Comparison of Traditional and Skin-Sparing Approaches for Surgical Treatment of Necrotizing Soft-Tissue Infections

Abstract

Background: A skin-sparing approach for the treatment of necrotizing soft-tissue infections (NSTIs) removes necrotic tissue planes while leaving viable overlying skin. Subsequent closure of the spared skin may decrease the need for graft-based reconstruction, which is associated with contracture, pain, and deformity. This study compared the outcomes of a traditional approach (excision of overlying skin with diseased fascia) with that of a skin-sparing approach for patients with NSTI treated at a major metropolitan medical center. Methods: Demographic, clinical, and operative details for patients treated for NSTI between July 2012 and December 2016 at a single institution were reviewed retrospectively. Pre-operative and post-operative photographs were evaluated independently by three surgeons to determine reconstructive outcomes. Cohen's κ was used to assess inter-rater reliability. Multiple regression and Poisson regression models were used to assess the association between outcomes and the surgical approach. Results: A total of 487 patients were divided into two cohorts: Traditional approach (TA), treated between July 2012 and December 2014 (n = 230), and skin-sparing approach (SS), treated after January 2015 (n = 257). The mortality rate in the two groups was equal at approximately 10%. The median percentage of each wound closed by skin graft was significantly lower for the SS group than for the TA group (20% versus 90%; p < 0.0001) with a correspondingly higher median percentage of primary skin closure for the SS group (50% versus 0; p < 0.0001). Conclusions: Relative to traditional debridement, skin-sparing debridement for source control of NSTI results in significantly more wounds closed completely by delayed primary suture of existing skin flaps and a significantly lower overall wound percentage closed by skin graft, while demonstrating equivalent efficacy of source control and a similar low mortality rate.