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Copyright 2006 by the American Orthopaedic Foot & Ankle Society, Inc.
Metin Ozalay, M.D.1 ; Gurkan Ozkoc, M.D.1 ; Sercan Akpinar, M.D.1 ; Murat Ali Hersekli, M.D.1 ; Reha N. Tandogan, M.D.2
Adana, Turkey
ABSTRACT amputations and those who did not with respect to mortality
rate or age (p = 0.538 and p = 0.493, respectively). Those who
Background: Necrotizing fasciitis is a rare and often fatal soft- died were significantly older than the survivors (p = 0.038).
tissue infection. Prompt diagnosis and immediate aggressive Conclusions: The diagnosis of necrotizing fasciitis should be
surgical debridement of all compromised tissues are critical to considered for any individual who has unexplained limb pain,
reducing morbidity and mortality in these rapidly progressive especially if that person has diabetes mellitus or chronic liver
infections. The purpose of this study was to analyze the clin- disease. There was no difference in mortality rates between
ical presentation and evaluate factors that determine mortality patients with or without amputation. The primary treatment
associated with this uncommon surgical emergency. Methods: is early and aggressive debridement of involved skin, subcuta-
The study retrospectively investigated the medical records of neous fat, and fascia.
22 patients who were diagnosed and treated for necrotizing
fasciitis of the lower extremity, 14 of whom had involvement Key Words: Amputation; Diabetic Foot Ulcers; Limb
of the foot (nine patients) or foot and ankle (five patients) at Threatening
our hospital. The data collected for each of the 22 patients
were age, sex, underlying systemic factors, location of infec-
INTRODUCTION
tion, duration of symptoms, portal of entry of infection, initial
diagnosis on admission, physical, radiographic and laboratory
findings, microbiological cultures, the type of therapy used Necrotizing fasciitis (NF) is a rare and often fatal soft-
(debridement or amputation), treatment outcome, and number tissue infection that involves the superficial and deep fascial
of days in the hospital. Results: A total of 23 extremities of layers of the extremities, abdomen, or perineum. This condi-
22 consecutive patients with necrotizing fasciitis who under- tion is the most aggressive form of soft-tissue infection. In
went surgical debridement or amputation were retrospectively some patients, there are definite clinical signs (hypotension,
reviewed. Radical surgical debridement was done in 16 extrem- crepitus, skin necrosis, bullae, gas on radiographs), but these
ities initially, and this treatment was repeated a mean of two are not always present. Necrotizing fasciitis is caused by
times (range one to four debridements) to completely remove a mixture of aerobic and anaerobic organisms. The infection
all the necrotic tissue. Nine patients (41%) required below-knee
leads to necrosis of subcutaneous tissue, usually including the
or above-knee amputation. There were three deaths, one related
directly to sepsis and organ failure, one due to gastrointestinal
fascia. Prompt diagnosis is imperative because most necro-
hemorrhage, and one caused by pulmonary embolism. There tizing infections spread rapidly and can result in multiple
were no significant differences between patients who had the organ failure, adult respiratory distress syndrome, or death.
The treatment for this disease is complete surgical debride-
1
Baskent University School of Medicine, Department of Orthopaedics and Trauma- ment of all involved tissues, but additional debridement or
tology, Adana Medical Center, Adana, Turkey
2
amputation may be necessary.5,7,15,17,19 The purpose of this
Baskent University School of Medicine, Department of Orthopaedics and Trauma-
tology, Ankara Medical Center, Ankara, Turkey study was to analyze the clinical presentation and eval-
uate factors that determine mortality associated with this
Corresponding Author:
Metin Ozalay, M.D.
uncommon surgical emergency.
Baskent University Hospital
Dadaloglu mah. 39.sok, No. 6
Yuregir, 01250 MATERIALS AND METHODS
Adana
Turkey
E-mail: mozalay@baskent-adn.edu.tr The medical records of all patients (22) who were treated
For information on prices and availability of reprints, call 410-494-4994 X226 for NF of a lower limb at our institution from 1998 through
598
Table 1: The details of the 22 cases who had necrotizing soft tissue infection of a limb
OZALAY ET AL.
