how to debride objectives a wound - podiatry management · figure 7—continuation of wound...

It’s important tounderstand these

five basic methods.

NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENTwww.podiatrym.com 121

wounds pose the ultimate chal-lenge for the physician treating thelower extremity. The problem arisesbecause a chronic wound does notfollow the usual healing phases. Toproperly treat this type of wound,the physician needs to correctly de-bride and off-load the wound. Interms of importance, debriding thewound may be as critical or evenmore critical in healing the wound,than off-loading(1). There are fivemain methods to debride a chronicwound: 1. Debridement withscalpel and tissue forceps, nippers,or scissors, 2. Biosurgical (maggot)

therapy, 3. Newer methods, such asultrasonic surgical debridement, 4.Mechanical Debridement (by re-moving dry gauze from a wound)and 5. Autolytic debridement (frommacerating tissue until it is able tobe removed). Again this is dressing-related. These five methods ofwound debridement are not standalone methods but are often usedin combination to correctly treatthe wound. The purpose of thispaper is to provide a practical basisfor performing the first three of theabove-mentioned methods.

Continued on page 122

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An answer sheet and full set of instructions are provided on pages 210-212.—Editor

ObjectivesAt the end of this article,

the clinician should be able to:

1) Identify the important at-tributes and indications forwound debridement.

2) Describe at least threedifferent types of wound debridement.

3) Understand the indica-tions and basic techniques un-derlying each of the above-mentioned types of wounddebridement.

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The diabetic foot is constantlyat risk of daily breakdown,sometimes preventable and

sometimes not. When it breaksdown and ulcerates, the foot maydevelop an acute wound, and acutewounds heal through the normalhealing process. The main concernwith diabetic foot wounds is thatmost of the time they behave notas acute wounds, but rather aschronic ones. These types of

How to Debridea Wound

By Joshua Johnson, D.P.M., Brent P.Nixon, D.P.M., M.B.A., David G. Arm-strong, D.P.M., M.Sc.

How to Debridea Wound

bleeding tissue should be removed.All callus, necrotic tissue, and es-char prohibit healing of thewound. If the border between theviable and nonviable tissue isclearly demarcated, then skinshould be excised along the bor-der. If the border is not clearly de-fined, then one should start in thecenter of the wound and removeconcentric circles of the skin untilviable tissue is reached. Tissueshould be removed circumferen-tially about the wound until theperiphery of the wound exhibits afirm connection between epider-mis and dermis(1). Upon reachingthe edge of the wound, normalbleeding should occur. Whenthere are clotted venules at theskin edge, further dissectionshould be carried out until normalbleeding is encountered(4). Anynon-viable tissue should be re-moved centrally from the wound,

as required, through sharp exci-sion or curretage. Digital pressuremay then be applied to the woundto achieve hemostasis. The woundmay then be probed to assess theinvolvement of underlying tissueand for the presence of occult in-fection. The wound will then bedressed with a standard wounddressing and properly off-loaded.The hallmark of an appropriatelyoff-loaded wound is the noticeablelack of undermining at thewound’s edge at follow up. Off-loading will help to decrease theunwanted tissue at further visitsfor surgical debridement.

The key disadvantage of aggres-sive surgical debridement is that itrequires a modicum of experienceon the part of the clinician and amodicum of healing potential (ie.arterial outflow) on the part of thepatient. These two issues are some-what less important when chronic

122 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2003

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Surgical DebridementSurgically debriding the wound

with the use of the scalpel and tis-sue forceps or nail nippers may bethe most efficient method of treat-ment to achieve a complete re-moval of nonhealing tissue(2). Onedrawback of this method is that itcan cause excessive pain andbleeding (in the sensate or coaguo-pathic patient, respectively) andneeds to be performed carefully.For larger wounds, the tissue maybe handled with sterile tissue for-ceps and scalpel or for smallerwounds with a tissue nipper orscissors(1). The skin may be incised(Figure 1-Figure 5) or the nippermay be introduced to the fullestextent of the undermining be-tween the epidermis and dermis(Figure 6-Figure 9). When debrid-ing the skin, all nonviable, non-

