General principles

Even before antibiotics, military surgeons had shown that radical, mutilating surgery, involving amputation at the root of the limb or even disarticulation could save a patient's life if carried out early on before the infection spread. This attitude, which is prevails to this day80,81, is not without significant mortality not to mention the severe functional sequellae20.

Nowadays, with the development of antibiotic and HBO therapies, the approach has changed with surgery now being aimed at eliminating necrotic tissue and reducing oedema-related compression that exacerbates spread of the infection by reducing microcirculation and with that antibiotic penetration82.

Basic surgical procedure includes wide and early debridement with incisions to open up the sub-cutaneous tissue to reach the fascia, and opening all affected tissue planes until the hand meets resistance which means uncleaved tissue has bean reached4,5,20-22,28. With the exception of dramatic life-saving amputations in lieu of alternative therapy, initial surgery is not mutilating. Only necrotic tissue must be removed, while doubtful but possibly viable tissue may be left in place. This approach is justified when HBO is combined with surgery, because HBO will save much of the otherwise doubtful tissue.

Extensive rinsing with antiseptic solutions completes the surgical management and drainage is left in place - usually liberally so. Antiseptics should be chosen for their lack of general or local toxicity but with effectiveness against all suspected bacteria and spores so that there are no spectrum gaps with subsequent selective bacterial contamination. Solutions of povidone iodine or chlorhexedine are usually preferred. Extensive rinsing with hydrogen peroxyde is no longer recommended as it does not increase the local oxygen tension and it may cause severe complications83,84. Lastly the point of entry requires specific treatment.

After initial surgery, wounds must be checked several times a day - in our practice, every 8 hours during the first 5 days. A form of mini-surgery is provided: necrotic tissue is removed as necessary and the remaining inflammatory tissues are extensively rinsed with antiseptic solutions and extra drainage provided. When the tissues become healthier (usually in the 2nd week), dressings can be reduced until they are performed daily and support of healing replaces the emphasis on cleaning. To this day the surgical approach to these wounds remains inconsistent. Although the emergent need for it is widely accepted85, errors of judgement remain troublesome: In our study48, initial surgery was unsatisfactory in 8 cases out of 10, either because immediate further surgery was required due to too little debridement, or because of an overly aggressive approach with extensive resections and even amputations that were not clinically indicated.

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