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Ang KL, Wormald J, Farag S, Ng M, Lane J, Furniss D. Epidemiology of upper limb necrotising fasciitis in England: A national study (1998-2018). J Plast Reconstr Aesthet Surg 2025; 104:334-338. [PMID: 40158410 DOI: 10.1016/j.bjps.2025.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 02/17/2025] [Accepted: 03/08/2025] [Indexed: 04/02/2025]
Abstract
BACKGROUND Necrotising fasciitis (NF) is a surgical emergency characterised by rapidly progressive infection of the subcutaneous tissues and fascial planes, leading to widespread fascial necrosis and systemic toxicity. Although NF can affect any part of the body, the upper limbs are a notable site, accounting for 27% of cases. Antibiotics and surgical debridement form the basis of treatment. METHODOLOGY We conducted a retrospective study on NF of the upper limb requiring surgical intervention from 1998-2018 using data from Hospital Episode Statistics. Age, sex, deprivation index, length of stay (LOS) and complications were analysed. RESULTS We identified 728 patients, comprising 468 males and 260 females, with a mean age of 54.97 years (95% CI: 53.76-56.17 years). The incidence of NF in the upper limb increased from 0.0035 per 100,000 in 1998 to 0.01 per 100,000 in 2018. Lower index of multiple deprivation scores correlated with higher NF prevalence, with 67.32% (n=474) presenting scores between 0 and 5. The average LOS was 27.55 days (95% CI: 25.08-30.02 days). Complications within 30 days of surgery included 8 (1.10%) cases of renal failure, 8 (1.10%) urinary tract infections (UTIs), and 103 (14%) deaths. Meanwhile, 90-day complications included 23 (3.15%) cases of renal failure, 6 (0.82%) pulmonary embolisms, 22 (3.02%) UTI, and 113 (16%) deaths. CONCLUSION This study highlights the impact of upper limb NF and provides crucial insights into its incidence, demographic correlations, and clinical outcomes, which can inform clinical management.
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Affiliation(s)
- Ky-Leigh Ang
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Justin Wormald
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK.
| | - Soma Farag
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Michael Ng
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Jennifer Lane
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK; Barts Bone and Joint Health, Queen Mary University of London, London, UK
| | - Dominic Furniss
- Department of Plastic Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
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Lipatov KV, Asatryan A, Melkonyan G, Kazantcev AD, Solov’eva EI, Krivikhin DV, Gorbacheva IV, Cherkasov UE. Effectiveness of negative pressure wound therapy in complex surgical treatment of necrotizing fasciitis of the upper limb. World J Orthop 2024; 15:1015-1022. [PMID: 39600855 PMCID: PMC11586739 DOI: 10.5312/wjo.v15.i11.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 09/22/2024] [Accepted: 10/10/2024] [Indexed: 11/15/2024] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) of the upper extremities is a severe surgical pathology, and the incidence of this disease has been steadily increasing in recent decades. Surgical treatment is accompanied by the formation of extensive wounds, which can be treated with significant difficulties. In recent years, negative pressure wound therapy (NPWT) has proven to be highly effective. It is also promising for the treatment of NF. AIM To explore the effectiveness of NPWT in the treatment of NF of the upper extremities. METHODS The results of the treatment of 36 patients with NF of the upper extremities in two groups (NPWT group and control group; 2022-2023) were retrospectively analyzed. In the NPWT group, the NPWT method (120 mmHg; constant mode) was used after surgical treatment. The number of vacuum-assisted dressings in patients ranged from 1 to 3, depending on the dynamics of the wound process. The duration of fixation of one bandage was up to 2-3 d. In the control group, conventional methods of local wound treatment were used. The following indicators were analyzed: The treatment delay, the prevalence of inflammation, the microbial landscape, the number of debridements, the duration of wound preparation for surgical closure, and the nature of skin plastic surgery. RESULTS Most patients experienced a significant treatment delay [4 d, interquartile range (IQR): 2-7 d], which led to the spread of the pathological process to the forearm and shoulder. The most common pathogens were Staphylococcus aureus (14; 38.9%) and Streptococcus pyogenes (22; 61.1%). The average number of debridements per patient was 5 (IQR: 3-7), with no difference between groups. The average time to prepare wounds for surgical closure was 11 ± 4 d in the NPWT group and 29 ± 10 d (P = 0.00001) in the control group. In the NPWT group, the wounds were more often closed with local tissues (15; 83.3%), and in the control group, split-thickness skin grafts were more often used (4; 50%). CONCLUSION The predominant isolation of Staphylococcus aureus and/or Streptococcus pyogenes from the lesions allowed us to classify these patients as NF type II. Multiple debridement procedures have become a feature of this disease treatment. The use of NPWT has significantly reduced the time required to prepare wounds for surgical closure. Early closure of wounds allows for more frequent use of local tissue repair, which ensures better results. NPWT is a highly effective way to prepare wounds for early surgical closure in patients with upper extremity NF.