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Figure 4—The wound after removal of initial callus tissuewith scalpel

Figure 2—Callus buildup around the wound before scalpeldebridement

Figure 3—Excision of callus buildup with scalpel and tissueforceps

Figure 1—Callus buildup around the wound before scalpeldebridement


volume wound care centers in Eu-rope and Asia. One factor in thisincrease is over the past decadeinpatient care of wounds has de-clined, and outpatient woundmanagement has increased(7). Ourcenter uses this modality fre-quently in care of patients whoare not candidates for aggressivefrequent surgical debridement, asdescribed above.

Maggot therapy has been usedfor many years and is securing aplace in wound care(2,5,6,7,8,9). The ob-ject is to apply the maggots to thewound and keep them from escap-ing from the wound, while allow-ing them to breathe and grow. Themaggot therapy application processis consistent throughout the litera-ture.

First, the wound needs to besurgically debrided as much as isappropriate and have any escharremoved. As famished as they

wounds are instead treated withmaggot debridement therapy andultrasonic surgical debridement(5).

Biosurgical (Maggot) TherapyMaggot therapy has been used

for centuries and was well under-stood by the military physicianswho found that battle wounds in-fested by maggots had healedquickly without infection(6). Mag-got therapy was first introducedin the United States in the 1930sby Bier(6,7), and became quite pop-ular until the invention of the an-tibiotic and aggressive surgical de-bridement(6). Maggot therapy rein-troduced itself in the U.S. in thelate 1980s, and the use of medici-nal larvae or maggot debridementtherapy has steadily increased inusage in the past 10 years, partic-ularly in many progressive, high-

Debride... may be, the maggots donot eat through the es-char formation as quicklyand efficiently as other necrot-ic tissue.

Second, a cage-like dressing hasto be made around the wound. Thisis performed by preparing the peri-wound area with a skin adhesive.This allows the peri-wound barrierto firmly attach to the skin and notleak.

Third, the peri-wound barrier isconstructed. This peri-wound barri-er is either made of hydrocolloiddressing or waterproof tape. Thisdressing can be formed by cuttingstrips and applying them to the pe-riphery of the wound connecting atthe corners.

Fourth, a nylon or Dacron chif-fon dressing is constructed to ac-cept and contain the larvae on thetissue. The chiffon can be laid on


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Figure 7—Continuation of wound debridement with tissuenippers

Figure 5—The wound after complete removal of callusleaving a good granular base

Figure 8—Continuation of wound debridement with tissuenippers

Figure 6—Insertion of nail nippers into callus surroundingwound

weight-bearing surface then caremust be taken to off-load the areaso the maggots are not disturbed.It has been suggested that 10 mag-gots/cm2 of necrotic tissue be ap-plied(9). It is easier to leave smallermaggots on for 2-3 days, but it hasbeen reported that larger maggotschanged every 24 hours debridethe wound more efficiently andfaster(9).

When the dressing is changed,the maggots are flushed from thewound or picked out of thewound using tissue forceps. Thelarvae are significantly larger, upto four times the size of whenthey were applied, about 1 cm inlength(10). If the necrotic and fi-brotic tissue has been adequatelyremoved from the wound, then astandard wound dressing may beapplied. If the wound base is notcompletely granular, then anoth-er application of maggot therapy

can be applied. The goal behindmaggot therapy is to r id thewound of unwanted tissue andstimulate the formation of granu-lation tissue. Maggot therapy isan effective method to debridethe wound (Figure 13–Figure 17).

Ultrasonic Surgical DebridementUltrasonic wound debridement

technology has been used for manyyears in neurosurgery and generalsurgery in Europe and Asia. In theUnited States, it has only been usedin the treatment of diabetic footwound. Research suggests that ul-trasound is the gentlest option forcleaning injured skin, as well as de-creasing the blood loss or pain asso-ciated with the treatment(11).

