Toward a Common Language Mark S Granick
COMPREHENSIVE SOFT-TISSUE WOUND CLASSIFICATION
Just as the debridement requires classification, so does the wound. Cierny has a classification that describes “the host” risk in patients with osteomyelitis. The host will be of either a minimal (A), moderate (B), or high risk (C), based on the presence of a systemic or nutritional disorder and smoking status (41). For open fractures, there are several wound classification systems in the literature, such as those proposed by Gustilo et al. (42,43), Tscherne (44), and Lange et al. (45). These take into consideration the size of the wound and the energy of the injury. They have some use in directing treatment and predicting treatment outcomes, but are far from being com- prehensive and reproducible.
FIGURE 2
(A) This patient had a stage IV sacral pressure ulcer with extensive undermining and necrotic muscle and fascia. (B) The wound was debrided using a scalpel on the skin and a Versajet™ (Smith & Nephew, Largo, FL) on the underlying tissues. All under- mined skin was excised, but all of the damaged skin was not removed (S2). The sub- cutaneous tissue was removed to a bleeding margin (C3). Muscle and fascia were removed to a bleeding surface (M3). Bone was not removed (B0). (See color insert.)
TABLE 3
Classification of Tissue Type
Subcutaneous
Tissue type Skin (connective tissue) Muscle/fascia Bone
The Evolution of Surgical Wound Management 25
FIGURE 3
(A) Sacral ulcer. (B) Debridement performed by direct excision of skin, Versajet™ (Smith & Nephew, Hull, U.K.) removal of subcutaneous tissue, and osteotome removal of bone. Debridement score S4C3M0B3. (C) After immediate reconstruction with a gluteus maximus myocutaneous flap, the patient healed uneventfully. (See
color insert.)
FIGURE 4
(A) Open ankle fracture following serial debridements (S2C2M2B2). (B) Open ankle fracture debrided with Versajet™ prior to definitive closure (S3C3M3B3). (See color
26 Granick and Chehade A comprehensive wound classification system is required that better captures information about the wound “personality.” Too many classification systems are “comprehensive” in a descrip- tive manner, but the increased complexity merely adds to the difficulty in recording data and in the reliability of that data. They often add little to the predictive capacity or usefulness in direct- ing management. Information collected should incorporate relevant data on the host, the wound etiology, the tissues involved, and the extent of the wound. The classification should be flexible and expandable to code complex wounds when required. It must also be relevant and applicable to all wound types. Such a classification should be able to direct specific treatment protocols and correlate closely with prognosis. It will be essential for future studies to assess the effect of wound- management strategies.
The International Advisory Board of Surgical Wound Management is working to develop these wound and debridement classifications to drive evidenced-based, best-practice wound management. The board is similarly interested in disseminating the experience and knowledge of its international team of experts representing numerous surgical specialties. The following chapters would clearly demonstrate the renewed interest in the surgical community to partici- pate along with the medical-wound community to optimally manage our patients with both acute and chronic wounds.
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