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Affiliation(s)
- Konstantin V Lipatov
- Department of General Surgery, Institute of Clinical Medicine named after N.V. Sklifosovsky, Sechenov First Moscow State Medical University (Sechenov University), Moscow 119021, Russia
| | - Arthur Asatryan
- Department of General Surgery, Wound and Wound Infection Surgery, State Budgetary Institution “City Clinical Hospital named after S.S. Yudin of Moscow Healthcare Department”, Moscow 115446, Russia
| | - George Melkonyan
- Department of General Surgery, Physician of The Hospital for War Veterans No 3, Moscow 129336, Russia
| | - Aleksandr D Kazantcev
- Department of General Surgery, Institute of Clinical Medicine named after N.V. Sklifosovsky, Sechenov First Moscow State Medical University (Sechenov University), Moscow 119021, Russia
| | - Ekaterina I Solov’eva
- Department of General Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119048, Russia
| | - Denis V Krivikhin
- Department of General Surgery, Wound and Wound Infection Surgery, State Budgetary Institution “City Clinical Hospital named after S.S. Yudin of Moscow Healthcare Department”, Moscow 115446, Russia
| | - Irina V Gorbacheva
- Department of General Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119048, Russia
| | - Urii E Cherkasov
- Department of General Surgery, I.M. Sechenov First Moscow State Medical University, Moscow 119048, Russia
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Adhil I, Dahal S, Gyawali S, Neupane P, Kharel A, Neupane P, Pachhai P, Khadka R, Khatiwada RD, Shrestha JM. Evaluation of laboratory risk indicator for necrotizing fasciitis score as an early diagnostic tool for necrotizing fasciitis: a prospective observational study. Ann Med Surg (Lond) 2023; 85:5874-5878. [PMID: 38098577 PMCID: PMC10718372 DOI: 10.1097/ms9.0000000000001447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/18/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction From its historical identification to modern times with advancements in management modalities globally, the mortality of necrotizing fasciitis (NF) is high ranging from 19 to 30% for all affected sites. Although many diagnostic adjuncts have been developed to assist with the prompt and accurate diagnosis of NF, the primary diagnosis is still based on high clinical suspicion. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed as a tool for distinguishing NF from other soft tissue infections. The main objective of this study is to evaluate LRINEC as a tool for early diagnosis of NF and differentiating it from other soft tissue infections like cellulitis. Methods This is a single-centered, prospective observational study. Patients presenting with soft tissue infections of the limbs to the emergency department from November 2020 to October 2021 were included in this study. The clinical findings and blood parameters for the LRINEC score were collected and the score was calculated. Based on clinical suspicion of NF, patients underwent debridement and had a tissue biopsy to confirm the diagnosis. The data obtained was analyzed using SPSS version 24 and MS Excel. The AUC curve was used to calculate a cutoff, sensitivity, specificity, positive predictive value, and negative predictive values for the LRINEC score based on our study. Results Forty-five patients with 28 males and 17 females were included. The average age was 53.667 years within a range of 19-79 years. Among them 44.4% of the patients had NF and 66.6% had other minor forms of soft tissue infections. The ROC curve obtained a cutoff value of greater than or equal to 6, with an AUC of 0.751. At this cut of value study showed a sensitivity of 85% with a specificity of 52%. Similarly, positive predictive value was found to be 58.62%, negative predictive values of 81.25%, and overall accuracy of 66.67% in early diagnosis of NF. Conclusion In conclusion, our study showed that the LRINEC score can be a reliable tool for the early diagnosis of NF in an ED setting. This scoring system is best to be used to rule out NF.
