Hydrosurgical Debridement Use Associated With Decreased Surgical Site-Related Readmissions: A Retrospective Analysis

Debridement is the cornerstone of wound care management. The act of removing devitalized tissue allows for faster wound healing and decreased infection rates.¹ Various modalities of debridement are available, including mechanical, surgical/sharp, enzymatic, biologic, and autolytic.¹ Use of each of these techniques is performed with the goal of removing devitalized tissue while maintaining the integrity of viable tissue in the wound bed.

Surgical debridement has changed considerably, from early use of wet-to-dry dressings and sharp tissue excision to the current gamut of devices competing for superiority in the field. As part of a departmental quality assurance project, the type of debridement used for wound care as well as the post-debridement algorithm of care was evaluated for its association with unplanned readmission. The goal of this study was to compare different methods of wound debridement to extrapolate any difference in long-term wound-related readmissions and outcomes. The postoperative algorithms were assessed in a separate data set. 

This was a retrospective analysis of 190 patients who underwent wound debridement. Current Procedural Terminology (CPT) codes 11042 and 11043, debridement to subcutaneous tissue and debridement to muscle and/or fascia, respectively, were used to identify 289 unique patients treated for lower extremity wounds of all types that were cared for by the vascular surgery service at a large tertiary care wound program from January 2016 to June 2018. This represented care provided by 3 physicians board-certified in both general surgery and vascular surgery. 

Chart review was completed for each patient, and interventions—including debridement, types of dressings used, and skin substitute placement—were mapped out for each of the wounds. Outcomes such as wound infection, readmissions, and amputations also were recorded. All data were gathered and entered into Microsoft Excel (Microsoft Corporation); all patient identifiers were excluded.

The initial data from the 289 patients were examined, and 99 patients were removed due to lack of debridement during their wound care course or incomplete data. The remaining 190 patients had undergone mechanical debridement in the operating room. These patients were separated into 3 groups based on the tool used for debridement: (1) standard sharp soft tissue excision with scalpel and/or scissors, (2) standard sharp soft tissue excision with pulse irrigation, or (3) tangential hydrosurgical debridement (VERSAJET II Hydrosurgery System; Smith+Nephew). 

These data sets were then imported into SAS University Edition (SAS Institute) to perform statistical analysis. Logistic regression was performed with the aforementioned debridement methods and subsequent surgical site infection (SSI) hospital admission as the dependent variable. 

Of the 190 patients, 132 were treated with standard soft tissue debridement, 17 with pulse irrigation in addition to standard soft tissue debridement, and 41 with hydrosurgical debridement. Forty of the 190 patients (21.1%) experienced an unplanned readmission within 30 days of discharge for a wound-related complication. Reasons for readmission included progressive gangrene, worsening osteomyelitis, and postoperative wound infection.

Binary logistic regression was performed. A statistically significant difference was evident between use of hydrosurgical debridement vs pulse irrigation with standard soft tissue debridement or standard soft tissue debridement alone (P < .05) (Table 1).

The odds ratio (OR) also was calculated using this logistic regression, and the OR for hydrosurgical debridement was found to be 0.31 (95% CI, 0.142–0.677) in reference to unplanned readmission due to SSI, as shown in Table 2. The OR of 0.31 shows a negative correlation between the occurrence of SSI and use of hydrosurgical debridement. 

Overall, hydrosurgical debridement was found to be more effective, as evidenced by the statistically significant lower risk of readmission owing to SSI associated with hydrosurgery compared with standard soft tissue debridement with and without the addition of pulse irrigation. In the present authors’ experiences with hydrosurgical debridement, superiority in debriding wounds with irregular contours, thorough debridement of wound edges, and wound base were observed as demonstrated in Figure 1 and Figure 2.

There has been substantial advancement in the tools used for surgical debridement, and various modalities of debridement currently are available for use. The specific hydrosurgical debridement device evaluated by the authors is composed of a disposable handpiece, a power console with a foot pedal, and a waste bin. The device projects a high-velocity stream of sterile saline across the operating field that is then suctioned, along with debris, on the side opposite the stream emission from the handpiece.² The handpiece is held parallel to the tissue to allow the jet stream to rapidly remove devitalized tissue from the surface of the wound.

