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Debridement oftheDiabetic Foot
andLeg
ChristopherE.Attinger andJaysonN.Atves
12
Introduction
The word “debridement” derives from the French
débridement, which translates into “to remove a
constraint.” This term was rst used by Henri
LeDran (1685–1770) (Fig.12.1) in the context of
an incision of skin and fascia to release swelling
associated with injury [1]. However, during eighteenth and nineteenth century wartime this denition was greatly rened to include “removal of
all materials incompatible with healing in order
to prevent gangrene” and it is this denition that
still guides clinicians today [2]. Debridement is
the excision of foreign, dead, dying, damaged, or
infected tissues in order to optimize the healing
potential of the remaining healthy and viable tissues. It is performed in a myriad of ways and settings in preparation for soft tissue closure within
the steps of the plastics and reconstructive ladder
ranging from simple primary closure to the use of
complex aps [3, 4].
Debridement is merely one albeit vital factor
in modern wound bed preparation. The fundamental tenets in the management of most lower
extremity wounds include the eradication of
infection, optimization of local and systemic
healing factors, adequate ofoading, and/or
immobilization with achievement of a biome-
C. E. Attinger ∙ J. N. Atves (*)
Department of Plastic Surgery, Georgetown
University School of Medicine and MedStar
Georgetown University Hospital,
Washington, DC, USA
e-mail: Christopher.Attinger@medstar.net;
jayson.atves@medstar.net
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_12
Fig. 12.1 Henry LeDran (1685–1770) rst published on
debridement in the context of an incision of skin and fascia to release swelling associated with injury
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C. E. Attinger and J. N. Atves
chanically stable and well-aligned extremity
through biomechanical correction or accommodation. Diabetic foot and leg wounds in particular
require adherence to a multifactorial treatment
algorithm that affords the greatest potential for
healing while also mitigating costs and minimizing the possibility for recurrence.
Although outside the scope of this chapter,
there are numerous factors which may contribute
to an acute wound’s stagnation into the chronic
state and consideration of these factors in addition to sufcient debridement is essential to
obtaining and preserving a healthy wound bed.
Factors may include a patient’s comorbidities,
nutrition, glycemic control, smoking status,
ambulatory status, wound etiology, biomechanical aberrations, tissue perfusion, access to
resources, adherence to prescribed rehabilitation,
and perhaps most importantly, wound location
and topography. Once the patient and wound
have been optimized, several options exist on the
plastics reconstructive ladder for denitive
wound closure, including primary intention, secondary intention, skin grafting, local tissue transfer, and free tissue transfer [4].
Determining the etiology of a patient’s wound,
though, is of the utmost importance in order to
guide decision making regarding the most appropriate course of wound optimization, including the
type of debridement performed. However, it is
imperative to understand that debridement type,
just as the wound character, may evolve over time,
especially in the comorbid population, including
individuals with diabetes. Consequently, a thoughtful understanding and careful consideration of the
patient, the wound, and feasible methods of
debridement are vital to a successful outcome [5].
The achievement of an infection-free, wellaligned and structurally stable lower extremity
combined with an appropriately selected mode
for soft tissue closure, with optimization of local
and systemic healing factors and appropriate offloading and immobilization where warranted,
will provide for the best opportunity of a successful outcome both in the acute phases of healing
and in the long-term durability and function of
the patient. Ultimately, the primary goal in this
cascade is the achievement or restoration of max-
imal ambulatory function within each patient’s
physical and medical capacity. Debridement
though, in its varied forms, is truly the foundation
and perhaps the single most important component of this limb salvage cascade (Fig.12.2).
In this chapter we review the guiding tenets of
debridement and offer an assortment of strategies
and techniques aimed at appropriate method
selection, successful performance, and ultimately
a prosperous wound bed preparation. The goals
of this chapter will be to gain an understanding
and appreciation for the exceptional potential of
adequate tissue debridement and its place as a
powerful tool in the surgeon’s arsenal.