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Affiliation(s)
| | | | | | | | - Ashok Kharel
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu
| | | | | | | | - Raj D. Khatiwada
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu
| | - Jayan M. Shrestha
- Department of Plastic Surgery and Burns, Tribhuvan University Teaching Hospital, Institute of Medicine
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Gan RK, Sanchez Martinez A, Abu Hasan MAS, Castro Delgado R, Arcos González P. Point-of-care ultrasonography in diagnosing necrotizing fasciitis-a literature review. J Ultrasound 2023:10.1007/s40477-022-00761-5. [PMID: 36694072 DOI: 10.1007/s40477-022-00761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/29/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Necrotizing fasciitis (NF) is a rapidly progressive necrosis of the fascial layer with a high mortality rate. It is a life-threatening medical emergency that requires urgent treatment. Lack of skin finding in NF made diagnosis difficult and required a high clinical index of suspicion. The use of ultrasound may guide clinicians in improving diagnostic speed and accuracy, thus leading to improved management decisions and patient outcomes. This literature search aims to review the use of point-of-care ultrasonography in diagnosing necrotizing fasciitis. METHOD We searched relevant electronic databases, including PUBMED, MEDLINE, and SCOPUS, and performed a systematic review. Keywords used were "necrotizing fasciitis" or "necrotising fasciitis" or "necrotizing soft tissue infections" and "point-of-care ultrasonography" "ultrasonography" or "ultrasound". No temporal limitation was set. An additional search was performed via google scholar, and the top 100 entry was screened. RESULTS Among 540 papers screened, only 21 were related to diagnosing necrotizing fasciitis using ultrasonography. The outcome includes three observational studies, 16 case reports, and two case series, covering the period from 1976 to 2022. CONCLUSION Although the use of ultrasonography in diagnosing NF was published in several papers with promising results, more studies are required to investigate its diagnostic accuracy and potential to reduce time delay before surgical intervention, morbidity, and mortality.
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Affiliation(s)
- Rick Kye Gan
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| | - Antoni Sanchez Martinez
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Muhammad Abdus-Syakur Abu Hasan
- Emergency Medicine Department, Kulliyyah of Medicine, International Islamic University Malaysia (IIUM), Kuantan, Pahang, Malaysia
- Emergency and Trauma Department, Sultan Ahmad Shah Medical Center, IIUM, Kuantan, Pahang, Malaysia
| | - Rafael Castro Delgado
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain
- SAMU-Asturias, Asturias, Spain
| | - Pedro Arcos González
- Unit for Research in Emergency and Disaster, Public Health Area, Department of Medicine, University of Oviedo, Oviedo, Asturias, Spain
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Ditsios K, Chitas K, Christidis P, Charatsis K, Katsimentzas T, Papadopoulos P. Necrotizing Fasciitis of the Upper Extremity - A Review. Orthop Rev (Pavia) 2022; 14:35320. [PMID: 36034724 PMCID: PMC9404292 DOI: 10.52965/001c.35320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/29/2022] [Indexed: 09/04/2024] Open
Abstract
Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.
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Affiliation(s)
- Konstantinos Ditsios
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Konstantinos Chitas
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | | | - Konstantinos Charatsis
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Triantafyllos Katsimentzas
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
| | - Pericles Papadopoulos
- 2nd Academic Department of Orthopedic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "G. Gennimatas", Greece
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Pérez-Sánchez I, Martínez-Gil L, Piqueras-Vidal P, Pont-Gutiérez C, Cebrián-Gómez R, Montoza-Nuñez J. [Translated article] Necrotising fasciitis: Management experience over the last two decades in our hospital. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:T11-T19. [DOI: 10.1016/j.recot.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/05/2021] [Indexed: 10/17/2022] Open
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Pérez-Sánchez I, Martínez-Gil L, Piqueras-Vidal P, Pont-Gutiérez C, Cebrián-Gómez R, Montoza-Nuñez J. Fascitis necrosante: experiencia de manejo en las últimas dos décadas en nuestro centro. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022. [DOI: 10.1016/j.recot.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Pomerantz ML. Necrotizing Soft Tissue Infections of the Hand and Wrist. Orthop Clin North Am 2022; 53:57-67. [PMID: 34799023 DOI: 10.1016/j.ocl.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Necrotizing soft tissue infections of the upper extremity threaten life and limb. Their presentation is often difficult to recognize and multiple factors contribute to the varied presentation, speed of spread, and morbidity of the disease process. The only treatment to be definitively shown to improve outcomes is prompt surgical treatment. It should be expected to perform multiple debridements as well as reconstructive procedures once the infection and necrosis has been arrested. The use of a multidisciplinary team is mandatory to optimize care for these patients. Despite advances in knowledge and treatment, these infections still have high mortality and morbidity.
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Affiliation(s)
- M Lucius Pomerantz
- Synergy Orthopedic Specialists, Inc., 955 Lane Ave, #200, Chula Vista, CA 91914, USA; Orthopedic Surgery, University of California San Diego, San Diego, CA, USA.