The principles behind ultra-sonic debridement are the con-cepts of thermal, cavitation, and“direct” effects. “Thermal” refers


124 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER

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two pieces of moist gauze andset on the Mayo stand close to

wound for easy application.Fifth, the larvae are now applied

to the dressing (Figure 10-Figure12). Depending on the size anddepth of the wound, anywherefrom 50-1,000 maggots, 24-48hours old, are applied to thewound(5). The chiffon/4x4 dressingwith maggots is transferred to thewound and adhesive foam tape isused to secure the dressing to thehydrocolloid dressing.

Sixth, an air permeable dressingis applied to the wound, usuallydone by a gauze layer dressing al-lowing air into the wound, notcausing a necrotic liquification thatis harmful to the maggots. Thegauze layer absorbs the exudateproduced by the maggots.

If the wound is located on a

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Figure 12—Maggots being spread on chiffon dressing be-fore application to the wound

Figure 10—Maggots in the jar before application

Figure 11—Removal of maggots from the jar with atongue depressor

Figure 9—Complete debridement of wound with tissuenippers


bath but is put under a stream ofpressure delivered from the ma-chine. One of the systems used inultrasonic debridement is the Sono-ca Soring system. The system hasthe portable ultrasonic unit and thesonotrode (Figure 18). The threedifferent modes on the machine are1. superficial mode bubbling, thathas no tissue contact, 2. superficialmode touching, that has full skincontact, and 3. immersion mode.The superficial mode bubbling isused on soft coatings; the superfi-cial mode touching is used onnecrotic tissue; and the immersionmode is used for deep wounds andwound pockets. The sonotrode canbe in the form of a spatula, hoof, orball.

In one study, the treatmentwas applied three times per weekfor a duration of thirty secondsper square centimeter of wound atthe maximum available output of

to the heat generated by the ul-trasound bath that can be easilycontrolled and dissipated in thewater to prevent tissue damage.This application is used when thewound is completely immersed inthe water bath, but it is not usedin foot debridement. “Cavita-tion” refers to the shearing actionof stable microtubes in alternat-ing high and low pressure wavesthat are generated by the ultra-sonic transducers. The “direct” ef-fect refers to any result after theultrasonication that cannot bedescr ibed by the f i rst two ef -fects(12).

Ultrasonic debridement for footwounds is performed as if a surgicalinstrument were being directly ap-plied to the wound along with con-stant purging. The extremity is notimmersed in an ultrasonic water

Debride... 25kHz. The sonotrobewas set to superficialmode touching and 5 ml ofRinger’s solution was appliedper minute for continued purg-ing(13). It is recommended that forsmaller wounds the applicationshould be applied from 30-60secs/cm2, and for bigger woundsthe time should be limited. Differ-ent wounds have been treatedwith all three types of thesonotrobe, all three modes, andtimes ranging from seconds to 30minutes. When applying the treat-ment the patient should be situat-ed so that the water does not poolbut flows off the patient. It hasbeen recommended that whenfirst applying the application, thepower should be set at 60% andthen moved to 100%(14). The pro-cess can be painful and some topi-cal antibiotics may be needed.


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Figure 15—Continued healing of the wound

Figure 13—The wound before application of the maggottherapy

Figure 16—Continued healing of wound after maggottherapy

Figure 14—After application of maggots

therapy), and ultrasonic debride-ment, all three have a part inwound healing. The applicationof these three methods has beendiscussed. As stated earlier thesemethods can and will be used inc o m b i n a t i o nthroughout thelength of thewound treat-ment. Surgicaldebridement hasbeen around formany years andwill continue tobe used. Maggottherapy is mak-ing a strongcomeback inwound manage-ment. Ultrasonicdebridement isnewer and isslowly workingits way into

wound management in the U.S.Debriding the wound is essentialfor the wound to heal, and solearning how to effectively de-bride a wound is critical for the


Debride...

Also, the probe should con-stantly be moved around the

wound and concentrated in thecenter tissue, to avoid pain at theedge of the wound. Moving theprobe too slowly does not allowenough heat exposure and mov-ing the probe too quickly preventssufficient exposure to bacteria. Ul-trasonic surgical debridement doeseffectively reduce bacterial countand remove particulate matter(12)

(Figure 19-Figure 21).

