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Video of sharp debridement techniques

Discussion in 'Diabetic Foot & Wound Management' started by Leigh Shaw, Nov 5, 2008.

  1. Leigh Shaw

    Leigh Shaw Active Member

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    Hi, I have been asked to do a debridement workshop next year for mostly nurses and would like to have a acess to video material on sharp debridement of foot ulceration/ callus etc. Does anyone have one that I could use please.

    All material concidered, it will be a good oppotunity to show case podiatry skills to a new audience and would like to give it the wow factor.

  2. Craig Payne

    Craig Payne Moderator

  3. Paul Bowles

    Paul Bowles Well-Known Member

    That should give it the wow factor....................
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I have used the CLEAR video in presentations to other health professions.

    The best part is that it makes those who think it is a straightforward job to debride a wound, to reconsider, and seek the input of a podiatrist. It puts any significant wound debridement way out of their comfort zone (eg nurses, GPs).

  5. Leigh Shaw

    Leigh Shaw Active Member

    Thanks for that. The organisers are so excited that they would like me to also include autolytic, enzyme and laval with a new group of 20 rotating through every 20min.
    If anyone has run one of these before or attended one and has any tips for organisation or what they liked or disliked during there own attendence I would be grateful for your insights.

    I have attended different workshops myself at conferences and been left cold by the lack of hands on oppotunities. Look forward to your ideas.

  6. markjohconley

    markjohconley Well-Known Member

    WTF !!!!!!!!!
    Why not chainsaw the foot alltogether!
  7. First Step

    First Step Member


    So THAT'S how its done - pass the FeCl3. And now I sit back and wait for all those Community Nurses to refer.

    A Hasquvarna may have helped with that delicate seperation of viable and NV tissue.
  8. footdoctor

    footdoctor Active Member

    Mark, I second you on that!!! Complete butchery!!!

  9. Leigh Shaw

    Leigh Shaw Active Member

    Yes I was hoping for something a little less aggresive - makes me wonder why I spend time on debriding wound margins? So if anyone has something else that wont leave my audience quite so shocked I would welcome a copy.
    Also anything on other forms of debridement .

    Thanks Leigh
  10. PodGov

    PodGov Member


    If the video debridement approach is not utilised over 'less invasive' debridement around a completely mascerated avascular margin; you may wonder why some practitioners are struggling with wounfd care and may find their techniques fail.
  11. markjohconley

    markjohconley Well-Known Member

    Drummond, and a goodaye to you.
    Got to differ. With a 'less invasive' debridement the trauma inflicted by that clinician would be avoided. Debridement of said tissue could be attained without the trauma with scalpedl blade held near parallel to the skin surface. If the practitioner had 'stuck' to the 'completely macerated avascular margin' I'd have no problems. The reason why some practitioners are struggling might have nothing to do with their scalpel technique.
    All the best, mark c
  12. bob

    bob Active Member

    Of course, how much you debride is down to the patient's presenting problem, ulcer grade/history and neuro/vascular status, but I think this thread could still make an interesting poll.

    Perhaps we could vote on whether the CLEAR method is:

    A chop too far?
    Just right?
    Not enough?

  13. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    The clinicians behind CLEAR are podiatrists almost beyond peer review.

    This is appropriate surgical debridement - not to be confused with trimming hyperkeratosis around the periphery.

    Neuropathic wounds - virtually by definition - are well perfused and mild bleeding is typically encountered with this technique.

    I am surprised and concerned that some posters appear shocked by this. :wacko:

  14. bob

    bob Active Member

    NOBODY is beyond peer review! LOL

    I'd go so far as to say this isn't really surgical debridement anyway, it's just a clinical chop. I guess it comes down to the individuals - patients and clinicians. We can't be 100% prescriptive about how to do something for every single patient that walks through the door as everyone's at least a little bit different. I guess it's what works in your hands best, if that's a minimal nibble at the edges, or a more invasive approach. The most difficult bit is knowing whether you've gone too far or not enough, and in a diabetic foot with a big neuropathic ulcer this isn't always as straightforward as you'd like. It's good to see instructional videos like these being produced to see how their technique differs from your own, and I am sure this approach works in the right ulcer and patient, but there is a place for less (and more) invasive debridements - depending on the foot, patient and clinician.

    How do you start a poll anyway?
  15. markjohconley

    markjohconley Well-Known Member

    Bob's said it.
    LL, does "appropriate surgical debridement" always involve injury to viable tissue as in this technique? Certainly not in my (limited) surgical observations.
    Methinks the same degree of debridement could be attained without the 'damage' in the hands of your "average" plebian podiatrist.
    And I am certainly concerned that you're concerned, and 'wacko" back at you.
    mark c
  16. bob

    bob Active Member

    All this concern about concern is concerning me!

    Concerning surgical debridement of an infected diabetic ulcer, generally, you want to debride back to healthy bleeding tissue. So, yes, you're more than likely going to chop a bit of the good stuff out too, but if you're able to clear all infected tissue out, this is not so much of a worry. Less isn't always more, but neither is more. It's horses for courses and every other cliché you can think of!

