Necrotizing fasciitis—why you should unlearn what you think you know

When it comes to severe soft tissue infections like necrotizing fasciitis, orthopedic surgeons are not usually the go-to experts. In many hospitals however, they are more likely than others to be called in to consult on patients with these potentially life-threatening conditions. That’s why Dr Iain McFadyen, an orthopedic trauma specialist at the University Hospitals of North Midlands in Stoke-on-Trent, United Kingdom, is calling on orthopedic surgeons to change their approach to these kinds of infections. Here, he shares the story of his most difficult case, an extraordinarily difficult surgery that ultimately became a career-affirming moment.

Bacterial skin and soft tissue infections are nothing much out of the ordinary. Conditions such as cellulitis, which is most commonly caused by group A streptococcus bacteria, often involve symptoms such as redness, swelling, or pain and are easily treatable with oral antibiotics.

However, in rare instances, cases that seem comparably manageable at first will rapidly deteriorate and develop into severe soft tissue infections. One example of these is necrotizing fasciitis, which you may have seen described in the media as flesh-eating bacteria. While the term may seem a little over the top, it is indeed quite a scary and horrific condition. It can spiral out of control very quickly and without specialized care, many patients with necrotizing fasciitis are likely going to die.

Interestingly, all over the world, it is orthopedic specialists who regularly find themselves being called in to consult on these kinds of conditions. The reason behind this is simple: in many hospitals, the surgeon who not only knows their way around limbs but is also most likely to be present at any given moment will often be an orthopedic consultant. So, when the acute medical team refers patients with aggressive and persistent soft tissue infections, they often land with us.

Soft tissue infections are obscure and dangerous

The problem is that as orthopedic surgeons, severe soft tissue infections are not really our bread-and-butter work. For most colleagues, I would assume that at best, life-threatening infections of this kind are at the periphery of their expertise. Come to think of it, I am not even sure that any surgeon could be called an out-and-out expert in this kind of infection, which after all is rather rare: even in big hospitals like the one I work for, only a handful of soft tissue infections each year will end up requiring surgical care.

But—and this is something I tell my residents over and over—we absolutely have to take those referrals seriously. We must try and get to the bottom of what the referring medics are worried about. Because if they call us in, they will have a very good reason to do so. They are not simply trying to offload cases. In fact, for every patient they refer, they will have seen 90 others that they do not. So, we must ask ourselves: what makes this one case so drastically different from the other 90 and how can we best help?

One of the main issues here is insecurity. I know that dealing with these relatively obscure infections can make some colleagues feel slightly apprehensive. But even the slightest resistance will open the door to them not getting it right. The fact that we get referrals from other teams and are not necessarily primarily responsible only aggravates the problem. I would like to describe how I have worked at overcoming that and why I think it is so important.

Expectations can be misleading

The case study I am about to describe is at the extreme end of the spectrum. But it is completely within the realm of what is possible. A few years ago, I was called in to consult on the case of a 41-year-old woman who was decidedly fit and healthy. She was not diabetic, her immune system was sound, she was not on radiation or chemotherapy, and she took neither steroids nor intravenous drugs. There were no major medical issues running in her family. In short, this was not the kind of patient you would expect this in. But expectations can be misleading, which is why it is patients like these that scare me the most.

According to the woman, her entire family including herself had at some stage in the preceding weeks had a strep sore throat. Just when she thought she was getting better, she began developing a pain in her calf. By the time she saw her family physician, the pain had become intense. But except for a little bit of pink discoloration, the calf looked normal. The doctor reasonably diagnosed her with cellulitis and prescribed oral antibiotics.

A few days later however, the patient felt worse. In her own words she felt simply terrible, like she had the worst flu imaginable. She went to the emergency room, where she was diagnosed with cellulitis once again. She was admitted to the hospital and put on intravenous penicillin. She was also given the usual range of lab tests that you would expect in a case like this.

