Scoring systems to assess the quality of the debridement have already been published (4,5). Mar- golis et al. (5) designed a classification adapted to DFU ulcers. Three extents of debridement were defined: callus, ulcer’s edge undermining, and wound bed necrotic tissue. A score of 0 to 2 was applied to each of these categories using the following criteria: 0=debridement needed but not done, 1=debridement needed and done, and 2=debridement not needed. A total rang- ing from 0 to 6 could be defined, with the highest number being the optimal score. This instru- ment, the Debridement Performance Index, evaluates both the adequacy of debridement and whether the ulcer has been properly debrided. To initiate the validation of this scoring system and determine its predictive value for wound closure by week 12, the score was applied to 143 patients with DFUs who had been treated in a clinical trial involving either standard therapy or the application of a bioengineered skin construct. Each DFU was evaluated using sequential dig- ital photographs and the Debridement Performance Index score was applied at day zero, before initiation of either treatment. Results showed that the lower the baseline Debridement Perfor- mance Index the lower the incidence of ultimate wound closure by week 12 and patients with a Debridement Performance Index between 3 and 6 were 2.4 times more likely to heal than those with a score of 0 to 2. After controlling for treatment, the Debridement Performance Index was found to be an independent predictor of wound closure.
DEBRIDEMENT TECHNIQUES
Debridement can be performed using different modes (Fig. 2). The surgeon will act in continuity with other professionals and should limit his action to what cannot be done by others (Fig. 3).
Surgical Excision
Surgical excision can be realized with or without anesthesia, depending on the pain level and the equipment of the operating room. An instrument set including scalpel, scissors, a gouge, and a coagulation system can be enough to realize a fruitful debridement. More specific tools have recently been developed in order to detach devitalized tissues strongly adherent to the adjacent structures. In the performance of the debridement procedure, sound surgical judg- ment is critical to balancing the need for adequate tissue resection and limb preservation ver- sus the consideration of an amputation. A careful sharp surgical and complete parage can be performed in the operating room, in order to optimize tissue salvage. Options will vary depending on the availability of new technologies such as negative pressure therapy, or the capacity to cover the would using well-vascularized structures or other technologies. Cut- ting back along the would edges in order to refresh the local vascularization is usually per- formed. A precise evaluation of the vascular status of the lower limb is then critical. Preoperative
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FIGURE 2
prognosis of the vascular future of a tissue is one of the most difficult points: the operator has to keep in mind the general condition of the patient, the local tissue perfusion, and the degree of ischemia before giving a chance to an uncertain structure, the risk being reappearance of necrosis on the edges.
Necrotic tissues should be completely excised. Sloughy tissues will be removed, depend- ing on their proximity to vital structures. Aponeuroses are protective structures for the underly- ing longitudinal muscles, neurovascular bundles, or tendons. When opened, infection can easily extend along the tendons, nerves, and vessels. Debridement outcomes have to be anticipated using decision analytic methods (7).
Washing
Washing is the standard technique for evacuation of germs and stimulation of angiogenesis. Undermined cavities, pouches, and sinuses have to be washed carefully. Washing using sterile water is the most common procedure. Cleansing can be performed using water projected from a simple syringe in order to remove devitalized tissues located in undermined areas. The pres- sure is mild and the risk of germ projections is limited. Other devices, like Jetox, combine the mechanical forces of the waterjet and oxygen from the wall unit.
More specific tools have recently been developed in order to detach devitalized tissues strongly adherent to the adjacent structures.
Hydrojets
More powerful hydrojet devices have recently been proposed. Debritom® (Medaxis, Santa Mon- ica, CA) is a high-pressure device, developed in order to remove all devitalized areas using a very powerful jet, coming from a compressor, using a handpiece to concentrate pressure. This device needs a set of handpieces that can be sterilized and reused, limiting the cost. Tents have been developed in order to protect the environment from projections of germs. This technique is still under evaluation, but interesting preliminary series have evaluated the level of pain, which remains moderate, the numbers of stages needed to completely debride the wound, and the adaptability to an ambulatory use in the wards (Fig. 4) (8).
Versajet™ (Smith & Nephew, Largo, FL) was initially developed in Germany and more commonly used in the United States and Europe since 2004. Versajet is a unique device propos- ing a three-in-one combination of effects, debridement, aspiration, and removal of the sloughy and devascularized tissues (9). The handpiece is connected under a sterile manner to the aspi- ration machine. Based on the Venturi effect, removal of tissues is realized without any contam- ination of the surrounding tissues (Fig. 5). Cost of the machine and of the disposable device is
Surgical Debridement 93
FIGURE 3
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FIGURE 4
Heel pressure sore: (A) Before and (B) after a single application of DebritomTMhigh
pressure waterjet.
high compared with the other systems. However, Granick et al. (11) have recently evaluated the cost efficacy of Versajet with a positive input on the global wound management costs. Selectiv- ity of the debridement and reduced blood loss makes the technique attractive.
Pain provoked by hydrojet debridement varies following different situations: in DFUs, with reduced or absent sensation, Versajet is well tolerated. In trauma wounds or burns, pain can be severe and often require a general anesthesia. Versajet plus, a more powerful version with more capacity to remove hard tissues, looks promising.
Hydrojets should be used properly. Surgeons should keep in mind that fragile soft tissues cannot sustain excessive mechanical forces.
INDICATIONS FOR DEBRIDEMENT