  17. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Yes, in our egalitarian evidenced-based society - no-one is meant to be beyond peer review. Hence the use of the word - almost. However, if I had any of the CLEAR team supporting me as my defence experts in a litigation case, I would be feeling rather relaxed and confident. The body of evidence they have amassed over the past decade is ALMOST without comparison.

    For those not too familiar with different debridement techniques, this video demonstrates the most direct form of surgical debridement - complete ulcer excision (or saucerisation).

    It is aggressive, though technically rather straight-forward, and achieves the goal of instantly turning a chronic wound into an acute wound. It is commonly used also in general, vascular and plastic surgery and has many benefits in well perfused neuropathic lesions - particularly where there is extensive bioburden, wound bed senescence or chronic infection.

  18. bob

    bob Active Member

    How do you start a poll?

    Shall we have a poll about starting a poll?

    Who would like a poll?

    Would you:
    a) like a poll?
    b) not like a poll?

    I'd like a poll. Poll. Poll. Poll.
  19. markjohconley

    markjohconley Well-Known Member

    Googled 'surgical debridement' with 'contraindications' and top of the list 'Wound Healing and Ulcers of the Skin',, p 123 "Avoid damaging Health Tissue: While debriding wounds, be cautious and ensure that only necrotic tissue is removed. When nearing vital tissue, the procedure should be discontinued and further debridement may be accomplished by using an alternative method"
    may I suggest "change your blade to skin angle!"
  20. Paul Bowles

    Paul Bowles Well-Known Member

    One must remember that there is more than one way to skin a cat - and as CLEAR demonstrates and as Tony has suggested, this is a perfectly reasonable way to address surgical debridement of a neuropathic lesion. Sure it may appear aggressive to some initially, however in high risk foot management this would only be the tip of the iceberg so to speak.

    May I suggest a peer reviewed journal search engine rather than Google for more information on the topic. Although I find Google highly stimulating and incredibly informative, peer reviewed searches just make me feel all warm and fuzzy inside ;)

    I also understand Tony's comment that the team members of CLEAR are almost beyond peer review. Although there may have been some deep sarcasm seated somewhere in that comment (whether he realized it or not), I am sure Tony was intending to convey that this Team is at the top of their game in nearly every aspect of high end wound management and care.
  21. markjohconley

    markjohconley Well-Known Member

    Paul, what worries me is this almost certainly is a type 2 diabetic pt, so there's a HUGE possiblility there's a degree of PVD. With the scalpel blade held perpendicular to the skin surface the 'tip' of the blade seems to be incising deeper than is necessary to debride the non-viable tissue. I fail to see how this is insignificant.
    Why I mentioned the google search was to intimate it was that easy to find 'support' for my stance. Of course it's unsuitable for real enquiry.
    And I certainly don't query the CLEAR team members after yours and LL's commendation "in nearly every aspect of high end wound management and care" except their scalpel technique.
    All the best, mark c
  22. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Without wanting to take an adverserial approach to this debate, there are some misconceptions I would like to address from your post.

    Type 1, Type 2...irrelevant. Essentially the same issue from a medical and surgical standpoint. PVD (or more accurately, PAD) can be an issue. This is where acknowledging the differences between neuropathic limbs with or without significant ischaemia is essential. Generally speaking, a well perfused neuropathic limb is not of significant concern providing a vascular assessment confirms these findings. These patients are well suited to Class I, II and III diabetic foot procedures, which can commonly be osseous procedures.

    One of the great myths of the diabetic foot is that it should never be operated on, nor given an opportunity to bleed, lest some horrendous gangrene set it. This is simply not true, and has been discussed at length in the body of literature of diabetic foot surgery.

    I think you have failed to realise that the blade *is not* trying to be kept perpendicular to skin. It is intentionally trying to perform a surgical excision of the ulceration, and this is the intent of a saucerisation procedure.

    As an recently dearly departed colleague from the US use to say to me, "you guys just aren't comfortable with turning the blade 90 degrees".

    I'm sure if they were trying to trim the hyperkeratosis you would have no problem with the scalpel technique, a la traditional chiropody method. However, complete ulcer excision requires the scalpel to be orientated in this manner to achieve the desired result.

    If this method is not favourable to you, that's fine. The point is that the clinician is not doing anything wrong, they are just using a different technique to what you may be familiar with. More than one way to skin a cat.

  23. markjohconley

    markjohconley Well-Known Member

    Ahhh I get it now, in treating a neurotrophic ulcer by the 'saucerization' technique, the aim is to damage viable tissue.
    Thanks to LL and Paul for the education. Some research on my part coming up.
    How widespread is its use, as the high risk diabetic foot clinics I'm aware of certainly don't utilise it.
    Maybe not the most appropriate video for the original poster's needs.
    Again i feel truly humbled.
    Yep, "more than one way to skin a cat", mark c
  24. Paul Bowles

    Paul Bowles Well-Known Member

    I hardly see how I provided anyone any education - I just provided my opinion.
  25. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    In part. The aim is to take a recalcitrant chronic wound and turn it into an acute wound, which is generally easier to close or heal.

    eg. To take things a step further, here is a set of images of a complete excision and primary closure in a person with a 3yr history of chronic ucleration plantar to a hypertrophied and degenerative tibial sesamoid, and which could not be healed with standard techniques. This excision was combined with osseous work.


