International Wound Journal ISSN 1742-4801

ORIGINAL ARTICLE

Surgical debridement to optimise wound conditions and

healing
Michael Diefenbeck, Nils Haustedt & Hergo GK Schmidt
Septische Knochen- und Weichteilchirurgie, Schön Klinik Hamburg Eilbek, Hamburg, Germany

Key words Diefenbeck M, Haustedt N, Schmidt HGK. Surgical debridement to optimise wound
Debridement; Osteomyelitis; Skin and soft conditions and healing. Int Wound J 2013; 10 (suppl. 1):43–47
tissue infection
Abstract
Correspondence to
Michael Diefenbeck, MD, PhD Different treatment strategies are available for bone, joint and soft tissue infections,
Septische Knochen- und Weichteilchirurgie including use of local antibiotics; negative pressure wound therapy; one-stage, two-
Schön Klinik Hamburg Eilbek
stage or multi-stage revisions; or open wound therapy. All methods have one principle
Dehnhaide 120
in common: adequate surgical debridement is the prerequisite for successful treatment
22081 Hamburg
Germany
of bone, joint and soft tissue infections. According to the different textures of healthy,
E-mail: MDiefenbeck@schoen-kliniken.de infected or necrotic tissue, special techniques are used. In this article we will describe
the clinical presentation of necrotic and non-vital tissue in skin, soft tissue and bone
doi: 10.1111/iwj.12187 and appropriate techniques of debridement.

Introduction In this article we will describe the clinical presentation

Debridement is defined as ‘the removal of sequestrate and
resection of infected bone and soft tissue to improve the
healing potential of the remaining healthy tissue’ (1). This
treatment has been known and utilised for hundreds of years.
The first mention of surgical debridement is found in the script
of the Roman physician Aulus Cornelius Celsus in the first
century AD (2). Currently the goal of surgical debridement
is to remove as much necrotic tissue as possible in order to
reduce the bacterial bioburden.
There are different concepts for treatment of bone, joint
and soft tissue infections [e.g. use of local antibiotics, neg-
ative pressure wound therapy (NPWT), one-stage, two-stage
or multi-stage revisions or open wound therapy]. Each
method has its advantages and disadvantages with a much
controversial discussion in the literature. All authors agree
that adequate surgical debridement is the prerequisite for all
treatment modalities (3).
To highlight the importance of this surgical intervention,
debridement has often been called ‘radical’ or ‘exten-
sive’; but not further defined (4). In our opinion, ‘radi-
cal’ is not the appropriate term. All necrotic and scarred
tissues have to be removed, but on the other hand, as
much of healthy, non-infected tissue as possible has to be
retained to enable undisturbed wound healing. The term
‘radical’ implies the risk of removing too much healthy
tissue.
Therefore, we suggest calling this calculated, meticulous
surgical technique ‘intelligent’ debridement.
of necrotic and non-vital tissue (skin, soft tissue and bone)
and the appropriate methods of debridement. All patient
photographs and data were collected according to institutional
protocols. Informed consent was obtained from all patients.
Methods of surgical debridement
Skin
Non-vital skin initially becomes white/pale (ischaemic), then
turns dark purple and finally black (5). Final necrosis is easy
to recognise and can be excised with a scalpel. Borderline
poorly perfused to non-vital, necrotic skin is sometimes
difficult to differentiate. In this situation, excision should be
carried out in a stepwise fashion until there is bleeding from
Key Messages
• adequate surgical debridement is the prerequisite for
successful treatment of bone, joint and soft tissue
infections
• this paper describes the clinical presentation of necrotic
and non-vital tissue in skin, soft tissue and bone as well
as appropriate techniques of debridement
• during surgical debridement, clinical signs are mainly
used to distinguish between healthy, vital tissue and
infected, necrotic tissue

© 2013 The Authors

International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd 43
Surgical debridement to optimise wound conditions and healing Michael Diefenbeck et al.

Figure 1 Skin and soft tissue necrosis of right elbow (10 January 2012). Figure 3 Clinical result after 7 days of negative pressure wound therapy
(NPWT; 26 January 2012).

the small vessels, thereby indicating vital and perfused tissue

(5). The skin defect may be covered by a mesh graft. After
®
debridement, NPWT (V.A.C. Therapy, KCI Medizinpro-
dukte GmbH, Wiesbaden, Germany) can be used to produce
granulation tissue in order to optimise wound conditions.

Case report I
Patient was a 79-year-old female who presented with a
haematoma of the right forearm after a fall. Patient had
rheumatoid arthritis and was treated with prednisolone. The
following is a timeline of treatment:
5 January 2012: debridement of a subcutaneous
haematoma of the right forearm.
10 January 2012: skin and soft tissue necrosis devel-
oped (Figure 1).
11 January 2012: debridement of skin and soft tissue,
local antibiotic therapy with polymethylmethacrylate Figure 4 Intra-operative site after split-thickness skin graft (STSG; 26
®
(PMMA)-gentamicin-beads (Septopal , Biomet, Berlin, January 2012).

Figure 5 Clinical outcome 5 days after split-thickness skin graft (STSG;

Figure 2 Clinical result after debridement and local antibiotics for 7 days
31 January 2012).
(18 January 2012).

