-
The Cochrane Database of Systematic... Sep 2015Venous ulcers (also known as varicose or venous stasis ulcers) are a chronic, recurring and debilitating condition that affects up to 1% of the population. Best practice... (Review)
Review
BACKGROUND
Venous ulcers (also known as varicose or venous stasis ulcers) are a chronic, recurring and debilitating condition that affects up to 1% of the population. Best practice documents and expert opinion suggests that the removal of devitalised tissue from venous ulcers (debridement) by any one of six methods helps to promote healing. However, to date there has been no review of the evidence from randomised controlled trials (RCTs) to support this.
OBJECTIVES
To determine the effects of different debriding methods or debridement versus no debridement, on the rate of debridement and wound healing in venous leg ulcers.
SEARCH METHODS
In February 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting. In addition we handsearched conference proceedings, journals not cited in MEDLINE, and the bibliographies of all retrieved publications to identify potential studies. We made contact with the pharmaceutical industry to enquire about any completed studies.
SELECTION CRITERIA
We included RCTs, either published or unpublished, which compared two methods of debridement or compared debridement with no debridement. We presented study results in a narrative form, as meta-analysis was not possible.
DATA COLLECTION AND ANALYSIS
Independently, two review authors completed all study selection, data extraction and assessment of trial quality; resolution of disagreements was completed by a third review author.
MAIN RESULTS
We identified 10 RCTs involving 715 participants. Eight RCTs evaluated autolytic debridement and included the following agents or dressings: biocellulose wound dressing (BWD), non-adherent dressing, honey gel, hydrogel (gel formula), hydrofibre dressing, hydrocolloid dressings, dextranomer beads, Edinburgh University Solution of Lime (EUSOL) and paraffin gauze. Two RCTs evaluated enzymatic preparations and one evaluated biosurgical debridement. No RCTs evaluated surgical, sharp or mechanical methods of debridement, or debridement versus no debridement. Most trials were at a high risk of bias.Three RCTs assessed the number of wounds completely debrided. All three of these trials compared two different methods of autolytic debridement (234 participants), with two studies reporting statistically significant results: one study (100 participants) reported that 40/50 (80%) ulcers treated with dextranomer beads and 7/50 (14%) treated with EUSOL achieved complete debridement (RR 5.71, 95% CI 2.84 to 11.52); while the other trial (86 participants) reported the number of ulcers completely debrided as 31/46 (76%) for hydrogel versus 18/40 (45%) for paraffin gauze (RR 0.67, 95% CI 0.45 to 0.99). One study (48 participants) reported that by 12 weeks, 15/18 (84%) ulcers treated with BWD had achieved a 75% to 100% clean, granulating wound bed versus 4/15 (26%) treated with non-adherent petrolatum emulsion-impregnated gauze.Four trials assessed the mean time to achieve debridement: one (86 participants) compared two autolytic debridement methods, two compared autolytic methods with enzymatic debridement (71 participants), and the last (12 participants) compared autolytic with biosurgical debridement; none of the results achieved statistical significance.Two trials that assessed autolytic debridement methods reported the number of wounds healed at 12 weeks. One trial (108 participants) reported that 24/54 (44%) ulcers treated with honey healed versus 18/54 (33%) treated with hydrogel (RR (adjusted for baseline wound diameter) 1.38, 95% CI 1.02 to 1.88; P value 0.037). The second trial (48 participants) reported that 7/25 (28%) ulcers treated with BWD healed versus 7/23 (30%) treated with non-adherent dressing.Reduction in wound size was assessed in five trials (444 participants) in which two autolytic methods were compared. Results were statistically significant in one three-armed trial (153 participants) when cadexomer iodine was compared to paraffin gauze (mean difference 24.9 cm², 95% CI 7.27 to 42.53, P value 0.006) and hydrocolloid compared to paraffin gauze (mean difference 23.8 cm², 95% CI 5.48 to 42.12, P value 0.01). A second trial that assessed reduction in wound size based its results on median differences and, at four weeks, produced a statistically significantly result that favoured honey over hydrogel (P value < 0.001). The other three trials reported no statistically significant results for reduction in wound size, although one trial reported that the mean percentage reduction in wound area was greater at six and 12 weeks for BWD versus a non-adherent dressing (44% versus 24% week 6; 74% versus 54% week 12).Pain was assessed in six trials (544 participants) that compared two autolytic debridement methods, but the results were not statistically significant. No serious adverse events were reported in any trial.