M: Male, F: Female, R: Right, L: Left, DM: Diabetes Mellitus, NF: Necrotizing Fasciitis.
NECROTIZING SOFT-TISSUE INFECTION
601
602 OZALAY ET AL. Foot & Ankle International/Vol. 27, No. 8/August 2006
Table 2: The microbiological cultures, laboratory findings, debridement sessions, type of therapy used, treatment outcome,
number of days in hospital are shown in the table
ESR: Erythrocyte Sedimentation Rate, CRP: C-Reactive Protein, WBC: White Blood Cell Count, MRSA: Methicillin-Resistant Staphylococcus aureus,
MSSA: Methicillin-Resistant Staphylococcus aureus, PE: Pulmonary Embolism, GIS: Gastrointestinal System.
A B
Fig. 2: A and B, Magnetic resonance imaging demonstrating multiple abscesses (arrows) between muscle bellies in case 16.
Table 3: Comparisons of age, hospital stay, and mortality in the amputated group
versus the non-amputated group
Non-amputated Amputated
Mean SD MeanSD
Median (Min-Max) Median (Min-Max) P value
Age (yrs) 58.86 11.23 61.78 6.91 0.493
60 (44 77) 64(51 69)
Hospital Stay (days) 43.14 26.11 24.33 6.91 0.01
33.5 (13 120) 26(14 34)
Mortality 1/14 (7%) 2/9 (22%) 0.538
p = 0.493, respectively). The average hospital stay for the In 1952, Wilson proposed the term necrotizing fasciitis to
22 patients was 35.8 (range 13 to 120) days. The patients who replace terms like gangrenous erysipelas, hospital gangrene,
had amputation had a significantly shorter mean hospital stay acute cutaneous cellulitis, streptococcal gangrene, synergistic
than the patients who did not have an amputation (p = 0.01) necrotizing cellulitis, Meleney cellulitis, and others.16 Necro-
(Table 3). tizing fasciitis most often affects middle-aged adults, but
there are no sex, race, or geographic predilections with this
DISCUSSION condition. The lower extremities are affected most frequently,
followed by the trunk and head.8,10 The pathogenesis of NF
In the 16th Century, Ambroise Pare described a gangrene- is still not fully understood, but the rapid and destructive
like condition that resembled todays flesh-eating disease.16 clinical course of this condition is believed to result from
multibacterial symbiosis.4 Diabetes is the main predisposing diagnoses in the other 11 patients. These findings suggest
factor in adults, but other chronic conditions, such as hyper- that the diagnosis of NF often is overlooked, which means
tension, peripheral vascular disease, renal failure, obesity, that specific therapeutic measures are delayed. The literature
alcoholism, and malnutrition are other important underlying indicates that bacteria are isolated from the affected tissue in
factors.14 approximately 62% to 76% of NF patients.7,11 The typical
The initiating factors for NF reported in the literature polybacterial nature of NF is well documented.3 In our series,
include minor injuries, surgical and traumatic wounds, contu- 20 patients (91%) had positive tissue cultures, but only seven
sions, and varicella.10 In newborns, omphalitis, circumcision, (32%) had polymicrobial isolates. Group A -hemolytic
and placement of electrodes for monitoring of vital signs Streptococcus was the agent most frequently incriminated
also have been identified as triggering factors.10 Another in NF, but many other bacteria may be involved.
