Differentiating necrotizing soft tissue infections from cellulitis by soft tissue infectious fluid analysis: a pilot study

Background We conducted this study to evaluate the characteristics of the infectious fluid in soft tissue infection and investigate the utility of the biochemical tests and Gram stain smear of the infectious fluid in distinguishing necrotizing soft tissue infection (NSTI) from cellulitis. Methods This retrospective cohort study was conducted in a tertiary care hospital in Taiwan. From April 2019 to October 2020, patients who were clinically suspected of NSTI with infectious fluid accumulation along the deep fascia and received successful ultrasound-guided aspiration were enrolled. Based on the final discharge diagnosis, the patients were divided into NSTI group, which was supported by the surgical pathology report, or cellulitis group. The t test method and Fisher’s exact test were used to compare the difference between two groups. The receiver–operator characteristic (ROC) curves and area under the ROC curve (AUC) were used to evaluate the discriminating ability. Results Total twenty-five patients were enrolled, with 13 patients in NSTI group and 12 patients in cellulitis group. The statistical analysis showed lactate in fluid (AUC = 0.937) and LDH in fluid (AUC = 0.929) had outstanding discrimination. The optimal cut-off value of fluid in lactate was 69.6 mg/dL with corresponding sensitivity of 100% and specificity of 76.9%. The optimal cut-off value of fluid in LDH was 566 U/L with corresponding sensitivity of 83.3% and a specificity of 92.3%. In addition, albumin in fluid (AUC = 0.821), TP in fluid (AUC = 0.878) and pH in fluid (AUC = 0.858) also had excellent diagnostic accuracy for NSTI. The Gram stain smear revealed 50% bacteria present in NSTI group and all the following infectious fluid culture showed bacteria growth. Conclusions The analysis of infectious fluid along the deep fascia might provide high diagnostic accuracy to differentiate NSTI from cellulitis.

Reliability of Shear Wave Elastography for the Assessment of Gastrocnemius Fascia Elasticity in Healthy Individual

The mechanical properties of deep fascia (i.e. an index of stiffness) strongly affect the development of muscle pathologies, and muscular actions, such as compartment syndromes. Actually, a clear understanding of the mechanical characterization of muscle deep fascia still lacks. The present study focuses on examining the reliability of ultrasonic shear wave elastography device (USWE) in quantifying the shear modulus of gastrocnemius fascia in healthy individual and the device’s abilities to examine the shear modulus of gastrocnemius deep fascia during ankle dorsiflexion. Twenty-one healthy males participated in the study (age: 21.48±1.17 years). The shear modulus of the medial gastrocnemius fascia (MGF) and lateral gastrocnemius fascia (LGF) were quantified at different angles using USWE during passive lengthening. The operators took turns to measure each subject’s MGF and LGF over 1-hour period and by operator B with a 2-hour interval. In the intra-operator test, the same subjects participated at the same time 5 days later. The intra-rater [ Intra-class correlation coefficient (ICC) = 0.846-0.965)] and inter-rater (ICC = 0.877-0.961) reliabilities for measuring the shear modulus of the MGF and LGF were rated as both excellent, and the standard error in measurement (SEM) was 3.49 kPa, the minimal detectable change (MDC) was 9.68 kPa. Regardless of the ankle angle, the shear modulus of the LGF were significant greater than that of the MGF (p < 0.001). The significant increase in the shear modulus both of the MGF and LGF were observed at neutral position compared to the relaxed position. This results indicate that the USWE is a technique to assess the shear modulus of gastrocnemius fascia and detect its dynamic changes during ankle dorsiflexion. USWE can be used for biomechanical study and intervention experiments of deep fascia.

The Use of Color Duplex Ultrasound for Local Perforator Flaps in the Extremity

Background The local flaps, especially perforator and keystone flaps, are used as first-line treatment option in reconstruction of small tomoderate-sized defect of the extremity. However, the high complication rate associated with these flaps may hinder this usage. Methods This article reviews the technical and clinical aspect of using color duplex ultrasound )CDU) in the preoperative, intraoperative, and postoperative period for propeller and keystone flaps. Results CDU allows the surgeon to understand the anatomical aspect of the perforator such as the location, point of penetration on the deep fascia, subcutaneous pathway )axiality) and physiological aspect such as velocity and flow volume. Understanding and utilizing this information will allow accurate preoperative design, intraoperative decision making, and postoperative monitoring, leading to better outcome. Conclusion Carefully designed local perforator flaps based on anatomy and physiology using CDU will be a powerful armamentarium for reconstruction of the lower extremity.