AUTHORS' CONCLUSIONS
There is limited evidence to suggest that actively debriding a venous leg ulcer has a clinically significant impact on healing. The overall small number of participants, low number of studies and lack of meta-analysis in this review precludes any strong conclusions of benefit. Comparisons of different autolytic agents (hydrogel versus paraffin gauze; Dextranomer beads versus EUSOL and BWD versus non-adherent dressings) and Larvae versus hydrogel all showed statistically significant results for numbers of wounds debrided. Larger trials with follow up to healing are required.
Topics: Bandages, Hydrocolloid; Borates; Debridement; Humans; Hydrogel, Polyethylene Glycol Dimethacrylate; Randomized Controlled Trials as Topic; Sodium Hypochlorite; Varicose Ulcer; Wound Healing
PubMed: 26368002
DOI: 10.1002/14651858.CD008599.pub2 -
The Permanente Journal May 2021Nasal/sinus endoscopy with biopsy/polypectomy/debridement, or Current Procedure Terminology code 31237, is one of the top 10 most frequent and highest billed...
INTRODUCTION
Nasal/sinus endoscopy with biopsy/polypectomy/debridement, or Current Procedure Terminology code 31237, is one of the top 10 most frequent and highest billed otolaryngology procedures among Medicare patients. We analyzed temporal and geographic trends in endoscopic debridement, and correlated them with sinus surgery and balloon sinuplasty trends.
METHODS
Medicare Part-B National Summary Data Files were analyzed from 2000 to 2016 for temporal trends of endoscopic debridement. Medicare Physician and Other Supplier Public Use Files detailing provider information were collected and analyzed from 2012 to 2016. Individual providers performing a reportable number of procedures were included. Linear regression was used to correlate endoscopic debridement, sinus surgery, and balloon sinuplasty procedures.
RESULTS
Between 2000 and 2016, the number of endoscopic debridement procedures increased from 31,579 to 79,762 (6.0% average annual growth). The annual total payments increased from $5,944,582 to $19,438,956 (8.4% average annual growth), with average allowed charge per procedure increasing from $188.24 to $243.71. The greatest and least number of debridement procedures occurred in the Southeast (12,703) and New England (1810) regions, respectively. There was a positive correlation between providers (n = 752) performing endoscopic debridement and sinus surgery (r = 0.31, p < 0.001), which was similar to providers performing endoscopic debridement and balloon sinuplasty (r = 0.29, P < 0.001).
CONCLUSION
Otolaryngologists continue to perform increasing numbers of endoscopic debridements and receive increasing payments. There is some geographic variation in these trends. Among individual providers, there was a positive correlation between the number of endoscopic debridement procedures and both the number of balloon sinuplasty and sinus surgery procedures.
Topics: Aged; Debridement; Endoscopy; Humans; Medicare; Otolaryngologists; Paranasal Sinuses; United States
PubMed: 33970073
DOI: 10.7812/TPP/20.110 -
The Cochrane Database of Systematic... Apr 2022Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to... (Review)
Review
BACKGROUND
Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.
OBJECTIVES
To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes.
MAIN RESULTS
We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.
AUTHORS' CONCLUSIONS
We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.