Rapid deterioration and systemic toxicity

When the results came back, they did not look good at all: the patient had rising blood lactate levels as well as some organ dysfunction. Also, her kidneys were no longer working as they should. In short, she was showing systemic toxicity. The medical team made the right call at this point and requested an orthopedic consultant. And although this consultant did indeed take it seriously, they unfortunately decided that to them, it did not look like necrotizing fasciitis.

As a result, the patient remained under the supervision of the medics. However, overnight, things took a turn for the worse: the patient systemically crashed. She was admitted to the intensive treatment unit (ITU), intubated, and ventilated. She was also put on maximum inotropes in order to support her heart.

The following morning, I was called in to see her. I quickly recognized that something was going on in her calf: it was swollen, and there was a little patch of redness. It did not look too dramatic, but I knew we were in trouble—all her organs were failing, and plainly, the patient was dying.

It was way too late at this point to obtain imaging. We knew that if we were going to save this woman’s life, we would have to act quickly, and that we would have to start with the place where her problems had started. I was fairly confident that I could alleviate things surgically. Of course, I did not know exactly what was going on. But I knew that the cause of her systemic failure was in her leg. So, we decided to open up the calf and check for necrotic tissue as well as puss needing to be released.

We were able to get the patient into an emergency operating theater around three or four hours later. By that time—and this is a very stark illustration of how rapidly necrotizing fasciitis can develop—her leg had deteriorated considerably. Only a few hours before, there had been a small patch of redness on the calf, entirely below the knee. The difference between then and what I was looking at now gave me a profound scare.

When it comes to severe soft tissue infections like necrotizing fasciitis, orthopedic surgeons are not usually the go-to experts. In many hospitals however, they are more likely than others to be called in to consult on patients with these potentially life-threatening conditions. That’s why Dr Iain McFadyen, an orthopedic trauma specialist at the University Hospitals of North Midlands in Stoke-on-Trent, United Kingdom, is calling on orthopedic surgeons to change their approach to these kinds of infections. Here, he shares the story of his most difficult case, an extraordinarily difficult surgery that ultimately became a career-affirming moment.

Bacterial skin and soft tissue infections are nothing much out of the ordinary. Conditions such as cellulitis, which is most commonly caused by group A streptococcus bacteria, often involve symptoms such as redness, swelling, or pain and are easily treatable with oral antibiotics.

However, in rare instances, cases that seem comparably manageable at first will rapidly deteriorate and develop into severe soft tissue infections. One example of these is necrotizing fasciitis, which you may have seen described in the media as flesh-eating bacteria. While the term may seem a little over the top, it is indeed quite a scary and horrific condition. It can spiral out of control very quickly and without specialized care, many patients with necrotizing fasciitis are likely going to die.

Interestingly, all over the world, it is orthopedic specialists who regularly find themselves being called in to consult on these kinds of conditions. The reason behind this is simple: in many hospitals, the surgeon who not only knows their way around limbs but is also most likely to be present at any given moment will often be an orthopedic consultant. So, when the acute medical team refers patients with aggressive and persistent soft tissue infections, they often land with us.

Soft tissue infections are obscure and dangerous

The problem is that as orthopedic surgeons, severe soft tissue infections are not really our bread-and-butter work. For most colleagues, I would assume that at best, life-threatening infections of this kind are at the periphery of their expertise. Come to think of it, I am not even sure that any surgeon could be called an out-and-out expert in this kind of infection, which after all is rather rare: even in big hospitals like the one I work for, only a handful of soft tissue infections each year will end up requiring surgical care.

But—and this is something I tell my residents over and over—we absolutely have to take those referrals seriously. We must try and get to the bottom of what the referring medics are worried about. Because if they call us in, they will have a very good reason to do so. They are not simply trying to offload cases. In fact, for every patient they refer, they will have seen 90 others that they do not. So, we must ask ourselves: what makes this one case so drastically different from the other 90 and how can we best help?

One of the main issues here is insecurity. I know that dealing with these relatively obscure infections can make some colleagues feel slightly apprehensive. But even the slightest resistance will open the door to them not getting it right. The fact that we get referrals from other teams and are not necessarily primarily responsible only aggravates the problem. I would like to describe how I have worked at overcoming that and why I think it is so important.