Definition & Overview
Bone debridement is the surgical process of removing skin and bone close to and surrounding an infected wound associated with bone injuries or diseases. This procedure involves the removal of several layers of the skin, the subcutaneous tissue, associated muscles, fascia, and any foreign matter embedded in the wound. The ultimate goal of the procedure is to encourage better and faster healing of the remaining healthy tissue.
There are several classifications of debridement. Excisional debridement involves removing a margin of tissue, both necrotic and living, surrounding the wound. This procedure may involve excision to the deepest layer down to the bone itself. If no living or viable tissue is removed, the debridement is termed as selective, as only the necrotic tissue is taken out. If the process of removing necrotic tissue is performed over time and is gradual, it is termed non-selective debridement and is not performed by a physician in one setting.
In a typical bone debridement procedure, the resulting wound is increased by size, length, width, or depth in order for the physician to evaluate the status and extent of the open wound and to determine if additional treatment procedures are needed. Removing necrotic tissue also helps fight infection and discourages bacterial proliferation. In some cases, the procedure is an important process in order to avoid total amputation of a limb and even death.
Who Should Undergo and Expected Results
Debridement of bone is recommended for:
Slow healing wounds associated with bone fractures from accidents or trauma. This type of fracture typically involves a break in the skin, where the wound continuously bleeds or shows hematoma. If the fracture is extensive and merits a bone graft, debridement may be performed to clean the affected part in preparation for grafting procedures.
Patients diagnosed with osteomyelitis. This condition is characterised by the inflammation of affected bone due to infection. Considered a rare occurrence in highly urbanised countries, it is usually caused by the Staphylococcus aureus bacteria and can also spread into the bone marrow.
Patients diagnosed with benign lesions of the bone. In some cases, it may be necessary to perform bone grafting for complete treatment and bone debridement is one of the processes that need to be undertaken.
Diabetics whose limbs have open wounds and are at high risk of being infected. Because of their condition, foot infections are quite common among diabetics and special, aggressive care is typically required in an attempt to save the limb from total amputation.
Burn victims, especially for those whose injuries are more than superficial.
Coupled with an aggressive antibiotic treatment, bone debridement usually results in the successful treatment of wound infection. Most wounds are left open and require close supervision to make sure the area remains sterile and infection-free. Following bone debridement, patients are expected to rest for several days and engage in physical therapy afterwards to promote faster healing and regain limb function. After debridement, the patient may need to undergo additional sessions of bone and skin grafting to improve the function and appearance of the surgical site.
How is the Procedure Performed?
There are several factors that can indicate whether bone debridement is necessary or not. The procedure is carried out if the wound is more than 2 cm in diameter, has associated fractures, and there’s injury to the surrounding muscles and its fascia affecting the associated vascular structures and the peritoneum. Prior to the procedure, different images of the underlying bone structures are collected to determine the precise location of the affected areas.
Before the procedure, the patient is placed under general anaesthesia and administered with an anti-tetanus injection. Using a sharp surgical instrument, the surgeon proceeds to remove the necrotic tissue surrounding the open wound, starting with the upper layer of the skin or epidermis. This may involve taking a margin of healthy tissue to provide better chances of healing. The surgeon may go deeper into the dermis and the subcutaneous layer to excise as many dead tissues as possible. Some procedures may even use laser technology to cut off and cauterise the remaining tissue. If necessary, muscle tissue and the fascia surrounding the affected bone are surgically removed. Using specialised instruments such as a bone drill, a part of the bone tissue is taken out. The resulting gap or hole is then irrigated with saline solution to remove any remaining debris before filling it with an antibiotic substance to discourage bacterial infection. In extreme cases where an entire segment of the bone needs to be removed, the surgeon can employ either bone transport or bone shortening with re-lengthening techniques, whichever is deemed necessary.
After the procedure, the wound is typically left open to allow tissues to heal on their own. A splint is also attached to minimise movement of the affected limb.
Possible Risks and Complications
Apart from the possibility of adverse reaction to anaesthesia, there is also the risk of excessive bleeding and re-infection of the open wound so patient must take outmost care to make the wound as sterile as possible. Nearby nerves and blood vessels could also be compromised or injured, leading to reduced functioning or even paralysis of the affected part.
Vincent GM, Amirault JD. Septic Arthritis in the Elderly. Clinical Orthopaedics and related research. February/1990. 251:241-245.
Beronius M, Bergman B, Andersson R. Vertebral osteomyelitis in Göteborg, Sweden: a retrospective study of patients during 1990-95. Scand J Infect Dis. 2001. 33(7):527-32.