© 2013 The Authors

44 International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Michael Diefenbeck et al.
Figure 6 X-ray of left ankle joint after accident (20 June 2011).
Figure 7 X-rays of left ankle joint and left knee joint: Non-union
developed after 8 months (21 February 2012).
Figure 8 Surgical site with sequesters of distal tibia (22 February 2012).
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Surgical debridement to optimise wound conditions and healing
®
Germany) and Epigard (Medisave, Wiesbaden, Ger-
many) for 7 days (Figure 2).
19 January 2012: second debridement, NPWT with
polyurethane foam dressing for 7 days, continuous ther-
apy, 75 mmHg (Figure 3).
26 January 2012: split-thickness skin graft (STSG;
0·4 mm, 1:1·5) from right thigh (Figure 4).
31 January 2012: clinical outcome after 5 days
(Figure 5).
Subcutaneous tissue
As fat tissue necroses, its structure alters, becoming a liquid,
deliquescent substance, which can be easily removed by a
curette (5). In early fatty necrosis, when the tissue is still
firm, it should be removed with a scalpel until bleeding from
small vessels appears.
Irrigation with water under pressure (jet lavage) can also
be used to remove fat necrosis. The water jet creates a plane
of cleavage which excises the non-vital tissue while leaving
vital tissue intact.
Fascia
Necrotic fascia also becomes liquid, changes colour becoming
yellow or grey and loses its integrity. Such fascia must be
excised with a scalpel until bleeding from small vessels
appears. This is vital in the life-threatening necrotising
fasciitis, where the only chance of survival is to remove
the necrotic fascia completely. This often involves extensive
incisions and the removal of virtually all fascia of the
involved extremity (6).
Muscle
As muscle tissue becomes necrotic, its appearance changes
to that similar to ‘overcooked’ meat and can be removed
with a curette. The necrotic tissue is yellowish, doughy and
shows almost no bleeding. The structure of infected, yet vital,
muscle is intact, but loosened and bleeds extensively. This
tissue can be left in situ.
45
Surgical debridement to optimise wound conditions and healing Michael Diefenbeck et al.

Figure 9 Postoperative X-rays of left ankle and knee joint (24 February 2012).

Figure 10 Correct position of ring fixator 12 weeks after surgery (23 May 2012).

bone has small spots from small blood vessels, which gives
it a ‘dotted’ appearance. To distinguish between vital and
non-vital cortical bone, a chisel can be used tangentially. In
healthy bone, bleeding appears when chips are removed from
the surface (7). This is sometimes called the ‘paprika sign’,
as the bleeding looks like a sprinkle of paprika (8). Non-vital
bone is brittle and splits like porcelain.
The extent of the bone necrosis must be determined by X-
ray and/or computer-assisted tomography (CT) in association
with the intra-operative signs discussed above. Depending on
the size of the wound, fenestration of the bone, excision or
a segmental resection may be necessary. External fixation is
required for stabilisation of the bone, if instability of bone
fragments results. In such a situation, an original Ilizarov ring
fixator (Litos GmbH, Ahrensburg, Germany) (9) or Taylor
Figure 11 Radiographic control: bony union 6 months after debridement
and external fixation (10 August 2012).
Spatial Frame (Smith & Nephew GmbH, Marl, Germany) is
preferred.

Bone
Cancellous bone
The discussion of bone tissue should be divided into cortical
and cancellous bone. Necrotic cancellous bone becomes soft, has granulation
tissue between the trabeculae (5) and can be removed with
a curette. Distinguishing between necrotic, infected bone
Cortical bone
and vital, cancellous bone is often difficult. When any doubt
Necrotic cortical bone is white and looks like it is painted. It exists, extensive debridement must be performed, especially
can appear like ivory or porcelain/china (5). Normal cortical if the tibial plateau or tibial head is involved.
© 2013 The Authors
46 International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Michael Diefenbeck et al.
Figure 12 Clinical outcome: full weight-bearing, satisfactory range of motion of left ankle joint (3 August 2012).
Case report II
Patient was a 69-year-old male who presented with a fracture
of the left distal tibia (June 2011; pilon tibiale AO 43–C3;
Figure 6). The following is a timeline of treatment:
20 June 2011: closed reduction and external fixation
with AO-fixator (frame–fixator; ex domo).
July 2011: additional open reduction and internal fixa-
tion with screws and plate (ex domo).
July 2011 to February 2012: non-union of distal tibia
developed (8 months, Figure 7).
22 February 2012: first surgery in our hospital: Removal
of all hardware (screws, plate and external fixator),
debridement, excision of sequesters (Figure 8), open
reduction and external fixation with original Ilizarov
ring fixator (Litos GmbH) plus autologous bone graft
from left dorsal iliac crest (Figure 9).
February to May 2012: mobilisation with original
Ilizarov ring fixator with 10 kg weight bearing for
12 weeks (Figure 10).
24 May 2012: second surgery: removal of ring fixator.
May to July 2012: mobilisation in soft cast with 10 kg
weight bearing for 8 weeks.
23 July 2013: mobilisation with full weight bearing
(Figures 11 and 12).
Conclusion
Adequate surgical debridement is the prerequisite for the
successful treatment of skin, soft tissue, and bone infections.
It is crucial to distinguish between healthy, vital tissue and
infected, necrotic tissue. Clinical signs during surgery are
mainly used for this differentiation.
Acknowledgements
MD presented as a faculty member during the 2012 Interna-
tional Surgical Wound Forum (ISWF), an annual educational
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Surgical debridement to optimise wound conditions and healing
event sponsored by Kinetic Concepts, Inc. (KCI). His article
is part of a KCI-funded educational supplement based on fac-
ulty presentations at 2012 and 2013 ISWF sessions related to
wound care strategies with a focus on use of Negative Pressure
®
Wound Therapy with instillation (i.e. V.A.C. Instill Wound
Therapy and V.A.C. VeraFlo™ Therapy, KCI, San Antonio,
TX). KCI assisted with editorial review of manuscript.
NH and HGKS state no conflict of interests or financial
relationship with KCI.
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