Time to start putting down the knife: A systematic review of burns excision tools of randomised and non-randomised trials

Burns. 2018 Nov;44(7):1721-1737. doi: 10.1016/j.burns.2018.01.012. Epub 2018 Feb 16.


Aims: Dermal preservation during acute burn excision is key to obtaining superior healing/scar outcomes, however, determining the most appropriate excision tool is an ongoing challenge. Novel tool development means the knife is no longer our only option, yet for the majority it remains the gold standard. This systematic review aims to evaluate evidence for burns excision approaches (knife/hydrosurgery/enzymatic).

Methods: CENTRAL, EMBASE, MEDLINE (1946-2017) were searched with MeSH terms: 'debridement', 'burns', 'sharp', 'enzymatic', 'hydrosurgery'. Relevant randomised control trials (RCTs)/non-randomised controlled case series/trials were extracted/analysed. In vitro/burn non-specific studies were excluded. Main methodological parameters were intervention/excision efficacy.

Results: Eighteen articles met inclusion criteria (n=7148): three were RCTs, involving comparator enzymatic (NexoBrid™ (EDNX)) or hydrosurgical (Versajet™) excision to surgical Standard of Care. Both showed statistically significant decreased need for excisional excision and auto-grafting by viable tissue preservation allowing spontaneous healing by epithelialisation.

Conclusion: Level 1 Evidence comparing excision modalities for acute burns is sparse. Although early excision with a knife is still often considered best practice, there is no tool choice consensus or robust comparison with alternate, possibly superior, tools. EDNX or Versajet™ should be considered alternatively. Further RCTs are indicated, with regards final scar outcomes and to allow consensus within current evidence.

Keywords: Burn excision; Debridement tools; Enzymatic debridement; Hydrosurgery; NexoBrid™; Versajet™.

Publication types

  • Systematic Review

MeSH terms

  • Bromelains / therapeutic use*
  • Burns / therapy*
  • Cicatrix
  • Collagenases / therapeutic use*
  • Debridement / instrumentation
  • Debridement / methods*
  • Dermis / surgery
  • Enzyme Therapy / methods*
  • Epidermis / surgery
  • Humans
  • Hydrotherapy / methods*
  • Re-Epithelialization
  • Surgical Instruments*
  • Treatment Outcome


  • Bromelains
  • Collagenases