Some studies have compared hydrosurgery with more traditional debridement methods. However, to the authors’ knowledge, no studies have evaluated for the rate of postoperative SSI and unplanned readmission. In the present literature, the studies focus on bacterial load reduction, cost effectiveness, blood loss, healing capacity, and operative time. According to a study by Liu et al,³ hydrosurgery is advantageous in terms of decreasing operative time and intraoperative blood loss, but they were unable to demonstrate a significant difference in bacterial load.

In a review article, Bekara et al⁴ compared multiple debridement techniques (hydrosurgery, ultrasound therapy, and coblation) and their use in the management of chronic wounds. Bekara et al⁴ found hydrosurgery to be precise, selective, and efficient in decreasing operative time compared with traditional sharp debridement. Of note, their review did not comment on postoperative infection or readmission rates between the 3 groups.

Other studies have evaluated the efficacy of the hydrosurgical debridement device. Granick et al⁵ reported that with the hydrosurgical device fewer debridements were necessary to achieve adequate preparation of the wound bed for closure compared with pulse irrigation. 

In a study evaluating use of the hydrosurgical debridement device vs conventional debridement with scalpel and pulsed lavage on lower extremity ulcers, Caputo et al⁶ found that hydrosurgery resulted in shorter debridement time without compromising wound healing, which could translate into potential cost savings. A cost savings benefit of hydrosurgical debridement also could be presumed based on decreased readmissions for SSI, resulting in fewer hospital admissions and associated costs over the course of wound healing. 

Irkoren et al⁷ investigated the effect of hydrosurgical debridement on hospital stay and blood loss. The comparison was between 2 groups that were treated with hydrosurgery, with the distinguishing factor being the use of hydrogen peroxide. They ultimately found that the group that underwent hydrosurgical debridement with hydrogen peroxide had shorter hospital length of stay and decreased intraoperative blood loss.⁷ 

In another study, investigators attempted to compare bacterial burden prior to and following debridement with hydrosurgery. The authors found a decrease in bacterial load in 50% of the patients after debridement with hydrosurgery.⁸

The limitations of this study include the retrospective and single-center nature of the analysis. Additionally, the decision to use hydrosurgical debridement is usually made for specific types of wounds. At the study authors’ institution, such debridement typically is used on wounds with a relatively flat contour and with necrotic or fibrinous slough at the base of the wound. Thus, it is difficult to generalize the results of this analysis to all wound types.  

Further subset analysis of wound type by etiology is needed to learn whether a particular subgroup of wounds is affected to a greater (or lesser) degree with use of hydrosurgery. Such findings could potentially aid the surgeon in identifying which wounds could benefit most from this method of debridement.

These results help form a solid base to explore the efficacy of hydrosurgical debridement as a favorable modality of debridement in comparison with other traditional methods. The present results showed that there was a statistically significant difference in patients who underwent debridement with hydrosurgery compared with traditional sharp debridement with and without pulsed lavage, and that these patients had lower incidence of postoperative SSI and unplanned readmission. Therefore, with proper patient selection and proper use of a hydrosurgery device, such treatment may result in decreased risk of SSI and subsequent readmission after wound debridement.

Authors: Crystal Valerie James, MD^1,2; Munir Patel, MD^1,2; Nicole Ilonzo, MD³; Kojo Wallace, MD^1,2; Jani Lee, MD^1,2; Mabel Chan, MD^1,2; Scott Ellis, MD^1,2; and John C. Lantis II, MD^1,2

Affiliations: ¹Mount Sinai West, New York, NY; ²Mount Sinai Morningside Hospital, New York, NY; ³The Mount Sinai Hospital, New York, NY

Correspondence: Crystal Valerie James, MD, Mount Sinai Morningside Medical Center, 1090 Amsterdam Avenue, Suite 1200, New York, NY 10025; crystalvjames@gmail.com 

Disclosure: The authors disclose no financial or other conflicts of interest.