Type I, II Acute Necrotizing Fasciitis of the Low Extremity

Sang-Jun Song; In Seok Lee; Ju Hwan Chung

doi:10.4055/jkoa.2007.42.5.636

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Song, Lee, and Chung: Type I, II Acute Necrotizing Fasciitis of the Low Extremity

Original Article

Journal of the Korean Orthopaedic Association

Journal of the Korean Orthopaedic Association 2007; 42(5): 636-643.

Published online: 31 October 2007

DOI: https://doi.org/10.4055/jkoa.2007.42.5.636

Type I, II Acute Necrotizing Fasciitis of the Low Extremity

Sang-Jun Song, M.D., In Seok Lee, M.D.^*, Ju Hwan Chung, M.D.^*

Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea.

^*Department of Orthopedic Surgery, Pochon CHA University, Seongnam, Korea.

Address reprint requests to Sang-Jun Song, M.D. Department of Orthopedic Surgery, College of Medicine, Kyung Hee University, 1, Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea. Tel: +82.2-958-9489, Fax: +82.2-964-3865, songsjun@khmc.or.kr

Abstract

Purpose

To retrospectively analyze the clinical presentations, radiographic findings, and surgical results of type I and II acute necrotizing fasciitis of the low extremity.

Materials and Methods

From April 1998 to March 2005, 13 patients who underwent surgery for the necrotizing fasciitis were reviewed. At the initial diagnosis, 6 patients were diagnosed with cellulitis and 3 patients were diagnosed correctly with necrotizing fasciitis. The underlying diseases, affected sites, official readings of MRI, the intervals between the onset of symptom and surgery, the duration of admission, and complications were investigated.

Results

The underlying diseases were 3 cases of diabetes, 3 cases of liver disease, 1 case of alcoholism and 1 case of cervical cancer with chemotherapy. Regarding the location of the disease, 5 cases were observed below the knees, and 8 cases were observed above the knees. Five out of 9 cases who underwent a preoperative MRI study, were diagnosed correctly as necrotizing fasciitis by the radiologist. The average period between onset of symptoms and surgery was 4.8 days. The complications were hip disarticulation in 1 case, below knee amputation in 1 case, toe amputation in 1 case, and a limited range of motion of the knee joint in 1 case. The 9 patients who healed without complications had no limitation in the range of joint motion and daily activity.

Conclusion

Type I and II acute necrotizing fasciitis of the low extremity shows variable clinical presentations and radiological findings. Therefore, the possibility of the necrotizing fasciitis needs to be considered when dealing with patients with soft tissue infections in the low extremities.

Keywords: Low extremity, Necrotizing fasciitis

Figures and Tables

Fig. 1

The clinical photography of necrotizing fasciitis that developed on both low extremities show erythema, diffuse swelling and dusky skin color changes (arrow). The patient had rapid progression of the infection with migration of the margins of erythema and skin induration from the foot to thigh before surgery. The region of dusky skin color change (arrow) on the foot finally became necrotic and required a skin graft.

Fig. 2

Plain X-ray anteroposterior and lateral images of the left tibia show diffuse soft tissue edema with gas (arrow) lying on the fascia.

Fig. 3

T2-weighted axial and coronal MR images show diffuse edematous changes in the superficial and deep fascia and gas along the posteromedial aspect of the thigh.

Fig. 4

A 60-year old female had a hysterectomy 2 years ago, and was hospitalized with right leg pain, edema and fever. In the MRI images, necrotizing fasciitis was suspected by the radiologist but her illeness was clinically diagnosed as a unilateral leg lymphedema after the hysterectomy. She was spontaneously restored after conservative treatment.

Table 1

Summary of the Associated Diseases, Initial Diagnoses and Clinical Features of the Patients on Admission

Table 2

Complication Rate according to Time Interval between Admission and Surgery (Numbers)

^*Group A, Patients who underwent a fasciotomy, drainage and debridement within 48 hours from admission; ^†Group B, Patients who underwent a fasciotomy, drainage and debridement after 48 hours from admission.

Table 3

Complication Rate according to the Involved Extent of the Low Extremity (Numbers)

^*Group BK, Patients with lesions involving only the leg or foot in clinical and MRI findings; ^†Group AK, Patients with lesions involving the knee, thigh or buttock in the clinical and MRI findings.

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