Limb salvage after gas gangrene: a case report and review of the ...

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28WORLD JOURNAL OFEMERGENCY SURGERYREVIEWOpen AccessLimb salvage after gas gangrene: a case reportand review of the literatureJohn Aggelidakis 1† , Konstantinos Lasithiotakis 2† , Anastasia Topalidou 1,3 , John Koutroumpas 1 , Georgios Kouvidis 1and Paulos Katonis 1*AbstractGas gangrene is a necrotic infection of soft tissue associated with high mortality, often necessitating amputation inorder to control the infection. Herein we present a case of gas gangrene of the arm in an intravenous drug userwith a history of intramuscular injections with normal saline in the shoulder used to provoke pain for recovery afterdrug induced coma. The patient was early treated with surgery and antibiotics rendering possible the preservationof the limb and some of its function. Additionally, a review of the literature regarding case reports of limb salvageafter gas gangrene is presented.BackgroundGas gangrene or Clostridial myonecrosis is a necroticinfection of skin and soft tissue and it is characterizedby the presence of gas under the skin which is producedby Clostridium. It is a potentially lethal disease whichspreads quickly in soft tissues of the body. Tissue necrosisis due to production of exotoxins by spore forminggas producing bacteria in an environment of low oxygen.Gas gangrene is subclassified in two categories.Traumatic or postoperative is the most common formaccounting for 70% of the cases followed by spontaneousor non traumatic gangrene. C. perfringens is isolatedin approximately 80% of patients presenting withtraumatic gas gangrene followed by C.septicum, C.novyi,C.histolyticum, C.bifermentans, C.tertium and C.fallax[1-3]. Herein we report a case of gas gangrene whichwas treated early with surgical debridement and enabledsalvage of the limb with significant preservation of itsfunction. Additionally, a review of the literature regardingcases of limb salvage after gas gangrene is presented.Case PresentationA 35-year-old Caucasian man with a history of chronicintravenous drug use presented to the emergencydepartment with right upper limb pain and swelling* Correspondence: kwstaslasith@yahoo.gr† Contributed equally1 Department of Orthopaedic Traumatology, University Hospital of Heraklion,Voutes, Heraklion, 71100, GreeceFull list of author information is available at the end of the articlelasting 24 hours. His initial vital signs were notable fortemperature of 39°C, respiratory rate of 25 breaths perminute, heart rate of 120 beat per minute and bloodpressure of 141/76 mmHg. He was distressed and onclinical examination severe edema of the upper limb,erythema, blistering of the arm and crepitus over theshoulder and arm was noted [Figure 1a]. At this time,motor and sensory function of the limb was notimpaired and pulses of the radial and ulna artery couldbe palpated. His past medical history consisted of adiagnosis of hepatitis C. Intramuscular injections withnormal saline in the shoulder were also reported. This isa practice among illicit drug users used to provoke painfor recovery after drug induced coma.Blood counts showed a white blood cell count of 10.7K/μL (normal range 3.5-10.0 K/μL) (88.6% neutrophils,6.9%lymphocytes, 0.1%monocytes), hemoglobulin 13.6 g/dl (normal range 14-18 g/dl), platelet count 161 K/μL(normal range 150-450 K/μL). His creatinine phosphokinasewas elevated at 3594 IU/L (normal range 40-148U/L), c-reactive protein was elevated at 7.29 mg/dl (normalrange < 1 mg/dl) and SGOT/SGPT were two timesabove higher normal limits. His electrolytes and coagulationprofile were within normal limits.An X-ray of the affected limb revealed gas in soft tissuessuggestive of gas gangrene [Figure 1b]. Empiricalbroad spectrum antibiotic treatment was immediatelyinitiated consisting of piperacillin/tazobactam, clindamycinand vancomycin in usual dosages. Within one hourswelling of soft tissues was expanded to the forearm and© 2011 Aggelidakis et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28Page 2 of 7Figure 1 Gas gangrene in an illicit drug user. a. One and halfhours after his admission in the emergency department. b. X-ray