Managing Necrotizing Soft Tissue Infections of the Lower Limb: Microsurgical Reconstruction and Hospital Resource Demands-A Case Series from a Tertiary Referral Center

Abstract

Background: Necrotizing soft tissue infections (NSTIs) of the lower extremities represent a surgical emergency with high morbidity, complex reconstruction, and considerable healthcare demands. Free tissue transfer (FTT) is increasingly utilized for limb salvage in extensive soft tissue defects, yet its implications for hospital resource utilization remain unclear. This study aims to compare clinical outcomes and perioperative resource demands between FTT and local flap (LF) reconstruction in NSTI patients. Methods: A retrospective case series was conducted at a tertiary referral center between September 2022 and January 2025, including eight patients with NSTI of the lower extremity (FTT, n = 4; LF, n = 4). Demographic data, comorbidities, surgical timing, complication profiles, and resource utilization metrics-including operative duration, hospitalization length, and number of procedures-were analyzed. All FTT cases underwent preoperative CT angiography as part of institutional protocol. Results: Mean time to definitive reconstruction was longer in the FTT group (17.25 vs. 8 days, p = 0.15), reflecting staged infection control. FTT procedures demonstrated significantly longer operative times (331.75 vs. 170.25 minutes, p = 0.015), but there was no significant difference in total hospital stay (34.75 vs. 27.71 days, p = 0.65). No cases of flap loss or venous congestion were observed, and outcomes were optimized via delayed dangling protocols. Conclusions: FTT is a viable and effective reconstructive modality for lower extremity NSTIs. Despite increased surgical complexity, FTT did not significantly increase hospital resource utilization, supporting its role in limb preservation among appropriately selected patients.

Keywords: anterolateral thigh flap; dangling protocol; free tissue transfer; hospital length of stay; infection control; latissimus dorsi flap; limb salvage; local flaps; lower extremity reconstruction; microsurgical limb reconstruction; microsurgical reconstruction; multimodal analgesia; necrotizing fasciitis; necrotizing soft tissue infections; pain management; postoperative rehabilitation; regional anesthesia; retrospective case series; soft tissue defects; surgical debridement; surgical outcomes; surgical resource utilization; wound healing.

Figure 1

A 35 y.o. M developed necrotizing soft tissue infection of the left lower extremity following an elective endoscopic repair of torn anterior cruciate ligament of the knee. After multiple debridement, he had a circumferential wound spanning from the distal thigh to the ankle with exposed critical structures necessitating soft tissue reconstruction.

Figure 2

Post-operative appearance of wound 8 months following reconstruction. A musculocutaneous anterolateral thigh (ALT) flap was used (36 × 11 cm skin island and 16 × 6 cm vastus lateralis muscle) to cover the exposed bony structures of the knee and leg, while the posterior aspect of the leg was covered with a split thickness skin graft. At the time of the last follow-up (8 months), the patient had already returned to playing sports and was able to resume all his regular daily activities.