SummaryThe diabetic chronic wound is

difficult to treat, but proper treat-ment is essential . The woundneeds to be properly off-loadedand debrided for healing to takeplace. There are three effectivemethods for debridement: surgicaldebridement, biosurgical (maggot

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Figure 20—Continued application of ultrasonic debride-ment

Figure 18—Soring Sonoca ultrasound machine Figure 19—Application of ultrasonic debridement to thewound

Figure 17—Continued healing of wound after maggottherapy

Figure 21—Continued application of ultrasonic debride-ment



podiatric surgeon. Understanding these three methodsand their application will contribute greatly to woundmanagement. ■

References1. Armstrong, DG, Lavery, LA, Vazquez, JR, Nixon, BP, Boul-

ton, AJM: How and why to surgically debride neuropathic footwounds. J Am Podiatr Med Assoc 92:402-404, 2002

2. Steed, DL, Donohoe, D, Webster, MW, Lindsley, L: Effectof extensive debridement and treatment on the healing of dia-betic foot ulcers. J Am Coll Surg 183:61-64, 1996

3. Attinger, CE, Bulan, E, Blume, P: Surgical debridement: thekey to successful wound healing and reconstruction. Clinic inPodiatric Medicine and Surgery 17:599-630, 2000

4. Rayman, A, Stansfield, G, Woollard, T, Mackie, A, Rayman,G: Use of larvae in the treatment of diabetic necrotic foot. TheDiabetic Foot 1:7-13, 1998

5. Mumcuoglu KY, Ingber A, Gilead L, Stessman J, FriedmannR, Schulman H, Bichucher H, Ioffe-Uspensky I, Miller, Galun R,Raz I: Maggot therapy for the treatment of diabetic foot ulcers.Diabetes Care 21:2030-2031, 1998

6. Bonn, D: Maggot therapy: an alternative for wound infec-tion. The Lancet 356:1174, 2000

7. Sherman RA, Sherman J, Gilead L, Lipo M, MumcuogluKY: Maggot debridement therapy in outpatients. Arch Phys MedRehabil 82:1226-1229, 2001

8. Mumcuoglu KY, Ingber A, Gilead L, Stessman J, FriedmannR, Schulman H, Bichucher H, Ioffe-Uspensky I, Miller J, Galun,Raz I: Maggot therapy for the treatment of intractable wounds.Int J Dermatol 38:623-627, 1999

9. Mumcuoglu, KY: Clinical applications for maggots inwound care. Am J Clin Dermatol 2:219-227, 2001

10. Armstrong, DG, Mossel, J, Short, B, Nixon, B, Knowles,EA: Maggot debridement therapy:a primer. J Am Podiatr MedAssoc 92:398-401, 2002

11. Souhrada, L: New methods sounds out bacteria in skinwounds. Hospitals 62:80, 1988

12. Nichter, LS, Williams, J: Ultrasonic wound debridement.The Journal of Hand Surgery 13A:142-146, 1988

13. Cshulze, CH, Hulskamp, T, Schikorski, M, Thies, E: Effec-tive, gentle low-pain wound debridement with low frequency ul-trasound applied using mobile equipment. Section for general,accident and visceral surgery phlebology.1

14. Schulze, CH, Oesser, S, Seifert, J: Investigations into theantibacterial effect of low-frequency ultrasound applied by usingthe spherical soring Sonoca probe-tip (sonotrode) Endotoxin lab-oratory for surgical research: in vitro project report 03/2001 Edi-tion 08/20/02:1-5, 2002

Debride...

1) What is a complication of surgical debride-ment in wound management?

