General Principles of Surgical Débridement
Lawrence X. Webb, MD, MBA
Henry J. Dolch, DO
Dr. Webb or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of the Musculoskeletal Transplant Foundation; serves as a paid consultant to or is an employee of Biocomposites; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from Kinetic Concepts, Doctors Group, Smith & Nephew, Stryker, and Synthes; and serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association Southeastern Fracture Consortium Foundation. Neither Dr. Dolch nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
INTRODUCTION
A wound characterized by tissue that is contaminated and/or devitalized is best managed with surgical débridement; that is, removal of contaminants as well as the devitalized tissue.1 The goal of this process is to alter the wound environment, so that healing can occur readily and free of infection. The surgeon must carefully assess the nature of the wound. If surgical extensions are needed to better evaluate and débride the wound, then they should be incorporated. Bone stabilization should be done with an aim to provide stability. It should be accomplished in such a way as to minimize the likelihood for osteonecrosis which in turn potentiates infection. Stable soft-tissue coverage is needed to thwart necrosis of dessication-prone tissue such as exposed bone, joint or tendon devoid of paratenon.
VIDEO 68.1 Surgical Débridement. Lawrence X. Webb, MD; Henry J. Dolch, DO (6 min)Video 68.1
PROCEDURE
Video Case
The video supplement shows a leg wound with an open knee joint at its base with degloved skin and subcutaneous tissues along with substantial gross contamination. The contaminants include mud and grass, which are ground into the tissue. This type of contamination and devitalization presents challenges to the surgeon, and transforming a wound like this to effect uneventful, infection-free healing with stable coverage and good preservation of knee function is a task that demands carefully staged and appropriately timed surgical interventions.
Surgical Technique
The surgical exposure was aided by surgical extensions, which also exposed the extent of proximal degloving. Grossly devitalized and highly contaminated tissues are removed with a knife and forceps. We have found that a tangential excision tool is sometimes advantageous for removing contaminants in a wound with small adsorbed contaminants such as the ones shown in the video. This type of device works on the Bernoulli principle: a high-pressure saline stream across the working end of the tool creates a vacuum.2,3 The working end is dragged across the surface of the wound, allowing the vacuum it generates to pull the surface layer up into the high-pressure stream, which in turn tangentially excises the wound surface. In the process, the adsorbed mud and grass on the surface is pulled off with the tangential excision of its surface layer. This greatly facilitates the excision of these contaminants. Normal saline irrigation in a generous volume by gravity flow is an important next step. The prospective multicenter trial of fluid lavage for open wounds (FLOW trial) showed no difference in the pressure subsets (>20 psi, 5-10 psi or 1-2 psi) with the primary end point being revision surgery within 12 months.4 This study also showed that plain saline had a significantly lower incidence of revision surgery than did saline with castile soap.4 Given the violation of the knee joint space, the knee joint as well as the entire adjoining wound shown in the video are thoroughly irrigated with 3 L of saline solution.
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