known initiator of NF is minor environmental trauma, such Various aids for achieving early diagnosis of NF have
as an acute force or injury to the foot causing an imme- been suggested, but the key is a high level of suspicion.6
diate wound or soft-tissue injury that breaks the cutaneous Numerous radiological methods have been used to identify
barrier.13 Fourteen (68%) of the 22 patients with NF in our this condition. Plain radiographs can provide information in
series had identifiable antecedent trauma: periarticular steroid the form of soft-tissue thickening and internal gas formation,
injection in one, major trauma caused by tree thorns in two, but these films usually do not reveal any specific abnormality
and diabetic foot ulcers in 11. One report in the literature until the necrotizing process is well advanced. It seems that
described NF as a complication of steroid injection in a anaerobic conditions or diabetes are necessary for clinically
painful shoulder.2 As noted, one of our patients developed detectable quantities of gas to be produced. The MRI findings
NF after subcutaneous periarticular steroid injection in the in cases of necrotizing soft-tissue infection include thick-
knee for joint pain. One week after this injection, we debrided ening of the subcutaneous tissues, enhancement of this thick-
the patients calf and diagnosed NF. Many of our diabetic ened tissue with contrast, possible fluid collections within
patients were not aware of the fact that they had neuropathic the subcutis and superficial fascia, and high signal intensity
feet. Because these patients may not have had information in the deep fascia on T2-weighted images.12 Arslan et al.1
about foot care, they may have walked with bare feet and demonstrated that T2-weighted images (especially those with
easily could have developed foot ulcers that were initiating fat suppression) are highly sensitive for diagnosing NF, but
factors of the NF. Currently in the United States, more than that the specificity of MRI for this purpose is extremely
50,000 amputations related to diabetes are performed each low.1 Work by Yen et al.20 showed that ultrasonography
year.18 This type of operation dramatically reduces patient gives emergency physicians accurate information that can
function and quality of life and places a heavy burden on help identify NF. In our series, MRI was performed in only
affected individuals, their families, and health care systems. It one patient (Case 16). Plain radiography revealed gas in only
is vital that we reduce amputation rates in this patient group, 11 of the 22 patients. Reliance on adjunctive tests may delay
and the importance of preventing any form of minor trauma operative treatment and the diagnosis should be apparent if
(shoewear-related or minor environmental trauma) cannot be a meticulous physical examination is done within 24 to 48
overemphasized. This is especially true for patients who are hours after the first signs appear.
already compromised with neuropathy and vascular disease The mortality rate in this series of patients was 14%.
like diabetes mellitus or chronic liver failure. The corresponding figures in the literature range from 8%
The clinical manifestations of NF appear roughly 1 week to 100%.11 The high mortality rate for NF reflects the
after the initiating event, with induration and edema followed severity of this infection. Research has revealed associations
24 to 48 hours later by erythema or purple discoloration and between mortality and age of the affected patient, percentage
increasing warmth at the site.9 Systemic signs and symptoms of body surface involved, presence of systemic acidosis or
develop from the toxic process and septicemia. High fever hypotension, and time delay between admission to hospital
is disproportionate to the size of the cutaneous lesion.9 Pain and surgical debridement.15 In our study, we found no
is an important sign in the early stages, and some patients significant difference between the mortality rates in the
exhibit crepitus at the site. Forty-eight to 72 hours after patients with and without amputation. Early and aggressive
initial signs and symptoms arise, the skin becomes smooth debridement of the involved skin, subcutaneous fat, and
and lighter in color, and serous or hemorrhagic blisters fascia is the most important element of treatment. Diseased
develop. Without treatment, necrosis ensues and, by the fifth distal extremities usually can be managed with multiple
or sixth day, the lesion turns black and features a necrotic sessions of radical debridement. Antibiotics may not reach
crust. Sometimes gas production by aerobic and anaerobic the necrotic tissue because of thrombosis of vessels in the
bacteria is identified on the basis of crepitation.9 Although affected region; therefore, both necrotic skin and fascia must
inconsistently frequent, this sign is highly suggestive of NF. be excised. Amputation should be considered in patients who
It was present in 11 of our patients. In our series, NF was have proximal limb involvement.15 In our series, only six
diagnosed at admission in 11 of the 22 patients. Cellulitis, patients had diseased proximal extremities. Five of these
thrombophlebitis, and deep vein thrombosis were the initial individuals were treated with multiple debridement sessions
and all survived. The other patient died from multiple organ 9. Meleney, FL: Hemolytic streptococcus gangrene. Arch. Surg.
failure. 9:317 364, 1924.
10. Morales, AF; Castrellon, PG; Mckinster, CD; et al: Necro-
tizing fasciitis. Report of 39 pediatric cases. Arch. Dermatol.
138:833 899, 2002.
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