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Rampal S, Ganesan T, Sisubalasingam N, Neela VK, Tokgöz MA, Arunasalam A, Ab Halim MAH, Shamsudin ZB, Kumar S, Sinniah A. Local Trends of Antibiotic Prescriptions for Necrotizing Fasciitis Patients in Two Tertiary Care Hospitals in Central Malaysia. Antibiotics (Basel) 2021; 10:1120. [PMID: 34572702 PMCID: PMC8470198 DOI: 10.3390/antibiotics10091120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/08/2021] [Accepted: 09/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis (NF) is a rapidly progressive inflammatory infection of the soft tissue (also known as the fascia) with a secondary necrosis of the subcutaneous tissues, leading to a systemic inflammatory response syndrome (SIRS), shock and eventually death despite the availability of current medical interventions. The clinical management of this condition is associated with a significant amount of morbidity with a high rate of mortality. The prognosis of the disease is affected by multiple factors, which include the virulence of the causative pathogen, local host immunity, local wound factors and empirical antibiotics used. The local trends in the prescription of empirical antibiotics are often based on clinical practice guidelines (CPG), the distribution of the causative microorganism and the cost-effectiveness of the drug. However, there appears to be a paucity of literature on the empirical antibiotic of choice when dealing with necrotizing fasciitis in the clinical setting. This paper will outline common causative microorganisms and current trends of prescription in two tertiary centres in Central Malaysia. METHODS This was a cross-sectional study using retrospective data of patients treated for NF collected from two tertiary care hospitals (Hospital Seremban and Hospital Ampang) in Central Malaysia. A total of 420 NF patients were identified from the five years of retrospective data obtained from the two hospitals. RESULTS The top three empirical antibiotics prescribed are ampicillin + sulbactam (n = 258; 61.4%), clindamycin (n = 55; 13.1%) and ceftazidime (n = 41; 9.8%). The selection of the antibiotic significantly impacts the outcome of NF. The top three causative pathogens for NF are Streptococcus spp. (n = 79; 18.8%), Pseudomonas aeruginosa (n = 61; 14.5%) and Staphylococcus spp. (n = 49; 11.7%). The patients who received antibiotics had 0.779 times lower chances of being amputated. Patients with a lower laboratory risk indicator for necrotizing fasciitis (LRINEC) score had 0.934 times lower chances of being amputated. CONCLUSIONS In this study, the most common empirical antibiotic prescribed was ampicillin + sulbactam followed by clindamycin and ceftazidime. The antibiotics prescribed lower the risk of having an amputation and, hence, a better prognosis of the disease. Broad-spectrum empirical antibiotics following surgical debridement reduce the mortality rate of NF.
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Affiliation(s)
- Sanjiv Rampal
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Thanusha Ganesan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
| | - Narresh Sisubalasingam
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Vasantha Kumari Neela
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | - Mehmet Ali Tokgöz
- Kecioren Education and Training Hospital, Pınarbaşı Quarter Sanatoryum Street Keçiören, Ankara, Turkey;
| | - Arun Arunasalam
- Urology Department, Hospital Serdang, Ministry of Health of Malaysia, Putrajaya 62590, Malaysia;
| | - Mohd Asyraf Hafizuddin Ab Halim
- Department of Orthopaedic and Traumatology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Seri Kembangan 43400, Malaysia; (N.S.); (V.K.N.); (M.A.H.A.H.)
| | | | - Suresh Kumar
- Centre for Materials Engineering and Regenerative Medicine, Bharath Institute of Higher Education and Research, Chennai 600173, India;
| | - Ajantha Sinniah
- Department of Pharmacology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
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Necrotizing fasciitis: Usefulness of the LRINEC score in a third-level hospital. Injury 2021; 52 Suppl 4:S8-S15. [PMID: 34011440 DOI: 10.1016/j.injury.2021.02.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 02/02/2023]
Abstract
AIM To review patients seen in the emergency room, diagnosed with necrotizing fasciitis (NF) and the correlation of such complications with the Laboratory Risk Indicator for Necrotizing fasciitis scale (LRINEC). The purpose of this study is to assess the use of the LRINEC score for early diagnosis of NF and its prognostic use in a consecutive series of cases treated at our hospital. METHODS Retrospective observational study including patients with a diagnosis of NF in the emergency room of a tertiary hospital over 11 years. The results are shown as median, interquartile range and absolute range for quantitative variables. In the case of qualitative variables, the results are shown as absolute and relative frequency. The comparison between the categories of the LRINEC scale was performed through a post-hoc comparison from a non-parametric rank-ANOVA analysis. Comparisons between LRINEC groups in the qualitative variables were performed using Fisher's exact test. RESULTS A total of 45 patients with a mean age of 51 years were identified. There was a 20% mortality rate (9 cases). The highest mortality rate was registered in the high-risk group (LRINEC greater than 8) with 4 deceased individuals (44.44%), while in the low and moderate-risk groups, 3 and 2 deceased individuals (33% and 22%) were registered, respectively, without considering this result statistically significant (p=0.811). There was an amputation rate of 15.6% (7 cases). The average LRINEC score was greater in the cases that required amputation 9 (95% CI 7; 13) in comparison to the other patients, 6 (95% CI 5; 8), p=0.044. The average hospital stay lasted 32.5 days (95% CI: 25; 40); 30 days in the low-risk group, 41 days in the moderate-risk group and 40 days in the high-risk group. Mortality was associated to a smaller number of interventions (p=0.005) and was preceded by septic shock in all cases. CONCLUSIONS The LRINEC score may be useful to aid diagnosis. However, clinical suspicion is the most important in diagnosis. A LRINEC low score does not exclude NF. In this retrospective series, 35.71% of cases presented a low LRINEC score, making the rate of false negatives high. In view of these results, The LRINEC score cannot be used as a prognostic value since an initial low score does not rule out serious evolution.