Wound Healing
A review of the normal wound healing cascade is
necessary to more clearly understand the complex
wound state. Wound healing is a natural physiological reaction to tissue injury. An acute wound is
dened as a recent wound that has yet to progress
through the sequential stages of wound healing.
However, this is not a simple phenomenon but
rather involves a complex interplay between
numerous cell types, cytokines, mediators, and the
vascular system. The traditional cascade of wound
healing is described as the sequential and overlapping progression through three phases: inammation, proliferation, and remodeling [6]. The initial
vasoconstriction of blood vessels and platelet
aggregation is designed to stop bleeding. This is
followed by an inux of a variety of inammatory
cells, starting with the neutrophils. These inammatory cells, in turn, release a variety of mediators
to promote angiogenesis, thrombosis, and reepithelialization. The broblasts, in turn, lay down
extracellular components which will serve as scaffolding for ultimate wound healing and closure.
The inammatory phase begins with hemostasis at the initial insult after platelets have collected and adhered at the site of injury to form a
hemostatic plug. In this phase, the body activates
the clotting cascade and forms a clot to stop continued bleeding. During this process, platelets
which have traveled to the site of injury come
into contact with collagen, resulting in their acti-
ab
12 Debridement oftheDiabetic Foot andLeg
159
Fig. 12.2 Clinical representation of a sequentially
“primed” wound bed (a, b). In this patient, surgical
debridement and local wound care were utilized to eradi-
vation and aggregation. Thrombin initiates the
formation of a brin plug, which strengthens the
platelet clumps into a stable clot. Additionally,
platelets contain intracellular structures including alpha-granules that contain growth factors,
clotting factors, and other proteins involved in
wound healing. Transforming growth factor
(TGF-beta) and platelet-derived angiogenesis
factor (PDAF) play roles in wound matrix production by promoting collagen production and
new capillary formation. Platelet-derived growth
factor (PDGF) is one of the key components of
wound healing which recruits and activates proinammatory cells such as broblasts, macrophages, monocytes, and neutrophils. These cells,
in turn, secrete growth factors such as TGF-beta,
broblast growth factor (FGF), endothelial
cate infection and stimulate healing potential (a) which
led to the formation of a “primed” wound bed (b) and ultimately denitive closure via split-thickness skin graft
growth factor (EGF), and vascular endothelial
growth factor (VEGF). These cellular interactions and communications are critical elements in
the wound healing cascade. This phase normally
lasts a matter of days after the initial insult.
The proliferation or epithelialization phase
begins with the proliferation and migration of
epidermal cells. Epidermal cells will form linkages with one another and initiate deposition of
basement membrane components and degrade
the extracellular matrix. Neovascularization
occurs at the wound bed causing the formation of
granulation tissues, which inltrates the temporary matrix. Fibroblasts play a crucial role in
orchestrating the reorganization of the extracellular matrix into a collagenous matrix through
the use of proteases and other enzymes. Growth
160
ab
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C. E. Attinger and J. N. Atves
factors such as VEGF contribute to the stimulation of angiogenesis to support wound healing.
This phase of wound healing can normally last
days to weeks in duration.
The remodeling or maturation phase involves
slow advances in new tissue strength and exibility with wound contraction facilitated by broblasts that have converted to myobroblasts
stimulated by growth factors. Collagen is continually remodeled through enzymatic degradation
by matrix metalloproteinases (MMPs) until nal
collagen deposition and wound reepithelialization have occurred. This phase’s duration can
vary greatly lasting from weeks to years.
Wound Bed Preparation
Adequate preparation of a wound bed is the principal aspect of wound management and eventual
closure. Functionally speaking the overarching
goals of wound bed preparation include effectively removing any and all tissues which would
otherwise allow bacterial burden to proliferate,
decreasing the overall demand of the local wound
site and systemic physiological stress, and stimulating the underlying health of the remaining tissues in order to produce a wound bed which is
“primed” for closure (Fig.12.3). Debridement is
the predominant means of achieving these goals
of wound bed preparation and should be thought
of as not just the gold standard but a necessary
treatment modality for nearly every wound type
in nearly every patient. Various modes of debridement exist and although most are readily available regardless of clinical setting, individual
choice of the particular method of debridement to
undertake may depend on clinician and patient
access to resources and the logistical feasibility
of its implementation (Fig.12.4).