ofthe affected limb revealing gas in soft tissues.neck medially [Figure 2a]. The general condition of thepatient was worsening with severe pain and hoarsenessand he was intubated due to threatened airway. Withintwo hours since his admission, the patient was guided tothe operating theater and underwent arm and forearmfasciotomy due to threatening compartment syndromeand broad surgical debridement and drainage of theinfected areas. A Henry type anterior shoulder incisionwasusedfromtheanteriordeltoidmuscletotheforearmwith division of the transverse carpal ligament.Extended subcutaneous emphysema was noted, withfoul smelling areas of necrosis in most of biceps brachiiand the flexors of the forearm. Broad resection of necrotictissues of arm and forearm was done. Thoroughmechanical irrigation of the affected area was performedusing normal saline, hypertonic solutions and the Strykerirrigation-suction device. Approximating tensionsutures were used and the wound was let to be healedby third intention [Figure 2b]. Subsequently the patientwas transferred to the intensive care unit. Cultures oftissue specimens obtained intraoperatively revealed Staphylococcusepidermidis, Clostridium perfringens andStaphylococcus aureus.Postoperatively the patient remained in the intensivecare unit intubated and in septic shock. The first postoperativeday he developed acute renal failure attributedto myoglobinuria requiring hemodialysis. The secondpostoperative day his platelet count was decreased to45Κ/μL and increased gradually the following days.According to the results of antibiogram meropenem 1gr 12 hourly was administered the 3 rd postoperative day.Daily surgical debridement with resection of additionalnecrotic tissue was performed in the intensive care unit.His temperature returned to normal on postoperativeday 10 and his general condition was graduallyimproved thereafter. He was discharged from the intensivecare unit on postoperative day 30. In the orthopedicward he remained afebrile and his wound was progressivelyhealing with granulation of the tissue and regressionof the foci of necrotic infection [Figure 2c]. Bloodsupply of the limb was adequate. However, significantFigure 2 Surgical treatment of gas gangrene with preservationof the affected limb. a. Intraoperative figure showing necrosis ofsignificant proportions of biceps brachii and the flexors of theforearm. b. Approximating sutures after broad resection of necrotictissues of arm and forearm. c. Postoperative day 50: Healing withgranulation of the tissue. d. Four months postoperatively:Restoration of skin deficits with the use of free skin flaps.motor and sensor neural deficits of the radial and ulnarnerve were noted. Limb physiotherapy was administeredon daily basis. Four months postoperatively, skin deficitswere restored with the use of free skin grafts from thefemoral region [Figure 2d]. At this time flexure andextension of the elbow and shoulder against gravity waspossible along with minimal active movement of thewrist and fingers.Review of cases reported in the literatureThis review included Medline reported adult cases oflimb salvage following gas gangrene (clostridial myonecrosis)until June 2011. Only articles in the English

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28Page 3 of 7language, with reported culture results, in which limbsalvage was attempted and the outcome of that attemptwas clearly indicated were included. Data extracted fromeach article included age, gender, relevant and generalhistory, previous diagnoses, infection location, clinicalpresentation, antimicrobial treatment, surgical treatment,complications of the infection, duration of hospitalizationand functional outcome.We identified eleven cases which are presented inTable 1. There were two cases of multimicrobial myonecrosis(clostridia in combination with Gram positivecocci). Males dominated in this sample consisting 90%of total. Conditions related with clostridial myonecrosiscould be broadly classified as posttraumatic (n = 3, postoperative,after injury or intravenous use of illicit drugs)and related with gastrointestinal disease (n = 6, coloncancer, chronic pancreatitis). Gastrointestinal disease,especially colon