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Naik D, Jebasingh FK, Thomas N, Raveendran S, Raj Pallapati SC, Prakash JJ, Gowri M, Thomas BP. Necrotizing soft tissue infection of the upper extremities in patients with diabetes mellitus in a tertiary care center-a retrospective study. Diabetes Metab Syndr 2020; 14:1071-1075. [PMID: 32650278 DOI: 10.1016/j.dsx.2020.05.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 05/14/2020] [Accepted: 05/16/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Necrotizing soft tissue infection (NSTI) of the upper extremities is a rare, but potentially life-threatening infection in patients with type 2 diabetes mellitus (T2DM). We analyzed the clinical characteristics and the outcome of NSTI of upper extremities in these patients. METHODS This was a retrospective study analyzing the clinical characteristics and the outcomes of 33 T2DM patients with NSTI of upper extremities, who were treated in the department of hand surgery between January 2011 and December 2017. RESULTS Predisposing factors for NSTI were recognized in 16 (48.5%) patients. Eleven (33.3)% patients had septic shock while ten (30.3%) had acute renal insufficiency at the time of presentation, of which six required dialysis. The mean glycosylated hemoglobin was 9.6(±2.6)% and the random plasma glucose at admission was 271(±96) mg/dl. Monomicrobial infection was seen in 16(49%) patients and polymicrobial infection in 9(27%) patients. Gram-positive causation was found in 25(66%) patients. Twelve (36.4%) patients required amputation, six (18.2%) of which were major. Death occurred in more than one-fifth (21.2%) of the patients during treatment. CONCLUSION Necrotizing soft tissue infection of the upper extremities in T2DM is associated with increased risk of severe infection, amputation and mortality.
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Affiliation(s)
- Dukhabandhu Naik
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, 632004, India
| | - Felix K Jebasingh
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, 632004, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes & Metabolism, Christian Medical College, Vellore, 632004, India
| | - Sreekanth Raveendran
- Dr Paul Brand Centre for Hand Surgery, Christian Medical College, Vellore, 632004, India.
| | - Samuel C Raj Pallapati
- Dr Paul Brand Centre for Hand Surgery, Christian Medical College, Vellore, 632004, India
| | - John Jude Prakash
- Department of Microbiology, Christian Medical College, Vellore, 632004, India
| | - Mahasampath Gowri
- Department of Biostatistics, Christian Medical College, Vellore, 632004, India
| | - Binu Prathap Thomas
- Dr Paul Brand Centre for Hand Surgery, Christian Medical College, Vellore, 632004, India
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Abstract
Necrotizing soft tissue infections of the upper extremity have varying microbiologies and etiologies. Risk factors for development include diabetes mellitus, intravenous drug use, peripheral arterial disease, smoking, alcohol abuse, and immunocompromised state. Although clinical examination is the mainstay of diagnosis, laboratory tests and imaging can aid in diagnosis. Surgical débridements usually are needed for treatment, with resultant defects that often require reconstruction. Rates of amputation are reported as 22% to 37.5% and mortality from necrotizing soft tissue infections of the upper extremity from 22% to 34%. Prompt surgical and antimicrobial treatment is necessary to decrease risk of loss of limb or life.
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Affiliation(s)
- Atlee Melillo
- Division of Plastic Surgery, Cooper University Health Care, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
| | - Kamal Addagatla
- Division of Plastic Surgery, Cooper University Health Care, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
| | - Nicole J Jarrett
- Division of Plastic Surgery, Cooper University Health Care, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA.
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The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study. J Trauma Acute Care Surg 2020; 86:601-608. [PMID: 30601458 DOI: 10.1097/ta.0000000000002175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE Prognostic/Epidemiologic retrospective multicenter trial, level III.
