Canadian
maple
Medical Alliance for the Preservation of the Lower Extremity
Evidence for Debridement of Ulcers
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Debridement can be defined as the removal of dead, damaged, or contaminated tissue from a wound to promote healing. (We give clinical examples of debridement here.)
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Debridement has been an accepted part of wound care for many years now, and part of the reason is that it just makes sense.
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Removing necrotic tissue to better examine the extent of a wound, to open up the wound to drain possible infection, to diminish the pressure on a wound, to remove a food source for bacteria are all very reasonable sounding concepts.
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So just from the perspective of being able to better assess a wound, it probably makes sense to perform debridement of wounds.
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For instance, this review recommends debridement as a standard component of wound care. "Debridement should be carried out in all chronic wounds to remove surface debris and necrotic tissues."
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Kleopatra Alexiadou K, Doupis J. Management of Diabetic Foot Ulcers Diabetes Ther. 2012 Dec; 3(1): 4. Published online 2012 Apr 20. doi: 10.1007/s13300-012-0004-9 PMCID: PMC3508111 PMID: 22529027
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Indeed, the International Working Group on the Diabetic Foot (IWGDF) recommends sharp debridement.
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But let's look at the actual evidence for debridement.
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​​​​​​​​​​​​​​​​​Evidence For Debridement in Wound Healing
"Just as a snake sheds its skin, we must shed our past over and over again."
-- Attributed to Buddha
Given the degree of concurrence on the concept of debridement, the amount of objective research on debridement has been more limited than one might think.
​One of the first studies produced was in 1996 by Steed et al at the University of Pittsburgh. 118 patients were enrolled in a randomized, prospective, double-blind, multicenter trial to test whether topically applied growth factors was helpful in wound healing.
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What the authors noticed in the study was that those patients who underwent more frequent debridement did better, whether growth factors were used or not.
The authors concluded, "Wound debridement is a vital adjunct in the care of patients with chronic diabetic foot ulcers."
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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 Jul;183(1):61-4.
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Eight years later, in 2004, one of the authors of the 1996 study above, wrote that "although surgeons recognize the importance of debridement, few data have been generated in randomized trials to support its use." He concluded, "Debridement remains an important adjunct to good wound care, but questions of what type, how much, and how often it should be performed remain unresolved."
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Steed DL Debridement Am J Surg. 2004 May;187(5A):71S-74S.
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In 2008, an expert panel came out with another statement supporting debridement. "Maintenance debridement is a proactive way to "jump-start" the wound and keep it in a healing mode, even when traditional debridement may not appear necessary because of a seemingly "healthy" wound bed."
Falanga V(1), Brem H, Ennis WJ, Wolcott R, Gould LJ, Ayello EA.
Maintenance debridement in the treatment of difficult-to-heal chronic wounds.
Recommendations of an expert panel.
Ostomy Wound Manage. 2008 Jun;Suppl:2-13; quiz 14-5.
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A year later, in 2009, a retrospective study was produced that concluded, "frequent debridement of DFUs and VLUs may increase wound healing rates and rates of closure, though there is not enough evidence to definitively conclude a significant effect. Future clinical research in wound care should focus on the relationship between serial surgical wound debridement and improved wound healing outcomes as demonstrated in this study."
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Cardinal M, Eisenbud DE, Armstrong DG, Zelen C, Driver V, Attinger C, Phillips T, Harding K.
Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009 May-Jun;17(3):306-11. doi: 10.1111/j.1524-475X.2009.00485.x.
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In 2010, Cochrane, a non-profit, non-governmental organization with 30,000 volunteer experts who review existing research to judge the evidence for a treatment or therapy, reviewed the concept of various forms of debriding diabetic wounds.
In that review, they state, "Debridement is widely regarded as an effective intervention to speed up ulcer healing." However, they declared that "more research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se."
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Edwards J, Stapley S. Debridement of diabetic foot ulcers.
Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003556.
DOI: 10.1002/14651858.CD003556.pub2.
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A major study showing the benefits of frequent debridement finally came In 2013. A huge retrospective study was performed, looking at data of 312,744 wounds in 154,664 individual patients in 525 individual wound care clinics between 2008 and 2012.
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The authors found that healing time was 21 days if debridement was performed weekly. Healing time was three times slower (64 days) if debridement was performed every two weeks, and slower still (76 days) if debridement was performed every three weeks.