cancer, was invariably associated withC. septicum infection. Diabetes mellitus was present inthree cases. Lower limb, particularly thigh was the mostcommon anatomical site of the infection. In most of thecases the duration of symptoms before admission didnot exceed two days. One patient reported by Kershawet al [4] experienced pain lasting 6 days prior to admissionwhich is considerable higher compared with therest of the patients. Clinical presentation involved painlocalized in the affected limb (90%), fever (70%) and crepitus(45%). Other presenting symptoms included swelling,discoloration, induration of the affected limb,tenderness, stiffness of involved joints, abdominal pain,nausea and vomiting.All patients underwent wide surgical debridement ofthe affected area and were administered antimicrobialtreatment. Three out of eleven patients underwent atleast a second wound debridement after initial operation[5-7]. A detailed list of antimicrobial regimens used inthese patients is presented in Table 1. Penicillins, clindamycinor metronidazole were included in the initialantibiotic regimen in 70% of cases. Other common antimicrobialagents used were vancomycin, gentamycin,imipenem and cefalosporins. Adjunctive therapy withhyperbaric oxygen was administered in two patients. Inone patient a polyvalent clostridial antitoxin was administered[4]. However, to our knowledge no commerciallyavailable polyvalent clostridial antitoxin exists inEurope and in the US. Skin grafting to cover affectedareas was required in three cases. Surgical complicationsincluded a case of erosion of the femoral artery treatedwith vascular grafting, severe bleeding of the groin areathat was managed with ligation of profunda femorisartery and its branches. The most serious systemic complicationsof the infection were respiratory failure, renalfailure, sepsis and resultant multiorgan failure. Notably,one patient who developed respiratory failure wasreceiving intramuscular pentazocin, an opioid analgesicfor chronic pancreatitis associated pain. Pentazocin isnot indicated for patients with pancreatitis and can itselfdepress critically the respiratory function [4,8]. Hospitalizationranged variably between16and126daysandwas relatively longer in patients with serious systemiccomplications of the disease. Functional status of thesalvaged limb was reported in eight cases, five of themregaining normal function of the affected limb.DiscussionGas gangrene of the limbs is a rare infection due toanaerobe bacteria associated with high morbidity andmortality. Amputation is usually necessary to controlinfection and save life whereas functional limb preservationis rare [1]. Intravenous drug users are considered athigh risk for gas gangrene and it has been shown thatClostridia are able to survive in heroin preparationsbeing mixed with citric acid and heated [2]. Moreover,repeating trauma of soft tissue resulting from peculiarpractices among illicit drug users, as the intramuscularinjections with normal saline in our case, introduceorganisms directly into deep tissue and create an anaerobicenvironment that is ideal for the proliferation ofClostridia. Such anaerobic environment also resultsfrom crash type injury, contaminated open fractures andretained foreign material and is associated with C.perfrigensgas gangrene [3,5,7,9]. Spontaneous gas gangrene ofthe limbs is due to C. septicum in the vast majority ofcases. C. septicum translocates from the gut sufferingfrom a benign or malignant disease and causes metastaticinfection [1,10-12].Incubation time is short usually less than 24 hoursand the physical finding of crepitus is characteristicfinding in the setting of soft tissue infection [5,7,10-12].The sudden onset of pain, rapidly progressive soft tissueinfection, development of blisters containing foul smellingbrownish liquid with gas bubbles, soft tissue indurationand discoloration may also be present [7,10]. PlanX-rays identify gas in deep tissues and CT or MRI mayassess spreading of infection along fascial planes. Bacteremiaoccurs in approximately 15% of patients and normallydevelops several hours before skin manifestationsin the case of spontaneous gangrene [1]. Needle aspirationor biopsy may provide etiological agent but nodiagnostic test or hyperbaric oxygen therapy shouldreplace or delay surgical and antimicrobial treatment.Signs of systemic toxicity develop rapidly and manypatients present with septic shock at the time of theiradmission to the hospital [13]. However, the cases oflimb salvage reported in the literature did not presentwith fulminant systemic disease and only four out ofeleven, including our patient developed serious complicationsdue to their disease (Table 1). This may indicate

