Surgical Strategies: Necrotizing Fasciitis of the Foot and Ankle Treated With Dermal Regeneration Matrix for Limb Salvage

Abstract

Although necrotizing fasciitis is a life-threatening entity that needs expeditious treatment, cases involving the lower extremity are less commonly encountered than in the upper extremity. Surgical intervention is often required and likely lead to amputation (below-knee or above-knee) vs debridement in the lower extremity. Coverage options in the foot and ankle after serial debridements can present many challenges for limb salvage. Patients are often left with large soft tissue defects requiring coverage with a subsequent increase in relative morbidity. Treatment options for coverage in these cases include negative-pressure wound therapy, split-thickness skin grafting, free flap coverage, or higher-level amputation. In the diabetic population, who present with a lower extremity necrotizing infection, limb salvage is often a challenge given the multiple comorbidities associated with these patients including peripheral vascular disease, immunocompromised state, and neuropathy. Optimal treatment strategies for these necrotizing infections in the foot and ankle remain uncertain. We offer a technique tip for utilization of a dermal regeneration matrix to allow coverage of large soft tissue defect with exposed tendon and/or bone without the need for free flap coverage or higher-level amputation, thus allowing for an additional limb salvage option. Level of Evidence: Level V, expert opinion.

The use of xenogenic dermal matrices in the context of open extremity wounds: where and when to consider?

“…20 Another consideration is accounting for patient allergies to bovine, chondroitin, and silicone, which can cause a local inflammatory reaction which would be counterproductive to wound healing. 23 Traumatic wound management often requires creative and innovative coverage strategies. Acellular dermal matrices are a helpful tool to accelerate wound healing and can also be considered in dire or salvage situations.…”

“… 20 Another consideration is accounting for patient allergies to bovine, chondroitin, and silicone, which can cause a local inflammatory reaction which would be counterproductive to wound healing. 23 …”

Necrotizing Fasciitis: Evaluation of 85 Cases and Usage of LRINEC Score

“…In diabetic patients, it is a problem to perform extremity protective surgery in necrotizing infections of the lower extremity, given morbidities such as peripheral artery disease, immunosuppression and neuropathy. In these patients, high-level amputation or flap applications covering the large soft tissue defect with tendons and bone can be reduced with the use of the dermal regeneration matrix recommended by Narayanan and his friends ( 16 ). In our study 15 (18%) cases had undergone amputation and none of them died.…”

A Case of Necrotizing Fasciitis in an Uncontrolled Diabetic Alcoholic with a Small Untreated Wound

“…In this case, the patient did not control blood sugar for 4 years, as seen by the increased blood sugar test (339) and HbA1c (13.2%). sure has been employed as supplemental therapy for large and complex wounds to lessen both functional and cosmetic downsides [9]. Dermal substitutes, such as Alloderm TM , can also be utilized to achieve early wound coverage following excision of full-thickness skins.…”