Theories of Wound Management

Hippocrates advocated keeping wounds dry, whereas Galen proposed the theory of laudable pus. This latter theory, which advocated the practice of encouraging wounds to suppurate, was adopted by much of ancient civilization because of Galen’s prolific writing on the subject. Therefore, very little progress was made in wound management until the 14th century. The next 4 centuries saw the adoption of surgery by barbers, with limited advancements in the treatment of wounds. The term debridement was introduced by Pierre Joseph Desault in the late 1700s to refer to the freshening of edges of war wounds. He noted a marked increase in survival after use of this technique.

The practice of debridement progressed sporadically through the 20th century. The World Wars and other conflicts presented war surgeons with injuries inflicted by higher-energy weapon. Military surgeons again showed improved survival and limb salvage with debridement. The advent of antibiotics also allowed for increased survival in patients with wounds, and a commensurate increase in demand for the management of these patients. Debridement has subsequently become ingrained as a surgical standard of care.

Strides made in the treatment of chronic diseases, such as diabetes and venous insufficiency, have similarly increased the number of wounds that require management. A landmark study published in 1967 determined the bacterial load of a wound at which a skin graft would likely fail. Various debridement techniques were subsequently shown to decrease bacterial burden. More recently, entire volumes have been devoted to wound management and debridement. Technologic advances spurred a surgical discussion of the nature of debridement and an understanding of when debridement is adequate.

Wound Bed Preparation

The introduction of expensive advanced wound therapies led to a concerted effort in the wound industry to optimize their efficacy. A meeting of medical wound-healing experts was convened in 2002 to develop a systematic approach to wound bed preparation. Their consensus document advocated removing barriers to healing in preparing an appropriate wound bed before making further attempts at wound closure. These barriers include tissue necrosis, bacterial overload, moisture imbalance, and impairment of the healing tissue edge. Debridement is the most efficient and effective technique of achieving wound bed preparation. Unfortunately, the medical literature is still sparse, with high-quality studies examining the efficacy of debridement and the specific techniques. Organizing a multicenter randomized controlled trial examining the benefits of debridement compared with no treatment would essentially represent a step backward in the management of wounds because of the clinically proven benefit of debridement. In addition, the organization of this study would raise ethical concerns regarding withholding of care.