ABSTRACT
Throughout this section, we describe clinical cases where control of infection is a critical component of care in patients with pressure (decubitus) or diabetic ulcers. Extensive surgical debridement removes infected and necrotic tissue and stimulates the healing process. Debridement should remove the undermined edges of the ulcer, because these areas act as a pocket for bacterial growth. Also, in patients with neuropathic diabetic ulcers, one should remove the cells surrounding the ulcer. This process of “saucerization” creates a wound that has fl atter edges and contains healthier tissue. In this regard, a popular notion is that aggressive surgical debridement transforms a chronic wound into an “acute wound.” This may be partly true, but it is probably too simplistic. Different explanations are possible. One that we favor is that removal of tissue from within and around the wound may actually be removing cells that have been adversely altered by the long-standing pathogenic event (i.e. pressure and ischemia). Bringing new young cells in may provide the wound with healthier and more active cells, at least for a period of time. We discuss this further in the section on vascular ulcers. However, it is important to note here that surgical debridement (and debridement by other means including enzymes and autolytic approaches) should not be thought of as a onetime or two-time procedure. We have proposed that the clinician needs to think of “maintenance debridement,” and have written extensively about this notion. This concept points to the fact that we, as clinicians, are not very good at identifying what is an optimal wound bed and whether proper wound bed preparation has been achieved. Therefore, in the setting of a persistently nonhealing wound, it may just be that a more continued debridement is needed (“maintenance”).