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Albasanz-Puig A, Rodríguez-Pardo D, Pigrau C, Lung M, Roldan E, Corona PS, Almirante B, Ruiz-Camps I. Necrotizing fasciitis in haematological patients: a different scenario. Ann Hematol 2020; 99:1741-1747. [PMID: 32399706 DOI: 10.1007/s00277-020-04061-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
To describe and compare the characteristics of necrotizing fasciitis (NF) in patients with and without haematological malignancy. All adult patients diagnosed with NF and treated at our hospital were included (January 2010-March 2019). Diagnosis was based on intraoperative findings or consistent clinical/radiological characteristics, and patients were classified as group A (with haematological malignancy) or group B (without haematological malignancy). Student's t (quantitative), Fisher's exact (qualitative), and Kaplan-Meyer tests were used for the statistical analysis. The study included 29 patients: 8 in group A and 21 in group B. All haematological patients had severe neutropenia (0.2 [0.02-0.5] ×109 cells/L; p < 0.001) and positive blood cultures (100% vs. 61.9%; p = 0.04) at diagnosis. Gram-negative bacilli NF was more common in group A (87.5% vs. 9.5%; p = 0.001), predominantly due to Escherichia coli (50% vs. 9.5%; p = 0.056). Surgical treatment was less common in haematological patients (5 [62.5%] vs. 21 [100%]; p = 0.015). Overall, 9 (31%) patients died: 4 (50%) in group A and 5 (23.8%) in group B (p = 0.17). The univariate analysis showed that mortality tended to be higher (OR 3.2; 95%CI 0.57-17.7; p = 0.17) and to occur earlier (2.2 ± 2.6 vs. 14.2 ± 19.9 days; p = 0.13) in haematological patients. The LRINEC index > 6 did not predict mortality in either group. In our study, NF in patients with haematological malignancies was mainly due to Gram-negative bacilli, associated to high and early mortality rates. In our experience, the LRINEC scale was not useful for predicting mortality.
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Affiliation(s)
- A Albasanz-Puig
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Department of Medicine, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Spanish Network for Research in Infectious Pathology (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - D Rodríguez-Pardo
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Department of Medicine, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Spanish Network for Research in Infectious Pathology (REIPI), Instituto de Salud Carlos III, Madrid, Spain.
| | - C Pigrau
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Department of Medicine, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Spanish Network for Research in Infectious Pathology (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - M Lung
- Microbiology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - E Roldan
- Haematology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - P S Corona
- Spanish Network for Research in Infectious Pathology (REIPI), Instituto de Salud Carlos III, Madrid, Spain
- Reconstructive and Septic Surgery Division, Department of Orthopedic Surgery, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - B Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Department of Medicine, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Spanish Network for Research in Infectious Pathology (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - I Ruiz-Camps
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Department of Medicine, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Spanish Network for Research in Infectious Pathology (REIPI), Instituto de Salud Carlos III, Madrid, Spain
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15
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Hsiao CT, Chang CP, Huang TY, Chen YC, Fann WC. Prospective Validation of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score for Necrotizing Fasciitis of the Extremities. PLoS One 2020; 15:e0227748. [PMID: 31978094 PMCID: PMC6980593 DOI: 10.1371/journal.pone.0227748] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 12/27/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The Laboratory Risk Indicator for Necrotizing Fasciitis score was developed as a clinical decision tool for distinguishing necrotizing fasciitis from other soft tissue infections. We prospectively evaluated the performance of the Laboratory Risk Indicator for Necrotizing Fasciitis score for the diagnosis of patients with necrotizing fasciitis in the extremities. METHODS We conducted a prospective and observational cohort study of emergency department patients with necrotizing fasciitis or severe cellulitis in the extremities between April 2015 and December 2016. The Laboratory Risk Indicator for Necrotizing Fasciitis score was calculated for every enrolled patient. The sensitivity, specificity, positive predictive value, and negative predictive value of cut-off scores of 6 and 8 were evaluated. The accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was expressed as the area under the receiver operating characteristic curve. RESULTS A total of 106 patients with necrotizing fasciitis and 825 patients with cellulitis were included. With an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥6, the sensitivity was 43% (95% confidence interval 34% to 53%), specificity was 83% (95% confidence interval 80% to 86%), positive predictive value was 25% (95% confidence interval 20% to 30%), and negative predictive value was 92% (95% confidence interval 91% to 93%); with an Laboratory Risk Indicator for Necrotizing Fasciitis cut-off score ≥8, the sensitivity was 27% (95% confidence interval 19% to 37%), specificity was 93% (95% confidence interval 91% to 94%), positive predictive value was 33% (95% confidence interval 25% to 42%), and negative predictive value was 91% (95% confidence interval 90% to 92%). The area under the receiver operating characteristic curve for accuracy of the Laboratory Risk Indicator for Necrotizing Fasciitis score was 0.696 (95% CI 0.640 to 0.751). CONCLUSION The Laboratory Risk Indicator for Necrotizing Fasciitis score may not be an accurate tool for necrotizing fasciitis risk stratification and differentiation between severe cellulitis and necrotizing fasciitis in the emergency department setting based on our study.