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Wilcox JR, Carter MJ, Covington S Frequency of debridements and time to heal:
a retrospective cohort study of 312,744 wounds JAMA Dermatol. 2013; 149(12):1441
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The strength of this study is limited somewhat by it being a retrospective study--one looking back in time to examine reasons for an outcome. A prospective study--one isolating a specific factor and watching for results--can be stronger evidence.
However, the huge number of wounds examined in this study across hundreds of wound care facilities is significant, and this study is probably the best in existence showing that regular debridement performed weekly is highly effective in helping wounds heal.
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In 2016, a meta-analysis was conducted using 14 studies on 800 patients. They found autolytic, larval, and surgical debridement were all effective.
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Elraiyah T, Domecq JP, Prutsky G, Tsapas A, Nabhan M, Frykberg RG,
Hasan R, Firwana B, Prokop LJ, Murad MH. A systematic review and
meta-analysis of débridement methods for chronic diabetic foot ulcers.
J Vasc Surg. 2016 Feb;63(2 Suppl):37S-45S.e1-2.
doi: 10.1016/j.jvs.2015.10.002. PMID: 26804366.
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In a 2021 Australian study, Nube compared weekly vs every-second-week sharp debridement and found similar healing outcomes.
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Nube VL, White J, Molyneaux L, Yue DK, Twigg SM. A randomized trial comparing weekly with every second week sharp debridement in people with diabetes-related foot ulcers shows similar healing outcomes: potential benefit to resource utilization. Diabetes Care. 2021;44(12):e203-e205. doi:10.2337/dc21-1454.​​
Bottom Line on Debridement:
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Most experts agree that frequent debridement ​of wounds improves healing,
likely be a) allowing for better examination of the wound, b) removing necrotic
tissue that cannot heal, c) discourages bacterial growth and d) removing pressure
from the wound.
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Most experts agree that debridement should be done frequently.
Recommended frequency of debridement is not known, but at present, our
recommendation is at least every two weeks.
With this said, it needs to be emphasized that wounds in dysvascular patients--those with poor circulation--are generally not debrided for fear of causing additional damage from which the patient may not be able to heal.
Clinical Example
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The patient to the right suffered
an amputation of the great toe
and the bone behind it, the 1st metatarsal. The wound was not closed (sutured up) and it was left to nursing to manage dressings until closure.
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The wound had had no debridement and had not improved in over 8 months.
This wound is somewhat unique in that it is not located on the bottom of the foot. Hence, it doesn't need much in the way of offloading. What it needs is debridement--the removal of the yellow slough overlying the wound. This necrotic tissue prevents us from really assessing the wound. It's hard to be certain of its depth. Does the wound extend to bone?
The slough also inhibits healing because it attracts bacteria that live on this dead tissue. Even if its not truly infected (which we'll define here as bacteria breaching the body's defenses and entering the living portion of the body), the bacteria are likely placing a burden on the wound, making it harder for new, healthy tissue to grow into the wound and seal the breach.
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Even the human tissue in the wound is not ideal. It is composed of older, less viable tissue. Debridement would allow younger, fresher cells, along with growth factors to repopulate the wound.
So the wound was debrided to a
fresher, bleeding base.
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And, as before, a dressing was
applied.
While the wound is not sterile, and bacteria are certainly present, the bacteria are not breaching the body's defenses, and there is no real evidence of infection. So no
antibiotic was given.
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Nor, given the location of the ulcer on the side of the foot, did the foot need much in the way of offloading (the redistribution of pressure from walking).
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Debridement was performed weekly.
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Closure was achieved at 10 weeks.
This is a good clinical example of the importance of debridement, as this is the only variable changed to get the wound healed.
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The dressing applied after debridement was the same as before. There were no antibiotics used. There was no offloading used. There was no change in blood sugar level. There was no change in nutritional status.
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Debridement is the one factor that was added to get this wound to heal.
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To visit our main page on debridement, click here.
To return to the top of this page,
click on the leaf to the right.
This page written by Dr. S A Schumacher
Podiatric Surgeon
Surrey, British Columbia Canada
All clinical photographs are owned and provided by Dr. S A Schumacher. They may be reproduced for educational purposes with attribution to:
Dr. S A Schumacher, Surrey, BC Canada