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28Page 4 of 7Table 1 Cases of limb preservation after treatment of gas gangrene (Clostridial myonecrosis)Age/Gender/ReferenceComorbidity,Previous historyLocalization/Cultures resultsClinical presentationAntibiotics/Othertreatment35/M[Presentcase]Intravenous druguser, Hepatitis CShoulder/C.perfrigens, Staphaureus, StaphepidermidisPain, fever, swelling, crepitus Pip/Taz, Clind, Vanc ®Meropenem/Skin grafting54/M [10] DM, cecal cancer Arm/C septicum 24 hr arm/abdominal pain, fever,nausea, vomiting, diarrhea, shouldertenderness, induration, crepitus37/M [5] Posttraumatic Headfracture26/M [9] Intravenous druguserShoulder/C perfrigensS epidermidisLower limb/Cperfringens, Beta-Streptococci,enterococci49/M [23] Postoperative Hand/C perfrigens Csordellii55/M [12] DM, peripheralvascular disease,cecal massshoulder pain, fever, agitation, crepitusSuspected DVT, thigh/left iliac fossatendernessPip/Taz, Clind, VancVanc ® Pen/Clind/Metr® Cefo, Metro ® Pen/Metro ® Metro p.osPen, Clind, Metr/femoralartery vascular graftingComplications/Hospitalization(days)/FunctionalstatusSeptic shock, myoglobinuria,RF/120d/limited functionAnemia/NR/NRAnosmia/40d/NormalFemoral vein, arteryand nerve erosion/126d/Mobile1 st postoperative day pain/fever Pen -/21d/normalHip/C septicum Pain, fever, crepitus Pip/Taz, Clind, Ceft®Pip/Taz, ClindRF, myoglobinuria/NR/NR58/M [6] Posttraumatic Heel/ Foot pain, fever, Antibiotics, hyperbaric MOFS/78d/normaloxygen, Skin grafting32/M [11] Postoperative Lower limb/CsepticumPain, crepitus NR NR/NR/NR83/M [14] Sciatica,pneumonia, coloncancer47/M [4] chronicpancreatitis, DM,pentazocininjection sites.Hip, thigh/C septicumThigh - buttock/Cperfrigens3 days, hip pain, fever, nausea,vomitingVanc, Genta, Imip/Sil ®Am/Cl/Righthemicolectomy6 day pain, swelling, fever, Pen, Metr, polyvalentclostridial antitoxin,/Skingrafting25/M [7] Crush injury Leg/C perfrigens Pain, fever, limb discoloration, edema,crepitusCefalotin ® Pen,hyperbaric oxygen/skinbonegrafting48/F [24] Posttraumatic Knee/C perfrigens Pain, stiffness, tenderness Terra ® Pen, Gasgangrene serum-/16d/ambulated withassistanceRespiratory failure,/NR/normal-/180d/able to bareweight-/21d/normalPip/Taz: piperacillin/tazobactam, Clind: clindamycin, Vanc: vancomycin, Pen: penicillin G, Metr: metronidazole, Genta: gentamycin, Imip: imipenem, Sil: silastatin,Am/Clav: amoxicillin/clavulate, Terra: terramycin,DM: diabetes mellitus,UC: ulcerative colitis,DVT: deep venous thrombosisMOFS: multiorgan failureRF: renal failureNR: not reported.alessaggressiveformofthediseaseorabettertreatmentoutcome because of early diagnosis. Liver necrosis,jaundice, hemolytic anemia and renal failure are someserious systemic complications of clostridial myonecrosis.Renal failure is attributed to the effects of hypotension,myoglobinuria, hemoglobinuria and directnephrotoxicity of clostridial toxins [1]. Severe pain, toxicityand high creatinine phosphokinase levels with orwithout radiographic findings are indications for surgeryin order to achieve early debridement and obtain tissuefor appropriate cultures.The mainstay of treatment is early aggressive surgicalintervention, antibiotic therapy and intensive care support.Delay of the operation for more than twelve hoursis associated with higher overall morbidity [13]. Cases oflimb salvage after gas gangrene reviewed in this articlewere almost invariably operated immediately after theiradmission with the diagnosis of gas gangrene and withsymptoms of duration of less than 48 hours. In only twocases diagnosis of gas gangrene was delayed for moretwo days even though the patients had been previouslyexamined by their doctors [4,14].