Topics: Adult; Anti-Bacterial Agents; Debridement; Fractures, Open; Humans; Lower Extremity; Male; Plastic Surgery Procedures
PubMed: 35363374
DOI: 10.1002/14651858.CD013555.pub2 -
BMJ Clinical Evidence Sep 2008Leg ulcers usually occur secondary to venous reflux or obstruction, but 20% of people with leg ulcers have arterial disease, with or without venous disorders. Between... (Review)
Review
INTRODUCTION
Leg ulcers usually occur secondary to venous reflux or obstruction, but 20% of people with leg ulcers have arterial disease, with or without venous disorders. Between 1.5 and 3.0/1000 people have active leg ulcers. Prevalence increases with age to about 20/1000 in people aged over 80 years.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of standard treatments, adjuvant treatments, and organisational interventions for venous leg ulcers? What are the effects of interventions to prevent recurrence of venous leg ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: compression bandages and stockings, cultured allogenic (single or bilayer) skin replacement, debriding agents, dressings (cellulose, collagen, film, foam, hyaluronic acid-derived, semi-occlusive alginate), hydrocolloid (occlusive) dressings in the presence of compression, intermittent pneumatic compression, intravenous prostaglandin E1, larval therapy, laser treatment (low-level), leg ulcer clinics, multilayer elastic system, multilayer elastomeric (or non-elastomeric) high-compression regimens or bandages, oral treatments (aspirin, flavonoids, pentoxifylline, rutosides, stanozolol, sulodexide, thromboxane alpha(2) antagonists, zinc), peri-ulcer injection of granulocyte-macrophage colony-stimulating factor, short-stretch bandages, single-layer non-elastic system, skin grafting, superficial vein surgery, systemic mesoglycan, therapeutic ultrasound, self-help (advice to elevate leg, advice to keep leg active, advice to modify diet, advice to stop smoking, advice to reduce weight), and topical treatments (antimicrobial agents, autologous platelet lysate, calcitonin gene-related peptide plus vasoactive intestinal polypeptide, freeze-dried keratinocyte lysate, mesoglycan, negative-pressure recombinant keratinocyte growth factor, platelet-derived growth factor).
Topics: Bandages; Debridement; Humans; Leg Ulcer; Occlusive Dressings; Ultrasonic Therapy; Varicose Ulcer; Wound Healing
PubMed: 19445798
DOI: No ID Found -
Wounds : a Compendium of Clinical... Dec 2019Early surgical debridement of nonviable tissue within 48 hours of burn injury is the standard of care (SOC) for burns extending into and beyond the deep dermis. Early...
Early surgical debridement of nonviable tissue within 48 hours of burn injury is the standard of care (SOC) for burns extending into and beyond the deep dermis. Early debridement has been reported to reduce infection and complication rates, shorten hospital stays, and improve burn wound healing compared with delayed debridement of these burns.1 However, surgical debridement challenges patients with considerable pain, blood and heat loss, and poor differentiation between viable and dead tissue resulting in unnecessary excision of healthy tissue.2 Alternative debridement interventions, such as larval, enzymatic, hydrosurgical, or autolytic, have improved outcomes of chronic necrotic wounds3,4 and may offer ways to spare healthy tissue and minimize the recognized challenges of surgical debridement in patients with deep dermal or full-thickness burns. This installment of Evidence Corner reviews recent research exploring hydrosurgical5 or bromelain-based enzyme6 interventions reported to improve burn debridement or repair beyond the current SOC.
Topics: Bromelains; Burns; Cicatrix; Debridement; Evidence-Based Medicine; Guidelines as Topic; Humans; Skin Transplantation; Wound Healing
PubMed: 31833838
DOI: No ID Found -
Journal of Orthopaedics and... Mar 2015Diagnosis and management of low-grade periprosthetic knee infection are still controversial and debatable. The diagnosis of low-grade infection after total knee... (Review)
Review
UNLABELLED
Diagnosis and management of low-grade periprosthetic knee infection are still controversial and debatable. The diagnosis of low-grade infection after total knee arthroplasty is often complex, as clinical symptomatology and diagnostic studies are highly conflicting and knees often exhibit well-fixed components. Although the criterion standard for staged reimplantation is interim placement of an antibiotic-loaded spacer, less-invasive surgical procedures have been advocated for managing infections caused by low-virulence bacteria. Debridement with polyethylene exchange and single-stage reimplantation could offer advantages, such as fewer surgeries, reduced potential for intraoperative complications, and lower direct social costs. The aim of this narrative review was to analyze the literature to evaluate the effectiveness of different surgical procedures in managing low-grade periprosthetic knee infections. Additionally, the most reliable investigations for diagnosing total knee infection caused by low-virulence bacteria were reviewed.
