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Surgical debridement refers to the use of sharp instruments to remove devitalized tissue from wounds. Skin grafting is an adjunctive therapy that uses human (autograft or allograft), nonhuman (xenograft), or artificial (synthetic graft) skin to cover nonhealing ulcers. Bilayer artificial skin plus compression is more effective for venous leg ulcers (VLUs) than standard dressings plus compression. Reconstructive surgery provides options for coverage of deep, refractory pressure ulcers; however, no randomized trials have compared these techniques with standard care. For patients with VLUs with superficial venous reflux, early endovenous ablation plus compression heals VLUs more quickly than compression with deferred ablation. Revascularization restores in-line arterial flow to ischemic extremities, facilitating wound healing and pain resolution. Bypass surgery has been shown to result in better luminal patency at 1 year than percutaneous transluminal angioplasty (PTA), but PTA is associated with fewer perioperative complications and shorter hospitalizations. PTA with and without stenting are comparable in terms of rates of perioperative complications and major amputation and mortality in patients with infrapopliteal arterio-occlusive disease. Amputation is the last option for patients with critical limb ischemia who are not candidates for or have not benefited from revascularization attempts.

Case 4. Mr Rejalde is a 75-year-old man with diabetes and hypertension. Today he comes to your office with a 3-week history of right great toe arterial ulcer, and 3 months of right calf ischemic pain at rest. On physical examination, the ankle-brachial index on the right side is 0.3.

Surgical Debridement

Surgical debridement refers to the use of sharp instruments, such as scalpel, scissors, or curette, to remove necrotic or devitalized tissue from wounds.39 This often is chosen over other debridement methods because of its speed, accuracy, and ability to remove significant amounts of tissue.

For deep or complicated wounds, surgical debridement allows for accurate wound assessment and obtaining of deep tissue samples for biopsy. It also permits the surgeon to perform other surgical interventions, such as tendon, muscle, or bone debridement; fasciotomy; placement of drains; and deep packing.

Historically, surgical debridement refers to the procedure performed in the operating room, often with general or regional anesthesia.39 Sharp debridement refers to bedside debridement, often with topical anesthetics. Clinicians can perform sharp debridement after completing training. The medical literature may refer to both techniques as surgical debridement.

A Cochrane review that evaluated debridement techniques for venous leg ulcers (VLUs) found no randomized controlled trials (RCTs) that investigated surgical or sharp debridement.39 However, a large retrospective study involving 312,744 wounds of all causes showed that a high frequency of debridement using any method resulted in faster healing and a larger number of healed wounds than a low frequency of debridement.96 This study included patients with pressure ulcers, VLUs, arterial ulcers, burns, and other types of wounds, and the type of debridement was not considered in the analysis.

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