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28Page 5 of 7Wide resection of all necrotic tissue is necessary. Onlyviable muscle that bleeds when cut or contracts uponstimulation with electrodiathermy should be left behind.Fasciotomies are necessary to prevent compartment syndrome.Evidence based indication for amputation oflimbs affected with gas gangrene does not exist. Unlikeseveral scoring systems existing for assessing the needfor amputation in traumatic limb injury (Lange’s, thepredictive salvage index, the limb score injury, the limbsalvage index, the mangled extremity syndrome indexand the mangle extremity severity score) no scoring systemhas been developed for necrotic infections of thelimbs. Even though some of the components of theaforementioned scoring systems may also be applied inlimb gangrene, they have not been validated and essentiallythey cannot replace experience and good clinicaljudgment [15].With improvements in prehospital care, acute resuscitationand surgical techniques, surgeons more often arefaced with situations in which a severely compromisedlimb can be preserved although this involves substantialcompromises. Realistic likelihood of functional recoveryof the limb must be balanced against the risk of deathassociated with attempts to preserve a limb. Amputationmight be beneficial in cases where no residual functionof the limb is expected postoperatively. This impliesmajor deficit of its neurovascular supply. Major nerveinvolvement may lead to preservation of a useless extremitythat is worse than no limb at all [15].For the lower limb, destruction of the tibial nerve isconsidered an indication for below-knee amputationsince the functional result of the preservation of thelimb is worse compared with the use of prosthesis.Modern prosthetics often provide better function thanmany “successfully salvaged” limbs. For the upperlimb, even minimal preservation of the movement andsensation might be beneficial for the patient (handle awheel chair, use computer systems etc) and generallyprovides better function compared with prosthesis.Non palpable pulse of the radial or dorsalis pedisartery intraoperatively should lead to sonographicassessment of the vascular supply of the limb. If novenous return is seen on triplex, amputation should bestrongly considered. Severe, irreparable vascular injuryin an ischemic limb is another indication for amputation.Before performing an amputation, a vascular surgeryconsultation should be considered if availablewithout delaying the treatment decision [15,16].Improved techniques currently allow for revascularizationof limbs that previously would have been unsalvageable.Revascularization is not without risk,however [9,15]. Attempts to salvage a severely compromisedlimb may lead to metabolic overload and secondaryorgan failure. Comorbid medical conditionsmust also be considered before heading down a longroad of multiple operations to save a limb [15].Even though cases with aggressive infection presentingwith systemic complications due to gas gangrene of thelimb are more likely to have more advanced local infectionwhich precludes limb salvage, there is no evidencethat amputation controls infection better than adequatewide surgical debridement. Therefore, in our patient thetreatment decision for limb salvage was not influencedby the presence of systemic complications. It was ratherbased on the estimation of what is left behind after anadequate resection of all devitalized tissue. If limb salvageis attempted, one must take into account that postoperativedaily surgical exploration might be necessaryfor several days until all necrotic tissue is removed. Incases of limb salvage after gas gangrene reported in theliterature, serial debridement following initial surgerywas necessary only in four patients including our case.This might indicate a more adequate initial operation incases with limb preservation or a less aggressive form ofdisease in these patients [5-7].Even though gas gangrene of the limb is an extremelyemergency surgical condition individual patients’ preferencesafter thorough information should be taken intoaccount. First a decision is taken whether the limb canbe saved. If the limb can be preserved the decisionwhether it should be saved should come in concert withthe patient. The tradeoffs involved with protracted treatmentcourse of limb salvage versus immediate amputationand prosthetic fitting should be made clear to thepatient. Saving the limb, often comes at a great cost.Multiple operations to obtain bony reunion and soft tissuecoverage are often necessary. Chronic pain and drugaddiction also are common problems of limb salvagebecause patients endure multiple hospital admissionsand surgery, isolation from their family and friends, andunemployment [15,16]. In the end, despite heroic effortsthe limb ultimately could require an amputation or a“successfully salvaged limb may be chronically painful orfunctionless [17,18]. The worst case scenario occurswhen a limb must be amputated after the patient hasendured multiple operations of an unsuccessful salvageor after years of pain following a “successful” salvage[18]. On the other hand, early amputation and prostheticfitting has been shown to be associated withdecreased morbidity, fewer operations, shorter hospitalcourse, decreased hospital costs, shorter rehabilitation incases of traumatic limb injury [15]. Thus, it is importantto present all information from the very beginning sothat the patient is able to make educated decisionsregarding which course to follow. The subjective importanceof body image for the patient, the possibility ofprolonged hospitalization, financial burden and possiblesocial isolation should be discussed with the patient in

