Evolution of Technology

Negative Pressure Wound Therapy (NPWT)

Negative pressure wound therapy (NPWT) is a method of soft-tissue injury treatment in which an impervious dressing is applied to skin or soft tissue, and then connected to a vacuum-generating device. Research has demonstrated decreased rates of infection, increased rates of healing, and fewer subsequent surgeries when NPWT is used in the setting of open fractures, infection, or extensive soft-tissue loss. Traditionally, NPWT required the use of large, immobile vacuum-generating devices, which often could not leave the hospital. This leads to increased cost to patients, and often served as a barrier to discharge or de-escalation of care-level.

Amputation sites following necrotizing soft tissue infections are often left open, or loosely closed, for eventual definitive closure. Uncertainty of extent of infection, profound local edema and soft tissue swelling, and impaired patient healing factors are all factors which often lead surgeons to delay primary closure. Negative pressure wound therapy (NPWT) has become the mainstay of treatment when delayed primary closure is utilized. Research has demonstrated a proven effect on NPWT’s ability to decrease local swelling and edema, decrease spread of infection, and promote healing factor migration to local areas. Owing to the fact that most patients with NSTIs spend prolonged periods of time in the hospital, portability of NPWT is not of paramount important. Rather, strength of suction and dressing availably moves to the forefront as the most important variables.

Evolution of Procedure

Below Knee Amputation

Necrotizing fasciitis of the lower extremity is often secondary to rapid progression of a prior diabetic foot ulcer. Poor patient healing capabilities when combined with impaired sensation and high levels of blood glucose create an environment ripe for overwhelming infection. Necrotizing soft tissue infections spread rapidly and without pause, and can lead to rapid onset of septic shock, hemodynamic collapse and death. Initial treatment is removal of infection which, in the case of lower extremity infections, is amputation. For progressive foot infections, below-knee, trans-tibial amputations allow for both source control, and for minimization of eventual oxygen consumption increase

Evolution of Diagnosis

Necrotizing Soft Tissue Infections (NSTI)

Necrotizing Soft Tissue Infections (also known as necrotizing fasciitis) are deadly, rapidly progressive, soft-tissue infections which, if untreated, are universally fatal. Due to the rate of expansion, and often unrealized extent of disease at presentation, amputation is usually the mainstay of treatment for necrotizing fasciitis of the extremities. While definitive closure is always the goal, oftentimes patients are subjected to multiple surgeries prior to their definitive amputation level is reached.