Fig. 12.3 Clinical representation of a sequentially
“primed” and ultimately closed wound bed (a–d) in a
patient with a transmetatarsal partial foot amputation. In
this patient, surgical debridement and local wound care
(a) with supplementation via skin substitute grafting (b)
were utilized to produce a “primed” wound bed (c) with
subsequent denitive closure via split-thickness skin graft
(d)
12 Debridement oftheDiabetic Foot andLeg
161
Fig. 12.4 Five modes of debridement exist, including
mechanical, enzymatic, autolytic, biologic, and nally
surgical. Overwhelmingly, surgical debridement is the
Types ofDebridement
Mechanical
Mechanical debridement is perhaps the oldest
form of debridement and involves the use of
moist or wet ushes or dressings, which are subsequently removed from contact with the wound
bed. The removal and physical wound base disruption causes nonselective debridement of loose
tissues and slough. Examples include direct
wound irrigation with saline, wet-to-dry dressings, and hydrotherapy, including bath and whirlpool. Dressing changes are quite simple and can
be performed independently by the patients in
many cases. However, because mechanical
debridement is considered nonselective in nature,
it may remove or damage healthy tissues if not
performed judiciously (Fig.12.5).
Enzymatic
Enzymatic debridement involves using chemical
agents to slough necrotic wound tissue.
Collectively, these enzymes are derived from
most common and varied form of debridement; however,
depending on a variety of factors an understanding of the
assorted options for debridement is essential
microorganisms such as Clostridium histolyticum
or from plants, including collagenase, varidase,
papain, and bromelain. This method is most useful for debridement of wounds with a large
amount of necrotic tissue and poses little risk to
healthy tissues. This mode of debridement is considered selective in nature; however, judicious
use of these products must be implemented so as
not to create an environment nonconducive to
overall tissue healing.
Autolytic
Autolytic debridement uses the body’s own
enzymatic processes to debride necrotic tissues
and slough. This process interrupts dead and
devitalized tissue over time by allowing wound
uids to maintain contact in the wound bed to
hydrate, soften, and liquefy necrotic tissue and
eschar. This method is achieved with the use of
occlusive or semi-occlusive dressings with or
without the supplementation of hydrocolloids,
hydrogels, and transparent lms and is suitable
for cases in which the amount of dead tissue is
not extensive and there is no infection.
162
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C. E. Attinger and J. N. Atves
ab
efgh
Fig. 12.5 Mechanical debridement in a sequential manner
is appreciated spanning approximately 6 months (a–h).
This specic patient utilized mainly mechanical debride-
Autolytic debridement is selective for necrotic
tissues, is easy to perform, and is virtually
painless to the patient. However, it is by far the
slowest type of debridement, and the wound
must be rigorously monitored for signs of
infection. For these reasons, this method is
often reserved for patients with poor access to
resources and those contraindicated for the
other debridement methods, such as those with
intractable pain to the wound during other
debridement modes (Fig.12.6).
ment secondary to limitations with pain and inability to
safely undergo anesthesia for operative debridement
Biologic
Biologic debridement employs the use of medical maggots that have been raised in a sterile
environment [7]. Several young larvae of the
green bottle y (Lucilia sericata) are introduced
into a wound bed and secured with a permeable
dressing which allows for larvae respiration [8].
The maggots feed selectively on the necrotic tissue of the “host” without injuring living tissue
and can quite effectively debride a wound in a
12 Debridement oftheDiabetic Foot andLeg
ab cd e
163
Fig. 12.6 Autolytic debridement in a sequential manner
is appreciated spanning approximately 4 months (a–e).
