed preparation as an effective method of managing chronic wounds     

Surgical wound bed preparation of chronic and acute wounds

Our aging population has presented us with many new challenges. One such challenge is the need to manage an increase in wound-related problems effectively and efficiently. Over time, two parallel, yet divergent, management systems have developed. One strategy, used by medical specialists, uses a variety of dressings, topical enzymes, and local and systemic medications ultimately aimed at the promotion of healing by secondary intention or, in some cases, optimization of the wound for surgical reconstruction. In the second strategy, used by surgeons, early surgical intervention is used to prepare the wound for reconstruction in a timelier manner while promoting the healing process. This article reviews the development of these two distinct management systems and their areas of commonality and sets forth a new model to support the role of surgery in the treatment of problematic wounds.     

The cost of wound debridement: a Canadian perspective

Debridement is integral to wound bed preparation by removing devitalised tissue, foreign material, senescent cells, phenotypically abnormal/dysfunctional cells (cellular burden) and bacteria sequestrum (biofilm). While the body of evidence to substantiate the benefits of debridement is growing, little is known about the cost‐effectiveness of each debridement method. The purpose of this analysis was to compare cost‐effectiveness of various debridement methods and clinical outcomes to help inform clinicians and policy makers of the cost‐effectiveness associated with the various types of therapies and the impact they can have on the Canadian health care system. Results indicated that sharp debridement was the most cost‐effective followed by enzymatic debridement method.     

Traumatic wound debridement: a comparison of irrigation methods

OBJECTIVES: To test wound debridement efficacy and soft tissue damage produced by high-pressure pulsatile lavage (HPPL), suction irrigation, and bulb syringe irrigation. DESIGN: Randomized trial in an in vitro model. SETTING: Medical school orthopaedic department. PATIENTS/PARTICIPANTS: No patients were used in this study. INTERVENTION: Beef flank steaks (100-g +/- 10-g) were divided into 8 test groups and incised uniformly. Four test groups were contaminated with 2 g of rock dust and 4 were not. The specimens were then treated as follows: nothing (control), bulb irrigation, suction irrigation, or HPPL. MAIN OUTCOME MEASUREMENTS: Runoff from the irrigation was collected, filtered, lyophilized, and ashed to allow for quantitative determination of organic and inorganic material removed from the wound by each irrigation method. Digital photographs of the tissue samples were subjected to blinded grading on a scale of 1 to 5 to assess macroscopic soft tissue damage. RESULTS: Qualitatively, tissue samples treated with HPPL consistently received worse grades for tissue damage than samples in any other experimental group. Quantitative soft tissue damage analysis revealed that significantly more organic material was removed from samples treated with HPPL (141.3 +/- 58.9 mg) than those treated with bulb syringe (50.7 +/- 28.6 mg) or suction irrigation (108.7 +/- 174.5 mg). Surprisingly, significantly less inorganic contaminant was removed from tissue samples treated with HPPL (1549.6 +/- 77.3 mg) than those treated with bulb syringe (1834.9 +/- 39.1 mg) or suction irrigation (1827 +/- 39.4 mg). CONCLUSIONS: There has been some concern regarding damage produced by HPPL. According to our quantitative soft tissue damage data, tissue treated by HPPL was damaged significantly more than tissue treated with bulb syringe or suction irrigation. Our qualitative tissue damage grade data showed that HPPL treated test groups appeared more damaged than other irrigation groups. Surprisingly, HPPL removed significantly less inorganic contaminant than other debridement methods, and it is proposed that HPPL may drive some contaminants deeper into the tissue rather than removing them. This study seems to support the concept that suction and sharp debridement, as practiced by most surgeons, may remove foreign bodies well without the use of HPPL.     

Topical use of citric acid for wound bed preparation

Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of split‐skin grafting. The formation of a healthy wound bed is a prerequisite to the use of advanced wound care products. Unless this is achieved, even the most sophisticated and expensive materials are unlikely to function correctly. An attempt has been made to use 3% citric acid ointment for wound bed preparation to prepare wound for grafting in five cases of wounds with large raw areas infected with multiple antibiotic‐resistant bacteria.     