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28Page 6 of 7order to help them make real informed decisions[15,16].Prompt initiation of antimicrobial treatment coveringaerobic and anaerobic organism is critical. In fact, earlyantimicrobial treatment was initiated in all cases withpreservation of the limb after operation for gas gangrene.Initial empirical antibiotic treatment should coverClostridia, Gram positive cocci aerobes and anaerobes.The optimal combinations of antibiotics as well as theduration of the treatment have not been defined inappropriate clinical trials so far. Ampicillin-sulbactam orpiperacillin-tazobactam or ticarcillin-clavulate in combinationwith clindamycin or metronidazone are suggestedempiric regimens, whereas antibiotic treatment shouldbe tailored according to the susceptibility results [1,19].Specific treatment for post traumatic gas gangrene dueto C. perfrigens should consist of Penicillin (3-4MIUevery 4 hours i.v.) plus Clindamycin (600-900 mg every8 hours i.v.). In cases of spontaneous gas gangrene dueto C. septicum antimicrobial treatment should includevancomycin (1 g every 12 hours i.v.) or metronidazole(500 mg every 8 hours i.v.) because this species may beresistant to penicillin or clindamycin [19]. Interestingly,in the vast majority of cases with limb salvage after gasgangrene reviewed here, empiric as well as specific antibioticregimen was in concordance with the aforementionedsuggestions.Neutralization of clostridial or streptococcal circulatingtoxins by the use of intravenous immune globulinhas shown promising results but there are no data tosupport a strong recommendation for its regular use inpatients with gas gangrene [20]. Adjunctive hyperbaricoxygen therapy has been suggested for patients withaggressive soft tissue infections and has been shown toincrease survival in animal model and in humans but noprospective controlled trials have been contacted inhumans so far. Better definition of necrotic tissue facilitatingmore precise debridement and its bacteriostaticeffects on clostridia both in vivo and in vitro is therationale for the use of hyperbaric oxygen therapy inpatients with gas gangrene [21,22].In most of the patients with limb preservation aftergas gangrene, a residual function of the affected limbwas present. In half of them functionality of the limbwas characterized as normal. Patients with limited functionof the preserved limb had generally longer durationof hospitalization. This might be at least in part becausethese patients, as our case, needed several interventionsfollowing initial surgery until the limb re-attained asmuch as possible of its functionality. This prolongationof hospital stay is well balanced by the invaluable benefitof functional limb salvage. Whether the preservation ofthe limb makes postoperative recovery more severe isessentially the question whether amputation offers bettercontrol of the infection compared with adequate debridement.Again there is no evidence that amputationcontrols better the infection compared with adequatedebridement. However, it is plausible that amputationmay achieve margins that are wider and clearer of infectionif it is compared with an inadequate debridementin order to “save” the limb [15,16].In conclusion, physician and emergency medicine personnelshould always maintain high index of suspicionfor necrotizing infections in illicit drug users presentingwith soft tissue infections. Early surgical debridement,antimicrobial treatment and intensive care monitoringmay lead to survival with limb salvage in carefullyselected patients.ConsentWritten informed consent was obtained from the patientfor publication of this case report and accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.List of abbreviationsCT: computerized tomography; MRI: magnetic resonance imaging; SGOT/SGPT: serum glutamic oxaloacetic transaminase/serum glutamic pyruvictransaminase.Author details1 Department of Orthopaedic Traumatology, University Hospital of Heraklion,Voutes, Heraklion, 71100, Greece.2 Department of General Surgery, UniversityHospital of Heraklion, Voutes, Heraklion, 71100, Greece.3 Alexander S. OnassisPublic Benefit Foundation, Voutes, Heraklion, 71100, Greece.Authors’ contributionsIA and AT had the original idea and drafted the manuscript. PK and KLdrafted, reviewed, finalized and revised the manuscript. GK and JK searchedthe literature and prepared the figures. All authors read and approved thefinal manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 24 February 2011 Accepted: 17 August 2011Published: 17 August 2011References1. Bryant AE, Stevens DL: Clostridial myonecrosis: new insights inpathogenesis and management. Curr Infect Dis Rep 2010, 12(5):383-91.2. Bryan C: Gangrene bug killed 35 heroin users. WJM 2000, 173:82-83.3. Stevens : Clostridial Myonecrosis and other Clostridial Diseases. In CecilTextbook of Medicine. Volume chapter 334.. 21 edition. Edited by: L Goldman,JC Bennett. Philadelphia: WB Saunders; 2000:1668-1673.4. Kershaw CJ, Bulstrode CJ: Gas gangrene in a diabetic after intramuscularinjection. Postgrad Med J 1988, 64:812-3.5. Lanting B, Athwal GS, Naudie DD: Spontaneous Clostridium perfringensmyonecrosis of the shoulder: a case report. Clin Orthop Relat Res 2007,461:20-4.6. Ferraù S, Sallusti R, Lozano Valdes A, Gonzales C, Jónsson M,Gunnlaugsson G, Gullo A: HBO and gas gangrene. A case report. MinervaAnestesiol 2001, 67:745-9.7. Hoffman S, Katz JF, Jacobson JH: Salvage of a lower limb after gasgangrene. Bull N Y Acad Med 1971, 47:40-9.8. Pentazocine: Drug information. Edited by: Basow, DS. Waltham, MA; 2011:,No authors listed. In: UpToDate 19.1,.

