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Factors Associated With Progression to Amputation in Upper Extremity Necrotizing Fasciitis
Deng Pan, MD, PhD
1, Sophia Chryssofos, BS
2, Andrea Biaggi-Ondina, MD
3, Fox K Ida, MD
4; Amy Kells, MD PhD
5(1)Washington University School of Medicine, St. Louis, MO, (2)WashU, St. Louis, MO, (3)Washington University, St. Louis, MO, (4)Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, (5)Washington University, St Louis, MO
Purpose: Necrotizing soft tissue infection (NSTI) of upper extremity (UE) is devastating. Surgical management of NF includes extensive debridement but may also require amputation. The decision to amputate is difficult and must balance preservation of function with prevention of mortality. Pre-operative clinical information may guide subsequent management but current literature on this subject is limited. The goal of this study was to see if any lab markers and outcomes were different across clinical management strategies.
Methods: We retrospectively reviewed the electronic medical record of patients suspected of NSTI who underwent surgical management at a level 1 trauma hospital from 2015-2025. A total of 59 patients with NSTI were reviewed. We compared those with underwent debridement only as surgical treatment to those who eventually underwent amputation.
Results: There is no difference between gender, age, ethnicity, or intravenous drug use between those who underwent debridement only to those who eventually underwent amputation. Prior to debridement, Patients with UE NSTI who did not undergo amputation had WBC 15.3, compared to the WBC of 18.5 among those who underwent any type of amputation (p = 0.212). After the initial debridement, patients who did not require amputation had a post-debridement WBC of 15.0 compared to 21.8 among those who subsequently underwent amputation (p=0.006). Similarly, those who did not undergo amputation had Serum sodium (Na) of 134.6, vs 131.7 of those who underwent amputation (p = 0.133). Post debridement of Na those who did not undergo amputation was 136.8 vs 132.3 for those who underwent amputation (p=0.0041). There was no difference for serum creatine, serum glucose or CRP for in these two groups either prior or after initial debridement. For microbiology, culture isolated from those who underwent amputation were more likely to have mixed microbes (73% vs 38.5%, p = 0.0174), and more likely to have non-pseudomonal gram negative bacteria (33.3% vs 5.1%, p=0.0126).
Conclusions: For upper extremity NSTI, elevated WBC and low Na post debridement are associated with increased odds of progression to amputation. Microbiology of those who eventually underwent amputation is more likely to show mixed microbiology and non-pseudomonal gram negative bacteria. Our study demonstrates the importance of laboratory values after initial debridement in predicting outcomes of upper extremity NSTIs.
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