    Attached Files:

  26. a.mcmillan

    a.mcmillan Guest

    Dear Members,

    This systematic review published in June may be of relevance to this thread. I have extracted some components from the full-text and pasted below:

  27. markjohconley

    markjohconley Well-Known Member

    That's thanks to LL, excellent, and to Andrew for some references, and a no thanks to Paul, mark c
  28. Paul Bowles

    Paul Bowles Well-Known Member

    My pleasure!

  29. Byron Perrin

    Byron Perrin Member

    The authors of the CLEAR video talked about this technique back in 2002 in JAPMA (92(7):402-404)- where they hoped to "foster further discussion..." about debridement. I would imagine they will be pleased with this discussion! In the JAPMA article they also talk about this technique being used in their institutions for "nonischaemic and noninfected neuropathic diabetic foot wounds".

    I don't think this technique is used very often in my part of the world either. I also don't think that the most appropriate offloading is impemented very well either in my region (or by the way it seems in the US, where a recent paper Diabetes Care paper reports very low rates of TCC use in clinics).

    Whilst aggressive debridement and aggressive offloading methods may seem perhaps too aggressive, labour intensive and expensive I think they may actually be more effective in healing this type of ulcer in a shorter amount of time (not getting into how to keep it healed!). The research is there for the use of the TCC, there is obviously a need for the research to be more established for the debridement issue- but I think the rationale is certainly there for such research.
  30. Leigh Shaw

    Leigh Shaw Active Member

    Wow, when I started this thread it was to find debridement footage that I could run in conjunction with a debridement work shop for prodominatly nurses who are often not aware of podiatry let alone what we can offer with in the wound care team. I know from experience that the nurses that send me patients for debridement are very grateful as they are not allowed to do any sharp debridement.

    I must admit that I dont do the 'saucerization' technique' but do care for the patients that have it done under the vascular team. I was hoping for a range of footage but instead seem to have opened up some lively debate.

    Its never dull on this forum!
  31. First Step

    First Step Member

    Hear I was sitting back expecting for a bunch of NZ Nurses to begin the 'saucerization' technique post your Debridement workshop.

    Maybe you could change the title of your workshop to Hyperkeratosis Trimming Chiropody Style either that or see if you can get a deal at your local Mowers and More on some Chainsaws.

    The differences in wound "debridement" between DPM's and Australian Pods is not a new thing.

    Why don't they teach the saucerization or saucerisation technique at La Trobe/QUT/UniSA? Maybe The Foot Spot PORTAL could present this technique online.

    “Owww look at me Marge, I'm making people Happy! I'm the magical man, from Happy Land, who lives in a gumdrop house on Lolly Pop Lane!!!!...... By the way I was being sarcastic...”
  32. Paul Bowles

    Paul Bowles Well-Known Member

    There are differences? Maybe techniques differ but I know Podiatrists in Australia who do utilize this technique and ones similar to it - so its not an "US" vs "THEM" issue.

    Well I am sure in theory they do teach it (and if they don't they should be) - I am sure the theory is mentioned and I am also sure they may see it on prac if students are lucky enough to spend time with a Podiatrist versed in the ways of aggressive wound debridement.

    As for PORTAL presenting techniques like this online, keep your eyes on what is coming up - PORTAL supplements education, it does not instate it. In 2009 things are about to take a massive jump forward in how continuing education is presented yet again, and wound care is one of the areas we are putting a major focus on.
  33. ehresources

    ehresources Member

    Hi Leigh,
    As a foot care nurse, we have a limited scope of practice regarding scalpel debridement.
    www.collegefhp.com/Safe_Scalpel_Technique_Course.htm provides a course with a great video. I'm not sure about getting permission to use it. It is very appropriate for the type of session you are doing.
    Hope this helps,
  34. cathedmeades

    cathedmeades Member

    I have been asked to present to practice nurses on the treatment of diabetic ulcers, including debridement etc...

    Is anyone aware of any new video footage?
  35. Erp

    Erp Member

    Dear All,

    The most valuable lesson I have gained from this discussion is that we all need to be video taping or photographing our debridement techniques to share and compare. We use debridement and off loading with TCC often with excellent results and we don't need to use ferric chloride. We do heal wounds if they have a vascular supply and the challenge is the step down process from TCC to cam or CROW and how compliant our patients are thru this stage.

    Our debridement involves causing the base of the ulcer to bleed to stimulate an acute wound response, but this does not include making the peri wound tissue bleed. We find this to be very effective.

    Thanks for giving me the idea for our next student's project - tape all 5 of our podiatrists debriding and compare techniques!

    Happy chopping!


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