WOUND DEBRIDEMENT in orthopaedics by Dr. Deepak

Wound debridement is the medical process of removing dead, damaged, or infected tissue from a wound to improve the healing potential of the remaining healthy tissue. It can be done using various techniques, such as surgical removal, mechanical methods, enzymatic agents, or autolytic debridement (using the body's own processes). This procedure is important because it helps reduce the risk of infection and promotes faster and more effective healing.

Would you like to know more about the different methods of debridement or how to prepare for such a procedure?

1. WOUND DEBRIDEMENT PRESENTER – DR. DEEPAK PAL

2. DEFINITION “The removal of foreign material and devitalized or contaminated from or adjacent to a traumatized or infected lesion, until surrounding (an underlying in a case of cutaneous ulcer) healthy tissue is exposed” - Dorland’s medical dictionary

3. Debride Urgent, atleast <6hrs Study shows that bacterial count reach infection threshold in open fracture at mean of 5.17hrs. Study- type 2 and 3 fractures debrided <5hrs – 7% infected >5hrs – 38% infected

4. Methods of debridement Mechanical Sharp/surgical Enzymatic Autolytic

5. Mechanical debridement Methods include wet to dry dressings, hydrotherapy (whirlpool), and wound irrigation (pulse lavage) This method is more painful than other methods , so consider premedicating the patient for pain. Non-selective debridement May be harmful to healthy granulation tissue on the surface of the wound.

6. Sharps / surgical debridement Use of a scalpel, forceps, scissors toremove dead tissue. Considered as gold standard by many clinicians. Viable tissue may also be removed inadvertently with this method. Used for devitalized or dead slough on wound surface. First choice for wounds demonstrating signs of advancing cellulitis or sepsis.

7. Enzymatic debridement Safe, effective and easy to perform Effective wound surface cleaning agents Muller and colleagues found debridement with collagenase to be quicker and more cost effective.

8. Autolytic debridement Uses the body’s endogenous enzymes to slowly remove necrotic tissue from the wound bed. In a moist wound it soften and liquify the necrotic tissue, that is then digested by macrophages. Takes longer time than other method Contraindicated in infected wounds.

9. Protocols of sharps debridement Preparing patient for debridement Adequate resuscitation Start broad spectrum antibiotics as soon as possible Inform the patient about the procedure and its significance in wound healing Procedure Wear cap, mask, gown and gloves Apply disinfectant such as povidone iodine on and around the area Drape the area properly Start debriding from the base of the wound

10. The reason for starting from base of the wound is that becox the blood from upper margins fall into base and give false impression of red bleeding tissue Be generous while debriding tissues and consider every debridement as last debridement Debride tissues until red bleeding margins are seen The goal here is to excise the area having thrombosed vessels and lymphatics Irrigate the area with normal saline and bactericidal agent such as hydrogen peroxide Dry the area with clean sponge and do dressing

11. Gustilo Anderson Classification

12. How to debride Superficial to deep (skin to bone) Skin 2mm of skin edges to e removed till bleeding is present Incision to be extended Contused and questionable skin to e left initially. Subcutaneous tissue Excise all devitalized tissue. These tissues have a sparse blood supply and on subsequent debridement, further devitalization may become apparent.

13. Fascia contaminated & necrosed to e removed Muscle removal of non viable muscle(deep group necrose first) Check for colour, consistency, contractability Bone Remove necrosed tissue from fracture ends, medullary cavity small fragments without attachment is removed large fragments, retained for reduction purpose Cartilage must be preserved reduction and joint reconstruction

14. Irrigation of wound Which fluid? Normal saline. How much

15. How to irrigate Gravity flow(<5psi) 3 litreNS suspended 6-8 feet high with compressible tubing Low pressure flow 50ml syringe (5to10psi) pulse lavage in low pressure mode High pressure flow jet lavage(>20psi)

16. Role of antiseptic and antibiotic during wash? No role These are toxic to host cells, affect microvascular flow, endothelial integrity, wound healing.

17. Principles of wound management

18. Antibiotics Patzakis (RCT) effectiveness of antibiotics in posttraumatic wound No antibiotics- 14% infection rate Cephalosporins- 2.4% infection rate ASAP, within 1hr Early timing of antibiotics- single important factor in reducing infection G&A open fracture type Type1- cefazolin dose 2g/8hr Type2- cefazolin dose 2g/8hr Type3- cefazolin dose 2g/8hr + aminoglycosides 5mg/kg Time period – 3-5 days