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Affiliation(s)
- Cheng-Ting Hsiao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medical, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology Chiayi Campus, Chiayi, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- * E-mail:
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16
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Abstract
Necrotizing infections of the hand and wrist are important clinical entities because of their rapidly progressive and potentially lethal nature. These infections encompass a spectrum of diseases with overlapping signs and symptoms, which can be subtle and nonspecific. If the brief prodromal period of these infections goes unrecognized, a local area of devitalized tissue can evolve into fulminant infection, multiorgan failure, and potentially death. Early recognition and treatment including administration of broad-spectrum antibiotics and surgical débridement are paramount to improving patient outcomes.
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17
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Novoa-Parra CD, Wadhwani J, Puig-Conca MA, Lizaur-Utrilla A, Montaner-Alonso D, Rodrigo-Pérez JL, Morales-Suárez-Varela M. Usefulness of a risk scale based on procalcitonin for early discrimination between necrotising fasciitis and cellulitis of the extremities. Med Clin (Barc) 2019; 153:347-350. [PMID: 31103240 DOI: 10.1016/j.medcli.2019.01.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE To assess the usefulness of a risk scale based on serum procalcitonin (PCT) compared to the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scale in the early discrimination between necrotising fasciitis (NF) and cellulitis of the extremities. MATERIALS AND METHODS Retrospective study of consecutive patients with confirmed diagnosis of NF in one limb (n=11). This study group was compared with 23 consecutive patients with a diagnosis of severe limbs cellulitis during the same period. The clinical data and laboratory parameters were analysed, the main variable was the serum level of PCT upon admission. The capacity for NF diagnosis of the two methods, PCT level and LRINEC scale score, were evaluated by ROC curve and determined by the calculation of the area under the curve (AUC). RESULTS The AUC was significantly higher with PCT measurement, both as a continuous variable and when the risk was categorised. The cut-off point for the PCT level with the highest AUC under the curve was from 0.87ng/ml (sensitivity 90.9%, specificity 82.6%), whereas it was a score of 5 on the LRINEC scale (sensitivity 72.7%, specificity 82.6%). CONCLUSION PCT measurement was a more effective method than the LRINEC score for early discrimination between NF and cellulitis of the extremities. A low level of PCT, associated with the patient's clinical status and physical examination is especially useful to rule out an early diagnosis of NF.
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Affiliation(s)
- Carlos Daniel Novoa-Parra
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España; Servicio de Cirugía Ortopédica y Traumatología, Hospital de Denia, Denia, Alicante, España.
| | - Jayant Wadhwani
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España
| | | | | | - Daniel Montaner-Alonso
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España
| | - José L Rodrigo-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Dr. Peset, Valencia, España
| | - Maria Morales-Suárez-Varela
- Departamento de Medicina Preventiva, Universidad de Valencia, Valencia, España; CIBER Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, España
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18
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Air entrapment resembling necrotising fasciitis as a frequent incident following total hip arthroplasty. Sci Rep 2019; 9:15766. [PMID: 31673095 PMCID: PMC6823472 DOI: 10.1038/s41598-019-52113-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/09/2019] [Indexed: 11/11/2022] Open
Abstract
In combination with pain and elevated inflammatory parameters that are frequently observed following elective total hip arthroplasty (THA), air entrapment on radiographic images could be indicative of necrotising fasciitis. The aim of the present study was to analyse presence/extent of air entrapment following THA, and to correlate radiological with clinical findings. One-hundred patients undergoing short-stem elective THA (ANA NOVA Alpha Proxy-system) were prospectively included. Patients received pre- and postoperative x-rays (day 1 + discharge) of the affected hip, together with a CT-scan of the lower extremity (discharge). C-reactive-protein-(CRP), leukocyte, haemoglobin-, creatinine-, glucose-, sodium-levels – and based on these the LRINEC score– as well as pain-scores (numeral-rating-scale, NRS) at postoperative days 1, 3 and 5 were documented. Air entrapment was visible in 98% of x-rays taken postoperatively and in 93% of CT-scans at discharge. Leukocyte-levels significantly decreased from postoperative day 1 to 5. CRP-levels had a peak at the 3rd postoperative day (p < 0.001). On discharge-x-rays of patients with low body-mass-indexes, air entrapment was significantly more often visible (p = 0.040). Neither implant-related nor laboratory parameters, LRINEC- or NRS-scores significantly correlated with presence/extent of air entrapment (p > 0.05). Considering the high rate of air entrapment following elective THA postoperatively and at discharge, suspicion of an infection with gas-producing bacteria may only be raised in case of persistent inflammatory parameters, deteriorating general condition and signs of local infection.
