Mechanical debridement of wounds, when used appropriately, is a highly effective method of promoting wound healing and removing unwanted tissue from the wound base and periwound area. However, sharp debridement requires proper technique and carries a relatively high level of clinical risk, which is a limitation for many healthcare providers; further, there is very little formal training on sharp mechanical debridement provided to wound care practitioners.
Traditional debridement tools, such as dermal curettes and scalpels, have their own respective limitations. Conventional curettes create rugged, semilunar cuts and can only achieve a given level of precision. Practitioners have previously attempted to overcome this limitation through innovative means, such as using the more precise uterine curette for wound debridement, but this provides only modest improvement.1 Scalpels are highly effective in the debridement of necrotic tissue in the wound base and periwound calluses. However, they are often impractical when it comes to debridement of hypergranulation tissue because of unfavorable holding angles and a short blade.2
The DermaBlade shave biopsy instrument (AccuTec, Inc) is a disposable dermatologic cutting tool that is traditionally used to perform shave biopsies and assist with Mohs micrographic surgeries.3 It is an excellent, but often unutilized, adjunct in the toolkit of a wound care practitioner. The shave biopsy instrument is easy to use and shows remarkable precision, making it an ideal tool for increasing the speed and accuracy of sharp debridement procedures.
In the context of wound care, this tool serves two main purposes: First, the tool allows rapid debridement of any hypergranulation tissue that protrudes above the wound base and periwound area. This is especially helpful when dealing with larger wounds, for which debridement using dermal curettes or scalpels is a daunting and time-consuming task. Even large curettes and scalpels present less cutting surface than is provided by this shave biopsy instrument. Second, the instrument enables precise leveling of the wound base, allowing keratinocytes to close the tissue defect by moving from the edges of the periwound centrally. As a result, the tool facilitates merging of wound edges in a method not often achievable with traditional debridement instruments.
The following are several examples in which utilization of the shave biopsy tool allowed for a higher level of precision in the debridement of complex wounds, which would not have been possible using conventional wound debridement tools. Informed consent was gathered from all patients in capturing photographs, and all identifying information and other patient data were removed.
PRACTICAL APPLICATIONS
Figure 1 models the steps required for hypergranulatory tissue debridement using the shave biopsy instrument. In panel 1 (top left), the blade is placed on hypergranulatory tissue on a lower-extremity residual limb wound. The practitioner holds the blade as straight as possible so that a trench is not created via an overly curved cutting surface. In panel 2 (top right), topical anesthesia with gauze soaked in lidocaine and epinephrine was administered. In addition, silver nitrate cautery was used to improve visualization and reduce capillary bleeding. Panel 3 (bottom left) shows debridement with the instrument. The technique is similar to that of a shave biopsy, in which a back-and-forth or "zigzag" motion is used until all desired tissue is removed. Thicker areas of hypergranulation may require multiple passes in the same line to achieve satisfactory debridement and may require injection of lidocaine with epinephrine to prevent excess bleeding. The same applies to patients on anticoagulation. Panel 4 (bottom right) shows an optional step, in which additional silver nitrate cautery can be administered mid-debridement as needed. Bactericidal gauze and dressings (such as silver alginate or polyvinyl alcohol foam) are preferred to absorb any postprocedural bleeding and suppress bacterial growth after debridement. The site also should be kept dry to prevent regrowth of hypergranulatory tissue.
Figure 2 shows an instance in which a shave biopsy tool was used to debride a large facial wound with favorable results. Preprocedural injection of lidocaine with epinephrine into the wound base was performed. In addition, cautery with silver nitrate was utilized (as seen in panel 2). The debridement instrument proved practical and efficacious in a wound setting where cosmetic considerations were of high priority.
Figure 3 shows the revision of hypergranulatory tissue overlying a traumatic elbow wound. Topical anesthesia was provided using gauze soaked with lidocaine and epinephrine, and silver nitrate cautery was performed (panel 2). The instrument enabled precise wound leveling of the hypergranulatory tissue in an effort to decrease wound healing time.
CONCLUSIONS
The shave biopsy tool can provide a useful alternative to the traditional curette and scalpel in the debridement of hypergranulatory wound tissue. Precise leveling of the wound base and periwound can benefit patients by providing a more favorable environment for wound healing. Wound care practitioners can benefit from the instrument's efficiency in reducing the time required to accurately debride large and complex wounds.
REFERENCES