Aggelidakis et al. World Journal of Emergency Surgery 2011, 6:28http://www.wjes.org/content/6/1/28Page 7 of 79. Assadian O, Assadian A, Senekowitsch C, Makristathis A, Hagmüller G: Gasgangrene due to Clostridium perfringens in two injecting drug users inVienna, Austria. Wien Klin Wochenschr 2004, 116:264-7.10. Gibson M, Avgerinos D, Llaguna O, Sheth D: Myonecrosis secondary toClostridium Septicum in a patient with occult colon malignancy: a casereport. Cases Journal 2008, 1:300.11. Larson CM, Bubrick MP, Jacobs DM, West MA: Malignancy, mortality, andmedicosurgical management of Clostridium septicum infection. Surgery1995, 118:592-7, discussion 597-8.12. Clay A, Behnia M: A 55-Year-Old Man With Fever, Renal Failure, and HipPain. Chest 2001, 119:281-284.13. Sudarsky LA, Laschinger JC, Coppa GF, Spencer FC: Improved results froma standardized approach in treating patients with necrotizing fasciitis.Ann Surg 1987, 206:661-5.14. Fernandez RJ, Gluck JL: Clostridium septicum gas gangrene of thegluteus maximus and an ascending colon malignant tumor. A casereport. Clin Orthop Relat Res 1994, 308:178-82.15. Heck R: General Principles of Amputations. In Campbell’s OperativeOrthopedics. Volume 1.. 11 edition. Edited by: Canale ST, Beaty JH.Pensylvania: Mosby, Elsevier; 2008:562-566.16. Smith D: Amputations. In Current diagnosis and treatment in orthopedics.. 3edition. Edited by: Skinner H. New York: Lange Medical Books/Mc Graw-Hill;2003:638-654.17. Lehner PJ, Powell H: Gas gangrene. BMJ 1991, 303:240-2.18. Mercer N, Davies DM: Gas gangrene. BMJ 1991, 303:854-5.19. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ,Gorbach SL, Hirschmann JV, Kaplan EL, Montoya JG, Wade JC: Practiceguidelines for the diagnosis and management of skin and soft-tissueinfections. CID 2005, 41:1373-406.20. Norrby-Teglund A, Muller MP, McGeer A, Gan BS, Guru V, Bohnen J,Thulin P, Low DE: Successful management of severe group Astreptococcal soft tissue infections using an aggressive medical regimenincluding intravenous polyspecific immunoglobulin together with aconservative surgical approach. Scand J Infect Dis 2005, 37:166-72.21. Tibbles PM, Edelsberg JS: Hyperbaric-oxygen therapy. N Engl J Med 1996,334:1642.22. Demello FJ, Haglin JJ, Hitchcock CR: Comparative study of experimentalClostridium perfringens infection in dogs treated with antibiotics,surgery, and hyperbaric oxygen. Surgery 1973, 73:936.23. Lorea P, Baeten Y, Chahidi N, Franck D, Moermans JP: A severecomplication of muscle transfer: clostridial myonecrosis. Ann Chir PlastEsthet 2004, 49:32-5.24. McNae J: An unusual case of Clostridium welchii infection. J Bone JointSurg Br 1966, 48:512-3.doi:10.1186/1749-7922-6-28Cite this article as: Aggelidakis et al.: Limb salvage after gas gangrene: acase report and review of the literature. World Journal of EmergencySurgery 2011 6:28.Submit your next manuscript to BioMed Centraland take full advantage of:• Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript atwww.biomedcentral.com/submit