This specic patient utilized mainly autolytic debride-
Fig. 12.7 Use of medical maggots for biologic debridement is a useful and underutilized modality of debridement. An appropriate maggot “house” dressing will
permit biologic respiration in order to prevent occlusion,
anoxia, and ultimately death of the medical maggots
matter of just a few days. The larvae derive nutrients by secreting a broad spectrum of enzymes
that liquefy necrotic tissue for consumption. In
ment secondary to limitations with access to and resources
and contraindications for operative debridement
an optimum environment, maggots molt twice,
increasing in overall size and leaving a clean
wound free of necrotic tissue once they are
removed. This method has gained popularity
over time, but some patients nd the method
painful, and a patient’s aversion to maggots
being placed onto the body may impede its use.
However, this method has the advantage of being
non-surgical in nature and performs quite expediently compared to autolytic or enzymatic
debridement with minimal risk to healthy tissues
(Fig.12.7).
Surgical
Surgical debridement is arguably the most common and varied type of debridement. A myriad of
instrumentation and adjuncts are used to physically excise dead, dying, or infected tissue from
the wound bed, either at the bedside, in the clinic,
or in an operating room (Fig.12.8). The surgeon
will debride tissue to viability, as determined by
tissue character and the presence of vascularity in
healthy tissues, using any combination of
instrumentation.
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C. E. Attinger and J. N. Atves
a
b
Fig. 12.8 Surgical debridement of severely necrotic tissues of the leg is appreciated both pre-debridement (a)
and post-debridement (b)
Surgical Debridement
Indications
Surgical debridement is best suited for progressive
or recalcitrant wounds; larger sized wounds and/or
those in atypical or precarious locations; grossly
infected wounds; and wounds considered to be of
an unknown etiology, which necessitate surgical
biopsy or resection. Surgical debridement is considered the most expedient method of debridement
because it is very selective and limited only by the
skill, experience, and judgement of the surgeon.
Overall, surgical debridement affords superior
control over which and how much tissue is
removed, is the fastest manner to achieve a clean
wound bed, and can expedite the healing process
in most patients with diabetic foot and leg wounds.
Instrumentation
The surgeon will debride to the level of viable tissue,
as determined by tissue character and the presence
of vascularity in healthy tissues, using any combination of instruments, such as rongeur, curette, scissors, and scalpel blade (Fig. 12.9). The onus of
determining the most appropriate instrumentation
should be based on the surgeon’s individual preference, availability of instrumentation, and specic
wound character, location, and topography. Wounds
with overt infection will require arguably more
aggressive debridement to reach the level of healthy
and living tissues, whereas wounds with no acute
signs or symptoms of infection or bioburden may
require relatively less overall aggressive debridement. Regardless, surgical debridement should
always be performed with the most appropriate
instrumentation as deemed by the surgeon and in a
manner which is considerate of the surrounding tissue integrity. Perhaps the most deleterious potential
complication of surgical debridement is the possibility of injury to the surrounding healthy tissues.
Adjunctive instrumentation for surgical
debridement such as the micro water jet device
has been developed for an even more meticulous
and selective debridement (Fig. 12.10). This
device produces a pressurized stream of saline
which is dispelled at high speed from its tip and
immediately suctioned into the handpiece where
the jet action of the saline effectively pulverizes
the tissues placed between the outow and inow
portion of the tip. The authors nd this of particularly advantageous use in large surface area
wounds where controlled debridement is required.
However, it should be noted that the water jet
device, although quite benecial from a practicality standpoint and which provides for precise and
controlled debridement, has signicant limitations in its ability to debride certain tissue type
(i.e., tendon and ligament) and variable tissue
topographies and thus should only be used as a
supplement to the standard manual instrumentation for traditional surgical debridement.
Furthermore, the depth at which the water jet is
able to debride in a single pass is fairly shallow
and this level of control should not lull the surgeon into believing that use of the water jet alone
is a sufcient debridement technique. Again,
manual instrumentation is the gold standard for
surgical debridement and the water jet should
only be utilized as an adjunct, not a replacement.
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