Factors Associated with Mortality and Amputation Caused by Necrotizing Soft Tissue Infections of the Upper Extremity: A Retrospective Cohort Study.

BACKGROUND: It is unclear what the exact short-term outcomes of necrotizing soft tissue infections (NSTIs), also known and necrotizing fasciitis of the upper extremity, are and whether these are comparable to other anatomical regions. Therefore, the aim of this study is to assess factors associated with mortality within 30-days and amputation in patients with upper extremity NSTIs. METHODS: A retrospective study over a 20-year time period of all patients treated for NSTIs of the upper extremity was carried out. The primary outcomes were the 30-day mortality rate and the amputation rate in patients admitted to the hospital for upper extremity NSTIs. RESULTS: Within 20 years, 122 patients with NSTIs of the upper extremity were identified. Thirteen patients (11%) died and 17 patients (14%) underwent amputation. Independent risk factors for mortality were an American Society of Anesthesiologists (ASA) classification of 3 or higher (OR 9.26, 95% CI 1.64-52.31) and a base deficit of 3 meq/L or greater (OR 10.53, 95% CI 1.14-96.98). The independent risk factor for amputation was a NSTI of the non-dominant arm (OR 3.78, 95% CI 1.07-13.35). Length of hospital stay was 15 (IQR 9-21) days. CONCLUSION: Upper extremity NSTIs have a relatively low mortality rate, but a relatively high amputation rate compared to studies assessing NSTIs of all anatomical regions. ASA classification and base deficit at admission predict the prognosis of patients with upper extremity NSTIs, while a NSTI of the non-dominant side is a risk factor for limb loss.

Complications and Factors Associated with Reoperation following Total Wrist Fusion.

Background Total wrist fusion can be elected to relieve pain in patients with osteoarthritis and rheumatoid arthritis. This study aimed to investigate the overall complications and the factors associated with reoperation and soft tissue complication after total wrist fusion. Methods We retrospectively identified adult patients who underwent total wrist fusion using Current Procedural Terminology (CPT) codes, International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) and verified these by medical chart review. We included patients ( n = 215) who were treated at a single institutional system from January 1, 2002 to January 1, 2019. The mean age was 53.3 ± 15.0 years and the median follow-up was 6.1 years (interquartile range [IQR] =1.7-9.0). The most common indications for wrist fusion included inflammatory arthritis ( n = 66, 31%), degenerative arthritis ( n = 59, 27%), and posttraumatic arthritis ( n = 47, 22%). All wrist fusions were performed using a dorsal fusion plate or dorsal spanning plate, either with a local autograft ( n = 167, 78%), iliac crest autograft ( n = 2, 1.0%), allograft ( n = 7, 3.3%), a combination of both ( n = 16, 7.4%), or without a graft ( n = 23, 11%). We performed a multivariable logistic regression to evaluate factors associated with reoperation. In addition, we performed a similar analysis to identify the factors associated with soft tissue complication after total wrist fusion. Results Forty-one (19%) patients underwent reoperation at a median of 6.9 months (IQR = 3.9-18). The indications included symptomatic implants ( n = 12, 27%), implant failures ( n = 8, 20%), infections ( n = 7, 17%), and nonunions ( n = 6, 15%). In multivariable analysis, total wrist fusion of the dominant hand (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.1-4.7, p = 0.033) was associated with a higher reoperation rate. Soft tissue complications occurred in 20 patients (9.3%) consisting of hematomas ( n = 8, 3.7%), observed blistering ( n = 5, 2.3%), and observed wound dehiscence ( n = 4, 1.9%). In multivariable analysis, smoking (OR: 2.5, CI: 0.95-6.4, p = 0.010) was independently associated with soft tissue complication after total wrist fusion. Seventy-two (33%) patients had a postoperative complication including symptomatic hardware ( n = 16, 7.4%), implant failure ( n = 11, 5.1%), infection ( n = 11, 5.1%), nonunion ( n = 8, 3.7%), and carpal tunnel syndrome ( n = 4, 1.9%). Conclusion Roughly one-third (33%) of the patients undergoing total wrist fusion experience a postoperative complication and 19% of the patients underwent a reoperation. Total wrist fusion of the dominant hand results in higher reoperation rates. The risk of a soft tissue complication after total wrist fusion is increased in smokers.