REVIEW QUESTION

To determine the effects of different debridement methods or debridement versus no debridement on wound healing in venous leg ulcers.

TYPE OF REVIEW

This is a Cochrane systematic review of 10 randomized controlled trials (RCTs) involving 715 participants.

RELEVANCE FOR NURSING

Venous ulcers are a chronic and debilitating condition that causes pain, anxiety, social isolation, and depression and can take up to 12 weeks to heal. Although compression therapy is considered first-line treatment in uncomplicated venous ulcers, it has been shown that after 26 weeks, only about 50% of ulcers heal. Because venous ulcers cause a continual buildup of devitalized, necrotic tissue, debridement is considered necessary to achieve healthy tissue and subsequent healing. Currently, there are six methods used to achieve debridement: surgical debridement, which requires removal of tissue by a surgeon; sharp debridement, which involves tissue removal using a sterile scalpel, scissors, or both; mechanical debridement, where tissue is removed through washing solutions, whirlpool therapy, wet-to-dry dressings, and lavage; enzymatic debridement, where topical application of enzymes breaks down the tissue attaching necrotic tissue to the wound bed; autolytic debridement, where the application of dressings facilitates development of the body's own enzymes to rid a wound of necrotic tissue; and finally biosurgical debridement, which involves the use of sterile maggots. Despite the suggestion of best practice documents and expert opinion that debridement helps to promote healing of venous leg ulcers, there has been no systematic review of the evidence to support this.

CHARACTERISTICS OF THE EVIDENCE

The 10 RCTs selected for inclusion in the review were conducted in various countries and settings. All trial participants were required to have a venous ulcer with dead tissue present in the wound. Eight RCTs evaluated autolytic debridement methods, including biocellulose wound dressing, nonadherent dressing, honey, hydrogel, hydrofiber, hydrocolloids, dextranomer beads, Edinburgh University Solution of Lime, and paraffin gauze. Two RCTs evaluated enzymatic preparations, and one evaluated biosurgical debridement. The review did not identify any studies that tested surgical, sharp, or mechanical methods of debridement nor did it identify any studies that compared debridement with no debridement. Significant limitations were identified in the 10 trials, which were attributable to small sample sizes and major limitations in study design. The authors concluded that most of the evidence had a high risk of bias, consequently producing unreliable results.

BEST PRACTICE RECOMMENDATIONS

Despite consensus in the wound care literature that debridement is necessary to promote wound healing, this review argues that the research base to support this assertion is limited. However, this conclusion is based on low-quality and limited evidence: studies were small and of short duration, and no studies evaluated surgical, sharp, or mechanical methods of debridement, or debridement versus no debridement. The authors point out that although the number of products developed to promote debridement is increasing, practitioners need to question the evidence base that supports their use.

RESEARCH RECOMMENDATIONS

While it is imperative that the efficacy of debridement is addressed more rigorously, research to date has been minimal and fraught with methodologic issues. The authors suggest that future research should focus on designing robust, experimental studies with larger sample sizes where the quality of participant recruitment is enhanced.

REFERENCE