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Nawijn F, Verhiel SH, Lunn KN, Eberlin KR, Hietbrink F, Chen NC. Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study. World J Surg 2019; 44:730-740. [DOI: 10.1007/s00268-019-05256-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Background
It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs.
Methods
A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs.
Results
Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64–52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14–96.98). The independent risk factor for amputation was a NSTI of the non-dominant arm (OR 3.78, 95% CI 1.07–13.35). Length of hospital stay was 15 (IQR 9–21) days.
Conclusion
Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.
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20
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Tong KS, Williams DC, Seifman MA, Hunter-Smith DJ, Rozen WM. Synchronous multifocal necrotizing soft tissue infections: a case report and literature review. EUROPEAN JOURNAL OF PLASTIC SURGERY 2019. [DOI: 10.1007/s00238-019-1503-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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Abstract
Hand infections can lead to debilitating and permanent disability, particularly if they are not treated promptly or properly. The unique anatomy of the hand, with its numerous enclosed and confined spaces, warrants special considerations. For instance, infections in deep spaces of the hand may require surgical drainage despite an appropriate course of antimicrobial treatment. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout.
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Affiliation(s)
- Wendy Z W Teo
- Department of Hand and Reconstructive Microsurgery, National University Health System, 1E Kent Ridge Road, Level 11, Singapore 119228, Singapore.
| | - Kevin C Chung
- The University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-5340, USA
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Collins J. Surgical intervention and customised dressings in an extremity wound caused by necrotising fasciitis: a case study. J Wound Care 2019; 28:S21-S27. [PMID: 31067168 DOI: 10.12968/jowc.2019.28.sup5.s21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Necrotising fasciitis can result in extensive loss of soft tissue and limb function. Therefore, surgical intervention requires a balance between extensive tissue removal and saving the limb. A 56-year-old male presented with necrotising fasciitis of the upper extremity. Debridement resulted in a full-thickness wound of the forearm and upper arm, an exposed olecranon and two proximally-based skin flaps. Reconstruction required multiple debridements to optimise the wound for skin grafting and to obtain flap adherence to underlying tissues of the upper arm. Conventional dressings over the flaps proved unsuccessful. Therefore, a customised versatile dressing to address each area of the wound was developed. Negative pressure wound therapy (NPWT) was applied over the exposed muscle (no exposed bone or tendon) of the lower arm and anterior upper arm; a hydropolymer foam dressing covered the elbow region. Closed incision negative pressure wound therapy (ciNPT) was applied over the incision on the posterior upper arm. Ultimately, complete wound closure was achieved, with normal/near-normal range of motion for all joints of the affected limb. There was complete take of skin grafts on the wrist, lower arm and anterior upper arm. ciNPT was effective in holding the incision together and promoting healing of the posterior upper arm, and the hydropolymer foam dressing aided with healing and coverage of the elbow region. In this case, healing of a large, complex upper extremity wound and restored limb function were achieved following use of a combination of surgical techniques and customisation of wound therapy modalities.
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Affiliation(s)
- Jessica Collins
- Plastic & Reconstructive Surgery, OasisMD Lifestyle Healthcare, San Diego, CA, US
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Keeling PA, Domes CM. A Systematic Review of the Laboratory Risk Indicator for Necrotizing Fasciitis Score and Its Utility in Orthopedics for Diagnosing Necrotizing Fasciitis in Adults. Orthopedics 2019; 42:e288-e294. [PMID: 30964538 DOI: 10.3928/01477447-20190403-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/12/2018] [Indexed: 02/03/2023]
Abstract
Given its association with trauma and surgery, necrotizing fasciitis is a disease orthopedists are likely to encounter. The laboratory risk indicator for necrotizing fasciitis score is an adjunct diagnostic test designed to help diagnose early necrotizing fasciitis infections, but studies evaluating the scoring system have reported conflicting results. The purpose of this systematic review was to provide clarity on the laboratory risk indicator for necrotizing fasciitis score's capabilities and when it is best used. [Orthopedics. 2019; 42(3):e288-e294.].
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van Son K, Savelkoul C, Mollen R, Tjan DH. A case of fulminant necrotising fasciitis. BMJ Case Rep 2017; 2017:bcr-2016-219142. [PMID: 28456758 DOI: 10.1136/bcr-2016-219142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kelsey van Son
- Emergency Department, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Claudia Savelkoul
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Roland Mollen
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - David Ht Tjan
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
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