Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

Chapter 27: Necrotizing Fasciitis and Other Complicated Skin and Soft-Tissue Infections

This is a review focusing on practical approaches to man agement of NSTIs including prompt recognition, initiation of specific management, exploratory surgery, and care after treatment. 39. Gelbard RB, Ferrada P, Yeh DD, et al: Optimal timing of initial debridement for necrotizing soft tissue infection: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2018;85(1):208-214. This is a systematic review showing that early surgical débridement within 12 hours of suspected diagnosis of NSTI is recommended. Level of evidence: III. 40. Nawijn F, Smeeing DPJ, Houwert RM, Leenen LPH, Hietbrink F: Time is of the essence when treating necrotizing soft tissue infections: A systematic review and meta-analysis. World J Emerg Surg 2020;15:4. This systematic review showed that early surgical débridement lowers the mortality rate for NSTI. Level of evidence: III. 41. Nawijn F, van Heijl M, Keizer J, van Koperen PJ, Hietbrink F: The impact of operative time on the outcomes of necrotizing soft tissue infections: A multicenter cohort study. BMC Surg 2022;22(1):3. This is a study showing that prolonged surgical time was associated with a prolonged intensive care unit and hospital stay. Level of evidence: II. 42. Tom LK, Maine RG, Wang CS, Parent BA, Bulger EM, Keys KA: Comparison of traditional and skin-sparing approaches for surgical treatment of necrotizing soft-tissue infections. Surg Infect (Larchmt) 2020;21(4):363-369. This is a study showing that skin-sparing débridement for source control of NSTI compared with traditional débride ment resulted in significantly more wounds completely closed by delayed primary suture of existing skin flaps and a signifi cantly lower overall wound percentage closed by skin graft, while demonstrating equivalent efficacy of source control and a similar low mortality rate. Level of evidence: II. 43. Sartelli M, Guirao X, Hardcastle TC, et al: 2018 WSES/ SIS-E consensus conference: Recommendations for the man agement of skin and soft-tissue infections. World J Emerg Surg 2018;13:58. This task force created by the World Society of Emergency Surgery and the Surgical Infection Society Europe in 2018 emphasizes the need for multidisciplinary collaboration in treating patients with NSTI. 44. Tessier JM, Sanders J, Sartelli M, et al: Necrotizing soft tissue infections: A focused review of pathophysiology, diagnosis, operative management, antimicrobial therapy, and pediatrics. Surg Infect 2020;21(2):81-93. The Surgical Infection Society of North America and the World Society of Emergency Surgery emphasize on the importance of early diagnosis and surgical intervention in necrotizing fasciitis.

30. Petitpas F, Blancal JP, Mateo J, et al: Factors associated with the mediastinal spread of cervical necrotizing fasciitis. Ann Thorac Surg 2012;93(1):234-238. 31. Stevens DL, Bisno AL, Chambers HF, et al: Practice guide lines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014;59(2):e10-e52. 32. Kazi FN, Sharma JV, Ghosh S, Prashanth D, Raja VOPK: Comparison of LRINEC scoring system with finger test and histopathological examination for necrotizing fasciitis. Surg J (N Y) 2022;8(1):e1-e7. This is a study showing that histopathology remained the gold standard for diagnosis of necrotizing fasciitis, whereas LRINEC score and finger test were good diagnostic tools for early diag nosis, with sensitivities of 83.33% and 86.11%, respectively. 33. Bechar J, Sepehripour S, Hardwicke J, Filobbos G: Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: A systematic review of the literature. Ann R Coll Surg Engl 2017;99(5):341-346. 34. Kim DH, Kim SW, Hwang SH: Application of the laboratory risk indicator for necrotizing fasciitis score to the head and neck: A systematic review and meta-analysis. ANZ J Surg 2022;92(7-8):1631-1637. This is a systematic review showing that LRINEC score is a useful adjunctive tool for predicting cervical necrotizing fasciitis in patients with a soft-tissue infection, with a more accurate diagnosis when using a cutoff value of 6. Level of evidence: III. 35. Tanaka S, Thy M, Khoury R, Tran-Dinh A, Khalil A, Montravers P: Severe necrotizing soft-tissue infection- associated mortality: Have a look at the computed tomog raphy! Crit Care 2022;26:27. This retrospective study from 2009 to 2019 on patients with severe NSTI hospitalized in the intensive care unit showed that presence of inflammatory changes of the fascia parameter in the CT scan had a sensitivity of 60%, specificity of 92%, positive predictive value of 75%, and negative predictive value of 86%. Level of evidence: II. 36. Martinez M, Peponis T, Hage A, et al: The role of computed tomography in the diagnosis of necrotizing soft tissue infec tions. World J Surg 2018;42(1):82-87. This retrospective study from 2009 to 2006 showed that a negative intravenous contrast-enhanced CT scan can reliably rule out the need for surgical intervention in patients with initial suspicion of NSTI. Level of evidence: II. 37. Fernando SM, Tran A, Cheng W, et al: Necrotizing soft tissue infection: Diagnostic accuracy of physical examina tion, imaging, and LRINEC score – A systematic review and meta-analysis. Ann Surg 2019;269(1):58-65. A systematic review showed that LRINEC score had poor sensitivity and should not be used to rule out NSTI, reinforcing that high clinical suspicion warrants early surgical consultation for definitive diagnosis and management. Level of evidence: III. 38. Hua C, Urbina T, Bosc R, et al: Necrotising soft-tissue infec tions. Lancet Infect Dis 2023;23(3):e81-e94.

Section 6: Bone, Joint, and Soft-Tissue Infections

45. Chang CP, Hsiao CT, Lin CN, Fann WC: Risk factors for mortality in the late amputation of necrotizing fasciitis: A retrospective study. World J Emerg Surg 2018;13:45. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2