Buried chip skin grafting in neuropathic diabetic foot ulcers following vacuum-assisted wound bed preparation: enhancing a classic surgical tool with novel technologies

In patients with diabetes mellitus, complications such as polyneuropathy and peripheral angiopathy inevitably lead to diabetic foot complications including foot ulcers, gangrene, and osteoarthropathy. These conditions necessitate minor or major amputation as part of treatment. In patients with Charcot's arthropathy and predominant neuropathy, recurrent foot ulcers are common in areas of high pressure. Such high pressure is caused by the degrading of the architecture of the foot and inadequate footwear. These patients are a clinical challenge. A select group of such patients may benefit from free surgical tissue transfer, though free or local flap surgery is often difficult or even impossible owing to an impaired arterial circulation. In such wounds, surgical debridement followed by skin grafts often fail due to bacterial burden in the wounds. To circumvent these problems, the authors developed a therapeutic approach using buried chip skin grafting to close granulation wound beds in diabetic feet. Locally applied vacuum therapy (VAC) for wound bed preparation of chronic, nonresponsive foot ulcers and subsequent grafting using the burying technique with a minute fraction of skin was used. Firm closure was achieved. The closed wound was resistant to mechanical irritation.     

Sternal wound debridement and muscle flap reconstruction: functional implications

The mortality rate for poststernotomy infection, which occurs in as many as 5% of median sternotomy incisions after cardiovascular surgery, was 37.5% until sternal debridement with muscle or omental flap reconstruction became the standard treatment for this postoperative complication and lowered the mortality rate to just more than 5%. There are few reports in the literature of physical functional deficits and long-term outcome resulting from such reconstruction. The authors evaluated two groups of patients who had undergone coronary bypass surgery at least 6 months earlier. One group had no postoperative complications; the other group had developed marked sternal wound infections that required debridement and pectoralis major or rectus abdominis muscle reconstruction. Both groups underwent pectoralis and rectus muscle strength testing, evaluation of pain and ability to perform those activities of daily living that are dependent on pectoral and rectus muscle function, and completed self-assessment questionnaires. Differences between the two groups were significant (p<0.05) with regard to pain and patient satisfaction with appearance and general functional capacity. Pectoral muscle function and strength were significantly different in patients in whom that muscle was transposed. Rectus muscle strength was not affected by the transposition of a single rectus muscle. Physical morbidity and loss of strength seemed to be related directly to loss of sternal stability stemming from marked infection and debridement rather than from loss of the muscles used in reconstruction.     

Efficacy and cost-effectiveness of a high-powered parallel waterjet for wound debridement

Current concepts of wound healing acknowledge the essential role of wound bed preparation in achieving a wound with good healing potential. Critical to wound bed preparation is the removal of necrosis, unhealthy tissue, foreign matter, and infection. One of the accepted methods of wound bed preparation is surgery. The high-power parallel waterjet is a new surgical device, which allows the operator to remove very precisely undesirable tissue and debris with maximal preservation of viable tissue. A retrospective study was performed to evaluate the efficacy, safety, and economic impact of using this technique of surgical debridement. Forty patients who had waterjet debridements were compared with 22 patients with matched wounds who had conventional surgical debridement. The waterjet group had significantly fewer procedures (p<0.002) than the conventional group. Based on these outcomes, the use of the new device in appropriate patients is expected to lead to cost savings of approximately 1,900 dollars per patient.     

Determinants of wound healing in bone marrow-impregnated collagen matrix treatment: Impact of microcirculatory response to surgical debridement

Although previous reports have suggested the efficacy of autologous bone marrow-impregnated collagen matrix experimentally and clinically, we occasionally encounter difficult wounds that fail to respond to the treatment. The current study retrospectively investigated the factors that affect clinical outcomes based on the hypothesis that periwound microcirculation may play a significant role. Fifty-three patients with chronic wounds received surgical debridement, followed by application of an autologous bone marrow-impregnated collagen matrix. The periwound transcutaneous oxygen tension (TcPO₂) was evaluated ( n =39). The patients were retrospectively divided into successful and unsuccessful subgroups. Successful treatment was defined as wound closure by spontaneous healing or skin graft. The TcPO₂ of the unsuccessful subgroup significantly decreased after debridement while that of the successful subgroup increased. Among various parameters, the TcPO₂ at 4 days after debridement showed the strongest association with the success of the treatment. As reference data, we collected the information of the patients ( n =22) who received standard wound care, and they showed the same trend wherein the TcPO₂ of the unsuccessful subgroup markedly decreased after debridement. Reactivity of the wound microcirculation to increased wound perfusion in response to the surgical debridement might be a key determinant for successful wound healing.     

Maggot therapy for wound debridement in a traumatic foot-degloving injury: a case report

A 43-year-old man was treated for a traumatic degloving injury to his foot with a transmetatarsal amputation and wound care because of the extensive soft tissue loss. After biweekly sharp debridements in the office for 4 weeks, very minimal skin ingrowth was noted. Maggot therapy was then implemented for a 48-hour treatment and a second treatment for 72 hours to help reduce excessive fibrosis and to painlessly debride the tissues to expose the granular base. Daily dressing changes for the next 6 weeks successfully allowed complete wound closure without any additional interventions. During the follow-up course, no complications were encountered and the patient has returned to ambulation with the use of a cane.