A) Excessive bleeding and painB) Good granular wound baseC) Eschar formationD) Excessive fibrotic tissue

2) A good time to use maggot therapy inwound management is when

A) Patients are not good candidates for ag-gressive surgical debridementB) As a last resortC) Before using surgical debridementD) There is a disvascular wound

3) Application of maggot therapy is first doneA) Before surgical debridementB) By debriding necrotic tissue and escharformationC) By applying Coban above the woundD) By making a peri-wound barrier

4) After having applied one round of maggottherapy, when is it appropriate to apply anotherround of maggot therapy?

A) When the wound is completely granularB) When the wound is bleeding and verypainfulC) When the wound does not have a com-plete granular baseD) When the wound edges are macerated

5) Maggots in the wound will help to stimulatewhich of the following?

A) Fibrotic tissueB) Eschar formationC) Ligament tissueD) Granulation tissue

6) Which of the following is a mode setting onthe ultrasound machine?

A) Superficial mode bubblingB) Superficial mode touchingC) Immersion modeD) All of the above

See instructions and answer sheet on pages 210-212.


(Left to right): Joshua Johnson is a second year surgical resi-dent at the Southern Arizona VA Medical Center. BrentNixon is the Chief of Podiatry in the Department of Surgeryat the Southern Arizona VA Medical Center. David Arm-strong is the Director of Research in the Department of Sur-gery at the Southern Arizona VA Medical Center

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E X A M I N A T I O N


12) What is the method of apply-ing maggots to the wound?

A) Directly applying them tothe woundB) Applying them after apply-ing the chiffon dressingC) Applying them before sur-gical debridementD) Applying them through ahole in the peri-woundbarrier

13) What determines the num-ber of maggots used on thewound?

A) Amount of fibrotic tissuepresentB) How long the wound hasbeen presentC) Size and depth of thewoundD) Where the wound is locat-ed on the foot

14) What detrimental effect inthe wound can cause the mag-gots to die off?

A) Necrotic liquificationB) Fibrotic tissueC) BleedingD) Exposed bone

15) When would the setting ofsuperficial mode bubbling beused in ultrasound therapy?

A) On soft coatingsB) Necrotic tissueC) Deep woundsD) Wound pockets

16) When applying ultrasoundtherapy to the wound, the mostpain can be felt in the

A) CenterB) EdgesC) Center and edgesD) It is not painful

7) In smaller wounds what is therecommended time to apply theultrasound therapy?

A) 30-60secs/cm2B) 20-70secs/cm2C) 1 minute onlyD) 3 minutes/cm2

8) Which of the following is aneffective method of wound de-bridement?

A) Surgical debridementB) Biosurgical/maggottherapyC) Ultrasound therapyD) All of the above

9) Why are chronic woundsmore difficult to heal than acutewounds?

A) Chronic wounds don’tfollow the normal healingpatternB) Acute wounds don’t bleedas muchC) Chronic wounds bleedmoreD) Acute wounds have morefibrotic tissue present

10) What are the 2 key factors intreating a wound?

A) Debridement and dressingB) Off-loading and dressingC) Debridement and off-loadingD) None of the above

11) Of the debridement meth-ods available, which is the mostefficient?

A) Biosurgical/maggottherapyB) Surgical debridementC) Ultrasound therapyD) Autolytic debridement

17) If the probe is moved tooquickly over the wound, whatcan be the possible outcome?

A) Too little exposure tobacteriaB) Increase in bacteria countC) Increase in fibrotic tissueD) Not enough heat expo-sure

18) Why did maggot therapy fallout of favor in the US years ago?

A) Invention of the antibioticand aggressive surgical de-bridementB) Ultrasound therapy was in-troducedC) It did not workD) It is too expensive

19) When the wound is properlyoff-loaded what will be noticedat the next visit?

A) Fibrotic tissueB) Increase in wound sizeC) Lack of undermining atthe wound’s edgeD) Hyperkeratotic tissuearound the wound edge’s

20) In surgical debridement, ifthe border of the wound is notclearly defined debridementshould begin

A) In the centerB) At the wound edgesC) Where the wound looksthe worstD) Where the wound looksthe best

E X A M I N A T I O N(cont’d)

SEE INSTRUCTIONSAND ANSWER SHEETON PAGES 210-212

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