A Closer Look At Hydrosurgical Debridement For Venous Leg Ulcers In An Obese Patient With Multiple Comorbidities

Due to a poor prognosis for healing and a high rate of recurrence, venous leg ulcers (VLUs) pose a significant challenge to clinicians. Accordingly, these authors present a case of chronic VLUs and how an emerging hydrosurgical debridement system contributed to successful treatment.

Venous insufficiency is one of the most common causes of chronic lower extremity ulceration with an annual incidence rate greater than two percent and an annual cost of $14.9 billion.¹ While the amputation risk associated with venous leg ulcers (VLUs) is lower than that of diabetic foot ulcers (DFUs), the prognosis for healing is only 40 percent with a 75 percent recurrence rate.²  

Wound healing is a critical metric in improving patient outcomes and improving quality of life.³ Debridement is the process by which one removes biofilm, necrotic tissue, eschar, fibrinous coatings and other deposits from a wound. Many consider debridement the key initial step in wound healing.⁴ 

Optimal debridement should achieve a balance between removal of necrotic tissue and preservation of healthy tissue without inhibiting subsequent healing.⁵ The formation of new granulation tissue following debridement may help to facilitate the wound healing cascade in otherwise stagnant chronic wounds.⁶ Chronic wounds will likely require ongoing maintenance debridement rather than a single intervention.⁴ The underlying abnormalities in chronic wounds cause a continual buildup of necrotic tissue. Regular debridement is necessary to reduce this burden and achieve healthy granulation tissue. There are many determining factors when choosing the best method of debridement for a patient and they include wound size, comorbidities, financial cost and patient risks.⁷ 

Frequently used methods of debridement include mechanical, surgical, enzymatic, autolytic, biological and hydrosurgical debridement.

• Mechanical debridement. This is a non-selective type of debridement using mechanical force, such as pulsatile lavage and wound irrigation.
• Surgical debridement. One performs this type of selective debridement with sharp instruments such as curettes, forceps and scalpels. 
• Enzymatic debridement. This technique is a highly selective method of debridement using topical application of exogenous, naturally occurring proteolytic enzymes. 
• Autolytic debridement. This method, which involves the use of moisture-retentive dressings to promote the body’s own healing capabilities, is the most selective and painless approach, but also the slowest option.
• Biological debridement. This describes the use of sterile maggots to remove necrotic tissue.
• Hydrosurgical debridement. With this technique, one uses a water jet and/or micro water jet technology to emit pressurized sterile saline that simultaneously debrides, irrigates and removes non‐viable tissue.

The efficacy of debridement methods varies as each presents its own benefits and disadvantages per patient case. Hydrosurgery is an efficient method of wound debridement and wound bed preparation that is faster, more precise, and results in less tissue damage than some other debridement methods.⁸ In a recent study involving the use of the hydrosurgical device Debritom+ (Medaxis AG), researchers found the micro water jet technology to be a precise, efficient, timesaving and tissue-preserving method in the treatment of predominantly chronic and persistent wounds.⁹  The study authors noted that the use of this debridement technology can result in no or only minimal pain that one can easily  eliminate via simple local measures.⁹ Furthermore, application of this micro water jet application removes the need to touch the wound during debridement and minimizes possible cross-contamination.

When A Patient Presents With Chronic Venous Leg Ulcers

In a recent case, we assessed a 53-year-old male with well-controlled type 2, insulin-using diabetes mellitus (HbA1C of 6.2 percent), diabetic peripheral neuropathy, hemiplegic cerebral palsy, rheumatoid arthritis, extreme obesity, hypertension and two chronic venous insufficiency left lower extremity ulcers of 4.5 months duration. Prior wound treatment consisted of sharp debridement, calcium alginate dressings and compression therapy. At the time of presentation, the patient’s current medications included atorvastatin 10 mg, furosemide 40 mg, insulin 100 units/ml (Lantus SoloSTAR (Sanofi-Aventis)), lisinopril 5 mg, methotrexate 25 mg/ml injection and prednisone 10 mg.

One ulcer on the lateral left lower leg was 6.5 cm x 3.8 cm x 0.2 cm in size (see first photo  above), and a second ulcer on the anterior left lower leg was 2.2 cm x 1.9 cm x 0.2 cm in size (see fourth photo above). We debrided these wounds with the aforementioned micro water jet technology delivered at a pressure setting of 150 bar on a weekly to biweekly basis. The patient reported minimal pain associated with this hydrosurgical debridement and did not require anesthetics prior to the procedure. There were no reported complications after the debridement procedure. Wound dressings comprised of Aquacel^® Ag Advantage (ConvaTec), a skin protectant cream for the periwound skin, a dry sterile dressing and compression via a modified Unna boot.

We utilized wound measurements and clinical photos (see all photos above) to help document the wound healing progression.  The lateral left lower leg wound reepithelialized in 7.5 weeks and the anterior left lower leg wound reepithelialized in 9.5 weeks. Both wounds remain reepithelialized seven months after initial closure.

In addition to using clinical wound photographs, we assessed wound tissue oxygenation pre- and post-debridement through Snapshot_NIR (Kent Imaging). A non-invasive imaging device, Snapshot_NIR utilizes light in the near-infrared spectrum that harmlessly passes through the skin and reflects off of the blood supplying the tissue to provide an approximate value of oxygen saturation, relative oxyhemoglobin level and relative deoxyhemoglobin level in superficial tissue. We noted an increase in wound oxygen saturation levels following micro water jet debridement (see seventh through tenth photos above). While these findings suggest a possible increase in oxygen and microvascular perfusion associated with micro water jet debridement, this warrants further investigation.

Concluding Thoughts

More than 70 percent of lower extremity ulcers are a result of chronic venous insufficiency with an increased prevalence in those greater than 65 years of age.² Both sharp debridement and hydrosurgery are effective in stimulating the healing of recalcitrant chronic venous leg ulcers, and one may employ these debridement approaches safely in the outpatient setting.^10,11  

The findings of this case study demonstrate successful use of micro water jet debridement in the healing of two chronic venous leg ulcers in a patient with insulin-dependent diabetes mellitus who was taking immunosuppressive medications. The potential increase in wound tissue oxygenation associated with micro water jet debridement is an interesting finding. Randomized controlled trials are necessary to better assess the effectiveness of micro water jet technology in the debridement and healing of chronic wounds.

Ms. Cheema completed her master’s degree in physiology and biophysics from Georgetown University, and is currently a second-year student at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. 

Dr. Wu is the Dean and a Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine, and a Professor of Stem Cell and Regenerative Medicine at the School of Graduate Medical Sciences at the Rosalind Franklin University of Medicine and Science in Chicago. She is also the Interim Associate Dean of Research at the Dr. William M. Scholl College of Podiatric Medicine. 

Acknowledgement

The patient in the case study above is a participant in an ongoing research study funded by Medaxis AG, the manufacturer of Debritom+. The company played no role in the conduct of the study, the analysis of the data nor the conclusions drawn from the data.

References

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