LEVEL OF EVIDENCE
Level V.
Topics: Anti-Bacterial Agents; Arthroplasty, Replacement, Knee; Debridement; Diagnostic Imaging; Humans; Prosthesis Failure; Prosthesis-Related Infections; Reoperation
PubMed: 24821631
DOI: 10.1007/s10195-014-0294-y -
Annals of Medicine Dec 2023Infections are rare and poorly studied complications of unicompartmental knee arthroplasty (UKA) surgery. They are significantly less common compared to infections after...
BACKGROUND
Infections are rare and poorly studied complications of unicompartmental knee arthroplasty (UKA) surgery. They are significantly less common compared to infections after total knee arthroplasties (TKAs). Optimal management of periprosthetic joint infections (PJIs) after a UKA is not clearly defined in the literature. This article presents the results of the largest multicentre clinical study of UKA PJIs treated with Debridement, Antibiotics and Implant Retention (DAIR).
MATERIALS AND METHODS
In this retrospective case series, patients presenting between January 2016 and December 2019 with early UKA infection were identified at three specialist centres using the Musculoskeletal Infection Society (MSIS) criteria. All patients underwent a standardized treatment protocol consisting of the DAIR procedure and antibiotic therapy comprising two weeks of intravenous (IV) antibiotics followed by six weeks of oral therapy. The main outcome measure was overall survivorship free from reoperation for infection.
RESULTS
A total of 3225 UKAs (2793 (86.2%) medial and 432 (13.8%) lateral UKAs) were performed between January 2016 and December 2019. Nineteen patients had early infections necessitating DAIR. The mean follow-up period was 32.5 months. DAIR showed an overall survivorship free from septic reoperation of 84.2%, with overall survivorship free from all-cause reoperation of 78.95%.The most common bacteria were Coagulase-negative , and Group B . Three patients required a second DAIR procedure but remained free from re-infection at follow-up obviating the need for more demanding, staged revision surgery.
CONCLUSIONS
In infected UKAs, the DAIR procedure produces a high rate of success, with a high survivorship of the implant.Key messagesDebridement, Antibiotics and Implant Retention (DAIR) is a successful and minimally invasive surgical option for the management of periprosthetic joint infections (PJIs) after UKA.The surface area available for bacteria to colonise is much smaller in UKAs compared to total knee arthroplasties (TKAs), and this may account for the higher success rates of the DAIR procedure in infected UKAs versus infected TKAs.A second DAIR procedure can be considered in the management of the early recurrence of PJIs with a well-fixed UKA.
Topics: Humans; Arthroplasty, Replacement, Knee; Retrospective Studies; Debridement; Anti-Bacterial Agents; Treatment Outcome; Prosthesis-Related Infections; Arthritis, Infectious
PubMed: 37074322
DOI: 10.1080/07853890.2023.2179105 -
BMC Musculoskeletal Disorders Nov 2018Elbow osteoarthritis (OA) is a common disabling condition because of pain and loss of motion. Open and arthroscopic debridement are the preferred treatment, however... (Review)
Review
BACKGROUND
Elbow osteoarthritis (OA) is a common disabling condition because of pain and loss of motion. Open and arthroscopic debridement are the preferred treatment, however there is no consensus on which treatment modality is suited to which category of patient or stage of disease. The objective of this study was to narratively review the literature for a more comprehensive understanding of its treatment options and associated outcomes, trying to provide a better treatment plan.
METHODS
The PubMed database, EMBASE, Cochrane Library, and Google Scholar were searched, using the keywords (elbow [title/abstract] and osteoarthritis [title/abstract] and (surgery or open or arthroscop* or debridement or ulnohumeral arthroplasty) including all possible studies with a set of inclusion and exclusion criteria.
