The Importance of Adequate Debridement
Dr. Shawn Cazzell discusses the role debridement plays in wound healing and how opinions vary as to the ideal frequency of debridement.
Transcript
My name is Shawn Cazzell, a long-time surgical podiatrist. I've lived in the diabetic foot ulcer and venous leg ulcer market space for a vast majority of my career. Amputation prevention, surgical and outpatient wound care, and preventive at-risk foot strategies have always been a passion of mine, and so I feel very fortunate to be in a position to participate at the level that I have been over the course of the last 10 or 15 years. I have a rather large surgical and wound practice. I dedicate about 60% to 80% of my time currently running randomized controlled trials for corporations across the globe, looking at reducing the number of days a wound remains open, knowing that each and every day a wound is open as another day that a wound could become infected.
Sure. I think that's a great question. And if I could, I'd like to give just a bit of background as we kind of expand upon that question that you just postulated. There's obviously four highly programmed phases of wound healing and most of the individuals that would be viewing this have a formal understanding of that. But just to recap, obviously we have hemostasis, the inflammatory process, proliferation, and the remodeling phase, and I'd like to give a great deal of credit to Dr. Bill Tettelbach for all of his efforts on this paper. I think it's proven extremely insightful. And so with that being said, I think this recent paper, it demonstrates that both an increased frequency of debridement and implantation of a placental-derived allograft provides the fewest number of days to closure and subsequent wound healing or healing confirmation, I guess I should say. But there definitely exists a conflict with both frequency and adequacy of debridement in regards to wound healing, specifically for the DFU or diabetic foot ulcer.
And so what we're seeing is that there is such variability in the frequency of debridement being performed, and I think that the paper touched upon this rather eloquently in the way that it was gone about, and that wounds that are debrided with greater frequency have a tendency to do better on average. Now, I know that's a blanket statement, but with that being said, obviously the adequacy of debridement is where I think we're really having difficulties as we're moving forward at this current time. What appears to be adequate for one individual in one geographic location may be vastly or remarkably different than what it might be in another part of the country and/or world.
And so when we're looking at a wound bed, I think that first debridement really needs to be relatively aggressive. And when I say that, I'm talking about saucerization of the wound, good, healthy bleeding wound bed. I think we need to eliminate and/or remove any sinus tracts, any undermining, any moisture associated skin damage so that we get down to a wound that is a viable candidate to move forward throughout the wound healing trajectory.
I would say specific to diabetic foot ulcers, I would place the greatest emphasis on frequency in concert with the adequacy of debridement itself. And so I think we have to continue to find ways to pair those two or marry those two together so that our wound care providers are able to provide the diligent care that our patients so desperately need.
I think over the years there's been numerous organizations that have wound care programs/trainings in place for wound providers or up-and-coming wound providers, individuals in general surgery residency programs, individuals in pediatric foot and ankle surgery residency programs. We've been fortunate to have the advent of diabetic limb salvage or diabetic foot salvage fellowships in the podiatric community over the years now.
I would say that the International Working Group on the Diabetic Foot has put out a very good consensus statement and/or guideline, which is pretty easy to follow, I think, for somebody that maybe doesn't have years of experience but is really interested in this subspecialty niche that we participate in. I would say the biggest difficulty right now is probably in the limitations that exist in the terminology that's being utilized specific to debridement. So the question really is, what does regular debridement mean in regards to frequency? Is that weekly? Is that bi-weekly? Is it monthly? I think that we don't have any two individuals that necessarily agree on what that is at this current point in time.
We talked a little bit about the fact that there's been consideration given to the specifically wound care fellowships. I think Dr. Tettelbach has been spearheading a lot of that work and has had some modest success to date. If you were to ask me as an opinion, I think that we need to develop an advisory panel amongst some of our national and principle investigators that are running these randomized control trials, open label studies, post-market surveillance studies, looking at schedule of events in regards to protocol and trial design, and the specific procedures that are being performed throughout what we would call the treatment phase or the 12 weeks during these randomized control trials that are so imperative to wound healing itself.