PREDISOPSING FACTORS; MANAGMENT AND OUTCOMES OF NECROTIZING FASCITIS Among patients who admitted to surgical ward at Al-Thawra hospital; January 2020 to January 2021: العوامل المسببة؛ إدارة ونتائج التفتت الناخر؛ لدى عينة من المرضى في قسم الجراحة بمستشفى الثورة بصنعاء

Background: Necrotizing fasciitis is a serious infection of skin and soft tissues that rapidly progresses along the deep fascia. It’s a fatal infection with high mortality if treatment delayed. Early diagnosis, surgical debridement and broad-spectrum antibiotic therapy are the optimal treatments to reduce the mortality. Objective: The aims were to identify risk factors for Necrotizing fasciitis and to describe the outcome of management. Methods: A prospective descriptive study was conduted at AL-THAWRA HOSIPTAL located in Sana’a, Yemen. All medical records of patients with confirmed NF who admitted to surgical department between January 2020 and January 2021 were reviewed. Results: The study enrolled 54 patients diagnosed with Necrotizing fasciitis. Male patients were 43 patients (79.6%) and female patients were 11 patients (20.3%). The age rang was 9 – 75 years old and the peak age incidence was at 46–60 years (33.3%). The incidence of NF increases with aging, male gander (79.6%), in comorbid patients (64.9%) especially DM (37%). The etiologies of NF were trauma in (16.6%) and perianal abscess in (14.8%), but (27.7%) of NF patients hadn’t specific cause. The defected wound was treated by skin graft in (32.5%) and primary closure in (27.5%). The mortality rate was (27.7% n=15); (60%) of them died on first 5 days. Septic shock was the reason of death in (73.2%). The higher mortality rate was seen at male gander (66.6%), age group > 60 years (46.6%), in patients who presented in shocked state (73.3%) and in comorbid patients (73.3%). Conclusion: Necrotizing fasciitis represents a life threatening condition with challenges in diagnosis. Incidence and mortality of NF are common in male gander, an elderly patient, or in who suffers of comorbidities; especially DM.

Septicaemia in pregnancy: a case report

Necrotizing fasciitis (NF) is a rare, life-threatening surgical infection in pregnancy with high rates of morbidity and mortality. It is a severe, potentially fatal infectious disease which rapidly extends from the subcutaneous tissue along the superficial and deep fascia causing vascular occlusion, ischemia, and necrosis of tissues. A 30-year-old gravida 2 para1 living 1 woman, at 32 weeks of gestation with previous caesarean section and recently diagnosed diabetes, hypertension was admitted to our hospital with signs and symptoms of severe sepsis with pruritic black lesions over abdomen and perineum. Patient was in a morbid state in our hospital. During clinical examination, fetal heart sound was not localised suggestive of intrauterine fetal demise (IUFD), with ulcerative lesions over abdomen and vulva. Patient was immediately taken for surgical intervention and was suggestive of ruptured uterus with extrusion of fetus in abdominal cavity with cellulitis of abdominal and vulva. During initial laboratory examinations, diabetes mellitus was diagnosed. Patient was kept on ventilatory support and was vitals were stabilised. Multidisciplinary therapy with immediate aggressive surgical debridement of necrotic tissues, multiple antibiotics, and intensive care monitoring was performed successfully. The patient’s postoperative course was uncomplicated and skin defect healed by second intention of healing. The following case emphasized the potential immunosuppressive role of pregnancy state in conjunction with diabetes mellitus in the development of severe necrotizing soft tissue infections.

