Disclosure: Dr. Granick was a medical consultant for Smith & Nephew Inc (Largo, Fla)

Chronic wounds represent a huge burden on the population in the United States in terms of both morbidity and annual health care expenditures. An estimated 6.5 million people in the US are afflicted with chronic ulcers due to pressure, venous insufficiency, or diabetes, and health care costs run in the billions of dollars each year. Even with successful treatment, the recurrence rate for ulcers ranges from 66%–90% depending on the etiology. The wound care marketplace has been inundated with products ranging from enzymatic creams, growth factors, and dressings to sophisticated skin substitutes, negative pressure wound closure devices, and high-pressure cutting waterjets. Medical management of wounds has traditionally focused on the use of topical agents such as gauze dressings and papain/urea or collagenase-based creams, while surgical management has concerned itself with the physical excision of nonviable tissue. The ultimate goal of wound therapy, however, is common to both—to create a clean, well-vascularized wound bed that can progress through the stages of wound healing. The purpose of this article is to describe a surgical approach to the assessment and management of chronic wounds with a focus on the role of surgical debridement.

Chronic Wound Assessment

Before deciding on a treatment strategy, a thorough history and physical should be performed with special attention aimed at elucidating the factors contributing to poor wound healing. A history of previously attempted therapies should be elicited as well, as popular topical agents, such as peroxide and iodine, have actually been shown to impede healing.¹ The most common factors responsible for wound chronicity include local infection, the presence of necrotic tissue or debris, repeated trauma, and disease states such as diabetes and peripheral vascular disease. Establishing the etiology of a chronic wound is important because surgical debridement may not be the initial treatment of choice in some cases. Wounds due to arterial insufficiency, for example, should not be aggressively debrided until blood supply is restored to the ischemic wound bed. Similarly, debridement of venous insufficiency ulcers must be accompanied by compression therapy or venous surgery to correct the vascular derangement in order for healing to occur.² Conversely, autoimmune diseases, such as systemic lupus erythematosus or pyoderma gangrenosum, may produce inflammatory lesions that would be better served by medical management of the underlying condition. Finally, Marjolin’s ulcer should be considered in persistent, long-standing wounds, and a biopsy performed to determine the presence of malignancy and the extent of resection required.

Examination of the wound should include a careful determination of wound size and depth. The level of exposed tissue should be noted, as well as the presence or absence of cellulitis or other signs of infection. A probe can be used to explore deep or tunneled wounds—if bone is contacted, there is an 85% chance that osteomyelitis is present.³ A thorough neurovascular exam should also be performed. Blood flow to the tissue is assessed by palpation of distal pulses or Doppler signal evaluation. Sensation to the area can be evaluated using a 5.07 Semmes-Weinstein filament. An inability to feel 10-g of pressure indicates loss of protective sensation.⁴ After wound therapy is initiated, healing progress should be monitored with weekly measurements. Normal healing results in a 10%–15% reduction in wound area per week.⁵ If the patient’s progress consistently falls short of this goal, consideration of alternative healing strategies is warranted.