RESULTS
A total of 229 studies were identified. Twenty-one articles published between 1994 and 2016 satisfied the inclusion and exclusion criteria including 651 elbows in 639 patients. After comparison, mean postoperative improvement in (ROM) was 28.6° and 23.3°,Mayo elbow performance score/index(MEPS/MEPI) 31 and 26.8 and the total complication rate was 37(11.5%), and 18(5.5%) for open and arthroscopic procedure.
CONCLUSIONS
This narrative review could not provide an insight on which surgical procedure is superior to the other due to the poor orthopedics literature. However, from the data we obtained the open and arthroscopic debridement procedures seem to be safe and effective in the treatment of elbow OA. The optimal surgical intervention for the treatment of symptomatic elbow OA should be determined depending on patients' conditions.
Topics: Arthroplasty; Debridement; Elbow Joint; Follow-Up Studies; Humans; Osteoarthritis; Treatment Outcome
PubMed: 30414617
DOI: 10.1186/s12891-018-2318-x -
Soins; La Revue de Reference Infirmiere Apr 2017Fast, effective and pain-free cleansing is essential in the management of wounds, in order to favour the formation of the granulation tissue and the filling of the... (Review)
Review
Fast, effective and pain-free cleansing is essential in the management of wounds, in order to favour the formation of the granulation tissue and the filling of the cavity. Faced with a chronic wound which was not progressing from the inflammatory phase, caregivers put in place a technique combining negative pressure therapy and instillations of sodium bicarbonate and oxygenated water. The initial results are promising, with the patient benefiting from effective and pain-free cleansing.
Topics: Debridement; Detergents; Humans; Negative-Pressure Wound Therapy; Pressure Ulcer; Sodium Chloride; Wound Healing; Wound Infection; Wounds and Injuries
PubMed: 28411655
DOI: 10.1016/j.soin.2017.02.018 -
The Cochrane Database of Systematic... Jan 2010Foot ulceration is thought to affect 15% of people with diabetes at some time in their lives. Debridement is widely regarded as an effective intervention to speed up... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Foot ulceration is thought to affect 15% of people with diabetes at some time in their lives. Debridement is widely regarded as an effective intervention to speed up ulcer healing. The most effective method is unclear.
OBJECTIVES
To assess the effects of debridement interventions on the healing of diabetic foot ulcers.
SEARCH STRATEGY
For this third update we searched the Cochrane Wounds Group Specialised Register (June 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2009, Issue 2; Ovid MEDLINE - 1950 to June Week 3 2009; Ovid EMBASE - 1980 to 2009 Week 25 and Ovid CINAHL - 1982 to June Week 3 2009.
SELECTION CRITERIA
Randomised controlled trials (RCTs) evaluating any method of debriding diabetic foot ulcers and measuring complete healing or rate of healing. There was no restriction on articles/trials based on language or publication status.
DATA COLLECTION AND ANALYSIS
Data extraction and assessment of study quality were undertaken by one review author and checked by an Editor of the Wounds Group.
MAIN RESULTS
Six RCTs of debridement were identified: four assessed hydrogels, with an additional study evaluating larval therapy against hydrogel and one evaluated surgical debridement. Pooling the three RCTs which compared hydrogel with gauze or standard care suggested that hydrogels are significantly more effective in healing diabetic foot ulcers (Relative Risk 1.84, 95% Confidence Interval (CI)1.3 to 2.61). Surgical debridement showed no significant benefit over standard treatment. One small trial suggested that larvae resulted in a more than 50% reduction in wound area compared with hydrogel. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in diabetic foot ulcers.
AUTHORS' CONCLUSIONS
There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
Topics: Animals; Bandages; Combined Modality Therapy; Debridement; Diabetic Foot; Humans; Hydrogels; Larva; Randomized Controlled Trials as Topic; Wound Healing
PubMed: 20091547
DOI: 10.1002/14651858.CD003556.pub2