A patient with severe limb infection in whom the amputation was the first option. Dr Majd Alhaddadin, Consultant General and Laparoscopic Surgeon, performed a transmetatrsal amputation with extensive tissue debridement and falp creation, followed by vacuum therapy and 2 stages wound closure. Fortunately xth limb was saved and the patient returned to his normal job.

1. Dr. Majd AlHaddadin, MBChB,MS,MRCS
Consultant General & Laparoscopic Surgeon
Al Hammadi Hospital – Riyadh – Nuzha
- Jordanian Board and Arab Board in General Surgery.
- Member of The Spanish Association of Surgery (AEC).
- Member of The Royal College of Surgeons – Ireland (MRCSI).
- Associate Fellow of the American College of Surgeon (AFACS).

2. Limb Salvage in Severe
Necrotizing Fasciitis
Dr. Majd AlHaddadin, MBChB,MS,MRCS
General Surgery Senior Specialist
Al Hammadi Hospital - Nuzha

3. Introduction
Necrotizing fasciitis is an uncommon but serious soft tissue infection that is
associated with extensive local tissue destruction, systemic toxicity and a
fulminant clinical course.
Despite surgical advances and the introduction of potent antimicrobial agents,
mortality rates of 30% to 60% have been reported.

4. This life-threatening condition has been recognized since 18th century with
various names including phagedena gangrenosum, hospital gangrene, Meleney's
gangrene, Fournier's gangrene etc.
Although rare, it is frequent enough that surgeons will likely have to be
involved with the management of at least 1 patient with NF during their
practice, but it is infrequent enough to achieve complete familiarity with the
disease.

5. Case Presentation
• A 45 year — old, gentleman past-medical history of Diabetes Mellitus TypeI,
Hypertension and Dyslipidemia on regular medication .
• OPD 17/Jul/2018
• Previously admitted to another hospital (23/Jun/2018)
- Diagnosis of Right Diabetic Foot with severe infection.
- During hospital stay ,patient developed 2nd toe gangrene.
- U/W 2nd toe Ray amputation and foot debridement.
- Worse, decision to do Below Knee Amputation.

6. Physical examination:
Looks well, not septic.
• Fully conciouss.
• BP: 165/70mmhg
• HR:118 per min.
• Temperature: 36.8 c.
• O2 sat: 97%
Lower limb examination:
Left : Grossly Normal.

7. Right lower limb:
• No signs of chronic limb ischemia.
• No muscular atrophy.
• Palpable femoral, popliteal,posterior and anterior tibial arteries.
• Loss of sensation below knee (Diabetic Neuropathy).
Foot examination:

8. Head of 3rd metatarsal bone

9. Diagnosis
Initial Diagnosis:
Right foot Necrotizing Fasciitis complicated by toes ischemia and gangrene.

10. Multidisciplinary Team Assessment
Medical Team Assessment
• stabilisation glycaemic control +/− insulin sliding scale.
• stabilisation of level of infection via antimicrobial therapy based on clinical presentation and
hospital guidelines on diabetic lower limb infection.
• close monitoring of patient's C-reactive protein, full blood count, temperature, and blood sugar.
Surgical Team Assessment:
• Determination of the extent of the infection.
• Assessment of the vascular status.
• Assessment of the viability of the soft tissues.

11. Operation
• On July 18 , 2018
Foot Debridement and Dressing under GA to decide the level of Amputation.
• July 21, 2018:
Transmetatarsal Amputation.

12. Intraoperative Photos
Consent was obtained from the patient to
show this photos and any accompanying
images.( As per policy).
Soft tissue
V-Flap

13. Viable Tissues

14. Postoperative course
• Uneventful .
• Dressing done 48hours post surgery and
tissues were viable.
• Vacuum-assisted closure of a wound
Device applied.
V.A.C Via Device

15. • Patient discharged on July 24, 2018
• Good general condition.
• Vacuum Machine.
• No complications.

16. Follow up
1st week
of V.A.C

17. Follow up
2nd week
of V.A.C

18. 3rd week
of V.A.C
Follow up

19. • August 6 , 2018 First sage
wound closure.
• November 1, 2018 Second
and last stage of wound
closure.

20. Discussion
Foot infections can be difficult problems for physicians to treat because of the
biomechanical complexities of the extremity and the underlying circumstances
that cause the infections.
Although originally ,thought to be an idiopathic process, NSTI has been
shown to have a predilection for patients with Diabetes and Immune
compromised. However , it can also affect patients with non-obvious immune
compromise.

21. • Development and progression of the Fasciitis to gangrene is often
fulminating and can rapidly cause multiple organ failure and death.
• Rates of fascial destruction as high as 2-3cm/hour have been described in
severe cases.
• Because of potential complications , it is important to diagnose the disease
process as soon as possible.

