Sharp Debridement Aids Recalcitrant Venous Ulcer Healing

       Reference: Williams D, Enoch S, Miller D, Harris K, Price P, Harding KG. Effect of sharp debridement using curette on recalcitrant nonhealing venous leg ulcers: a concurrently controlled, prospective cohort study. Wound Repair Regen. 2005;13(2):131–137.
       Rationale: Chronic nonhealing venous leg ulcer (CVLU) wound beds usually contain slough and nonviable tissue. It is common practice to remove devitalized tissue using autolytic, enzymatic, mechanical, biosurgical, surgical, or sharp debridement, with the latter 2 deemed the fastest-acting modalities. The role of sharp debridement in CVLU management has not been fully evaluated.
       Objective: This concurrently controlled, prospective, parallel, cohort study compared healing of CVLUs with surface slough or nonviable tissue managed with initial sharp debridement curettage to healing of similar CVLUs managed using the same standard treatment without sharp debridement for CVLUs with some granulation and no nonviable tissue.
       Methods: Over a 12-month period, all patients with static ulcers referred to a specialist wound center were enrolled into 1 of 2 cohorts for a period of 4 weeks before debridement and 20 weeks after debridement. One cohort of 26 patients with slough and nonviable tissue in the wound bed and no granulation tissue after 4 weeks received sharp curette debridement by 1 surgeon who debrided to a vascular base without topical anesthesia. All patients had 1 initial debridement except 1 patient who experienced pain on the first debridement and was redebrided the following week with local topical anesthetic. A calcium alginate dressing was applied to manage blood loss after debridement. The control cohort of 27 patients had CVLUs with 15–20% granulation tissue with no slough or nonviable tissue, so curettage would not have been appropriate. The control group received the same standardized care including appropriate graduated compression without sharp debridement. Ulcer areas were measured on enrollment, at debridement, and 4 and 20 weeks after the debridement.
       Results: Both cohorts experienced no significant reduction in ulcer area during the first 4 weeks. The sharply debrided ulcers reduced in area significantly more than the control group by 4 and 20 weeks after debridement. Five subjects in each cohort healed during the 24-week study. No differences in mean areas, antibiotic usage, or clinical infections between the 2 cohorts were significant at any time of measurement.
       Conclusion: Sharp debridement using a curette was a safe and effective method of expediting area reduction of intractable chronic venous leg ulcers.

Frequent Sharp Debridement Accompanies Diabetic Foot Ulcer Healing

       Reference: Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg. 1996;183(1):61–64.
       Rationale: Diabetic foot ulcers are a significant problem in the United States. Studies exploring effects of growth factors on their healing resulted in inconsistent evidence of efficacy. The role of adjunctive therapy, such as debridement, may play an unexplored role in healing these ulcers.
       Objective: This prospective, randomized, controlled study explored effects of recombinant human platelet-derived growth factor (rhPDGF) gel versus placebo gel in patients with diabetic foot ulcers.
       Methods: Subjects (n=118) with nonhealing, noninfected diabetic neuropathic foot ulcers of at least 8 weeks duration and adequate arterial blood supply were randomly assigned to topical treatment with either rhPDGF in a gel vehicle or placebo. Treatment continued for 20 weeks or until healing, defined as 100% closure, whichever came first. Before randomization, all ulcers in both groups underwent aggressive sharp debridement. During the study, sharp debridement of callus and necrotic tissue down to bleeding tissue was repeated as needed during the patients’ office visits. Analysis of subject records of the follow-up office visits where sharp debridement was performed explored the relationship between sharp debridement frequency and ulcer healing by center in the rhPDGF and placebo groups.
       Results: Significantly more ulcers healed by 20 weeks in the rhPDGF group (48%) than in the placebo group (25%, p = 0.01). Within the rhPDGF group, centers engaging in frequent sharp debridement at the highest percentage of office visits had the highest percent of patients healed. This was not so in the placebo group, but the converse was true: the center with the lowest proportion of office debridement visits had the lowest healing rate.
       Conclusions: The authors concluded that sharp debridement as practiced in this study played an important role in the management of these patients and that any growth factor is likely to be most effective in the context of optimal care including sharp debridement.

Clinical Perspective

       These 2 studies help clarify the role of sharp debridement in venous and neuropathic diabetic foot ulcers. Both studies support conservative sharp debridement to the plane of bleeding tissue. The venous ulcer study supported single-operator 1-time curettage for ulcers with devitalized tissue failing to decline in area during 4 weeks. In the diabetic foot ulcer study, healing results in the rhPDGF group favored operators who engaged in more frequent debridement. Many questions remain to be answered by prospective, randomized, controlled studies. Is there an ideal sharp debridement technique and frequency for all chronic wounds, or does a venous leg ulcer respond better to 1 protocol of sharp debridement while other chronic wounds may respond better to other methods? Does this research generalize to acute wounds, such as burn, surgical,² or traumatic wounds? How do healing results using sharp debridement compare to healing results using autolytic debridement with hydrating gels found effective in aiding diabetic foot ulcer healing in a Cochrane review?³ What other variables determine the ideal debridement technique, modality, depth, or frequency to achieve optimal healing effects? Considering how widespread the practice of debridement is, vast opportunities remain for optimizing clinical outcomes. There is an even more important issue than optimizing chronic wound debridement. Clinicians managing chronic wounds need to recognize that slough or necrotic tissue accumulating on any wound surface is a danger signal. It is the wound’s way of communicating that its tissue is dying. Wise wound care professionals will take a step beyond debridement to heed that danger signal then diagnose and alleviate the cause(s) of tissue death so the wound can resume healing.