Treatment of the hidden penis in boys

Introduction. “Hidden penis” (HP) is a developmental malformation of the penis characterized by normally developed, but abnormally located cavernous bodies in the surrounding tissues of the symphysis or scrotum, manifested by the visually shortened penis trunk. The most common type is «buried» penis (BP). This pathology requires, as a rule, surgical treatment.Purpose. To assess outcomes of BP treatment with an improved surgical technique.Material and methods. 40 boys, aged from 2 to 16 (average age 9 ± 1.59) and diagnosed with HP, were treated in 2014-2019. BP was diagnosed in 35 children (87.5%), webbed penis (WP) – in five (12.5%). Primary BP was in 18 children (51.4%) and BP in combination with the suprapubic obesity - in 17 patients (48.6%). Two children (5%) were operated after the previous circumcision. Indications for surgery were: congenital primary HP, secondary HP in adolescents with insufficient visualization of the penis, psychological discomfort of the patient and the absence of significant clinical effects after conservative care. The average age of children with primary HP was 3.9 ± 2.48; with secondary HP and pubic obesity - 12 ± 3.84 years. During surgery, circular or circular and ventral midline incisions to the middle of the scrotum were used; they were followed by mobilization of the penis from adhesions, excision of adipose tissue in the bosom, fixation of the pubopenile and penoscrotal angles with a non-absorbable surgical thread. The authors have proposed a new technique for foreskin fixation using 2 ventral and 2 dorsal incisions, through which the skin was sutured to the deep fascia of the penis to prevent its distal slipping.Results. All patients had good anatomical and functional results. The authors describe the developed surgical technique in details; they also make literature review on the discussed problem.Conclusion. In the treatment of HP an improved surgical technique with the additional use of incisions allows you to reliably fix the skin of the foreskin on the trunk of the penis, avoiding its distal displacement.

Fournier’s gangrene in females: A rare entity

Fournier’s gangrene is a form of necrotizing fascitis with abrupt onset of rapidly fulminating genital gangrene of idiopathic origin and gangrene up to deep fascia. It occurs usually in patients with urogenital infections and comorbidities such as diabetes, immunosuppression, or even trauma. Here, we present one such case of an 86-year-old female presenting with a history of pain and purulent discharge from the perianal region for 5 days. On examination, a wound of 20 × 15 cm perineal region extending up to the gluteal region posteriorly and labia majora anteriorly. The patient was planned for debridement under spinal anesthesia on an emergency basis followed by regular dressing and antibiotic therapy. The peri-operative period was uneventful. Along with surgical management, the patient was managed medically by control of sugars, treating sepsis with appropriate antibiotics. The patient recovered from sepsis, and the wound showed granulation tissue after 1 week of serial debridement. The wound was closed with a skin graft at a later date. Fournier’s gangrene should be kept as a differential diagnosis in females with perineal abscesses or necrotizing fascitis in females.

Is “Delayed Onset Muscle Soreness” a False Friend? The Potential Implication of the Fascial Connective Tissue in Post-Exercise Discomfort

Strenuous and unaccustomed exercise frequently lead to what has been coined “delayed onset muscle soreness” (DOMS). As implied by this term, it has been proposed that the associated pain and stiffness stem from micro-lesions, inflammation, or metabolite accumulation within the skeletal muscle. However, recent research points towards a strong involvement of the connective tissue. First, according to anatomical studies, the deep fascia displays an intimate structural relationship with the underlying skeletal muscle and may therefore be damaged during excessive loading. Second, histological and experimental studies suggest a rich supply of algogenic nociceptors whose stimulation evokes stronger pain responses than muscle irritation. Taken together, the findings support the hypothesis that DOMS originates in the muscle-associated connective tissue rather than in the muscle itself. Sports and fitness professionals designing exercise programs should hence consider fascia-oriented methods and techniques (e.g., foam rolling, collagen supplementation) when aiming to treat or prevent DOMS.

Descending necrotizing mediastinitis due to an odontogenic infection: A case report

Descending necrotizing mediastinitis a clinical entity formed by the spreading of cervical infection from the dental and oropharyngeal structures through the deep cavities between the deep fascia on the neck to the mediastinum, pleural and pericardial spaces with necrosis of soft tissue and has a high mortality. Herein we present the case of a 73-year-old admitted to emergency department with septic clinic. The patient was diagnosed with descending necrotizing mediastinitis due to odontogenic infection. Although sternal irrigation, sternal debridement and mediastinal drainage were performed patient was died postoperative third day.