22. Risk factors
70% :
Immunosuppression
diabetes
alcoholism
drug abuse
Smoking
malignancies
chronic systemic diseases
30% :
people with an apparently normal
general condition ( unknown reason).

23. Types of soft-tissue necrotizing infection
(Causative Microorganism)
Type I infection:
• This is the most common type of infection, and accounts for 70 to 80% of cases.
• It is caused by a mixture of bacterial types, usually in abdominal or groin areas. This type of
infection is usually caused by various species of Gram-positive cocci,(Staphylococcus
aureus, Streptococcus pyogenes, and enterococci), Gram-negative rods, (Escherichia coli, Pseudomonas
aeruginosa), and anaerobes, (Bacteroides and Clostridium species).
• Populations of those affected are typically older with medical comorbidities such as
diabetes mellitus, obesity, and immunodeficiency.
• Usually, trauma is not the cause of such infections.

24. Type II infection:
• This infection accounts for 20 to 30% of cases, mainly
involving the extremities.
• This mainly involves Streptococcus pyogenes bacteria, alone or in combination with
staphylococcal infections.
• Both types of bacteria can progress rapidly and manifest as toxic shock
syndrome.
• More commonly affects young, healthy adults with a history of injury.

25. Type III infection:
• Vibrio vulnificus, a bacterium found in saltwater.
• is a rare cause of this infection, which occurs through a break in the skin.
• Disease progression can be as rapid as type II infection without any visible
skin changes.
Type IV infection :
Some authors have described the type IV infection as fungal infection

26. Pathophysiology
NSTI causes tissue ischemia by widespread occlusion of
small subcutaneous vessels.
Vessel occlusion results in skin infarction and necrosis, which facilitates the
growth of obligate anaerobes (eg, Bacteroides) while promoting anaerobic
metabolism by facultative organisms (eg, Escherichia coli), resulting in gangrene.

27. Diagnosis
1. Symptoms and signs:
• The symptoms often start suddenly after an injury. pain that gets better over 24 to 36 hours and then
suddenly gets worse. The pain may be much worse than you would expect from the size of the wound or
injury. Skin that is red, swollen, and hot to the touch.
• A fever and chills.
• Nausea and vomiting.
• Diarrhea.
• Dizziness, generalized weakness.
• Patient may go into shock and have damage to skin, fat, and the tissue covering the muscles with gas and
bullae formation (gangrene).
• The infection may spread rapidly. It quickly can become life-threatening.

28. 2. Radiology:
• CT-Scan is the BEST diagnostic
modality to diagnose NSTI, the sensitivity 80%.
• MRI is more sensitive than CT Scan.
• Soft tissue Ultrasound.
• X Ray.

29. 3. Laboratory risk indicator for necrotizing
fasciitis (LRINEC) score:
Score Interpretation
Wong and colleagues
in 2004

30. Scoring System:
• 90% sensitivity in detecting
the NSTI.
• 99% chance of ruling out
necrotizing fasciitis.

31. 4. Surgical exploration
• The gold standard for diagnosis in a setting of high suspicion.
• When in doubt, a small incision can be made into the affected tissue, finger
easily separates the tissue along the fascial plane.

32. Treatment
1. ABC… Resuscitation.
2. Antibiotics:
• Empiric antibiotics are usually initiated as soon as the diagnosis of NSTI has been made, and then later changed to
culture-guided antibiotic therapy.
• broad-spectrum, covering gram-positive (including MRSA), gram-negative, and anaerobic bacteria.
3. Surgery
• Aggressive wound debridement should be performed early, usually as soon as the diagnosis of necrotizing soft
tissue infection (NSTI) is made.
• In case of limbs necrotizing fasciitis. In the majority of time, amputations are unavoidable.

33. Treatment
4. Added therapy:
• Hyperbaric oxygen: studies have shown that high oxygen tension in tissues helps to reduce edema,
stimulate fibroblast growth, increase the killing ability of white blood cells, inhibit bacterial toxin
release, and increase antibiotic efficacy.
• Inmunoglobulin.

34. TMA vs BKA
The advantages of TMA are:
• the preservation of a viable weight-bearing
platform allowing early ambulation.
• more acceptable appearance .
• less expenditure of energy during ambulation
than more proximal amputations, facilitating
mobility and independence.
• Compared to more proximal amputations,
the procedure proves to be the most
favourable option with regard to patient
satisfaction and function.

35. CONCLUSION
• NSTI is a progressive, aggressive and potentially fatal soft tissue infection.
• Delay in diagnosis is potentially catastrophic, as the concomitant delay in
surgical therapy significantly increases the mortality.
• Radical surgical debridement of all necrotic tissue remains the mainstay of
treatment, and further research is required before any strong
recommendations can be made about advanced adjunctive therapies.
• Limb amputation can be a life saving procedure BUT limb salvage can be
also life saving for some patients.

36. Thank You…