Abstract and Introduction
Abstract
Introduction: Chronic wounds pose a widespread challenge to health care, with many new, costly wound care modalities introduced in recent years with varying degrees of success. Bacterial biofilms have been postulated as one of the main culprits of the stagnation of chronic wound healing. For years, surgical fields have used pressurized irrigation for cleansing surgical wounds, but its utility in managing nonhealing chronic wounds has often been overlooked.
Objective: In this case series, the authors aimed to demonstrate that hydromechanical therapy with pressurized irrigation can be a cost-effective and clinically effective wound care modality.
Materials and Methods: The authors present 6 clinical cases of difficult nonhealing wounds managed with hydromechanical therapy with pressurized irrigation, a follow-up from the initial case report. Other, often more expensive modalities, had previously failed. In all 6 cases, irrigation was performed using tap water or saline either at home or long-term care facilities. Literature that focused on the mechanism of healing from hydromechanical therapy was reviewed.
Results: All chronic wounds in the series reached stable healing. The authors speculate that such healing was achieved through biofilm disruption and tissue stimulation with a mechanical impact. Literature supporting this hypothesis is presented.
Conclusions: The current clinical results offer a new perspective on the role of a traditional surgical modality of hydromechanical therapy in chronic wound care and on the associated opportunity of potential cost savings.
Introduction
Chronic wounds present serious medical and surgical challenges due to a significant degree of recalcitrance to standard, more expensive wound care treatments. Multiple systemic and cellular factors could be involved, such as arterial insufficiency, venous insufficiency, radiation fibrosis, nutritional deficiency, bacterial colonization, and biofilm. Nonhealing chronic wounds negatively affect the quality of life of patients and cost the United States health care system more than $25 billion per year.[1]
Bacterial colonization and biofilm are disruptive to the normal healing pathways; yet they are ineffectively managed with antibiotics, antiseptics, and/or serial sharp debridement.[2] Polymicrobial colonization of chronic wounds contributes to multispecies biofilm formation on wound surfaces with concurrent disruption of collagen synthesis, alteration of matrix metalloproteases, and inhibition of neutrophil and macrophage functions.[3] Bacteria produce numerous healing inhibitors such as proteases, enzymes, and toxins, lower local wound tissue oxygen levels, and deplete nutrients necessary for healing.[4] Furthermore, wound surface factors, such as foreign bodies and necrotic tissue, only serve as a milieu that promotes bacterial growth, further delaying or preventing normal healing through overstimulation of metalloproteases. Consequently, wounds remain in an unregulated state of inflammation without granulation, epithelialization, or wound contraction.[5,6]
Pressurized irrigation is frequently used in surgical field cleansing. Within the field of wound care, this methodology has garnered some attention. However, it is often overlooked despite its ability to achieve mechanical debridement by noninvasively dislodging harmful nonviable tissue while also disrupting and reducing wound surface bacterial burden in nonhealing wounds. This type of pressurized irrigation has been an appropriate treatment for all contaminated or infected surgical wounds and necrotizing soft-tissue infections. It is posited that pressurized irrigation breaks the recurring cycle of inflammation in chronic wounds, allowing them to progress to a subsequent normal wound-healing pathway.[7,8] Frequent pressurized irrigation, often pulsed, provides gentle and selective hydromechanical debridement that facilitates the removal of surface bacteria and devitalized tissue while promoting the generation of healthy granulating tissue.[9]
Furthermore, cyclical mechanical stimulation with low-frequency impact may lead to improved wound healing.[10] In a clinical, commonly acute, setting, pressurized irrigation is utilized as pulsed lavage to remove foreign bodies and devitalized tissues. This ability to selectively debride exudative tissue using hydromechanical forces while preserving and stimulating wound surface regeneration may provide a unique modality with synergistically beneficial healing effects in chronic wounds.
Pressurized irrigation is also inexpensive and can be accomplished in any wound treatment setting. Additionally, tap water is no more prone to risks of infection than sterile irrigation solution,[11] this modality can be easily and frequently carried out in the patient's home. Often, patients with complex chronic wounds are not ideal surgical candidates because of age, comorbidities, and malnutrition. Hydromechanical irrigation represents a tremendous cost-saving opportunity in caring for patients with chronic wounds compared with other wound healing products and modalities that are expensive and high resource-demanding, such as negative pressure wound therapy (NPWT), hyperbaric oxygen therapy, and biologic dressings.
Despite the potential advantages, wound care providers typically utilize more expensive modalities and approaches. Previously, the current authors presented a case of a difficult nonhealing wound in which NPWT failed, but the wound showed improvement after hydromechanical therapy using home tap water.[12] In this article, the authors present clinical cases of nonhealing, chronic wounds managed using hydromechanical therapy with either normal saline or tap water. The aim was to demonstrate that this inexpensive and readily available modality can significantly enhance the healing of complex, nonhealing wounds.
Wounds. 2021;33(11):296-303. © 2021 HMP Communications, LLC
