Overdiagnosis of necrotizing fasciitis: clinical–radiological suspicion versus intraoperative findings in 62 fasciotomy patients

Introduction: Necrotising fasciitis (NF) is a rare but life-threatening soft tissue infection, whose diagnosis remains challenging due to non-specific early clinical signs. This retrospective single-center study aimed to compare the clinical, radiological, and microbiological characteristics, as well as outcomes, of patients undergoing fasciotomy for suspected NF, distinguishing between those with surgically confirmed necrosis and those without. Methods: Data from 62 adults who underwent fasciotomy for suspected NF between 2013 and 2023 were retrospectively analyzed. Patients were stratified into two groups according to intra-operative confirmation of necrosis (n = 29) or its absence (n = 33). Demographic characteristics, clinical presentation, laboratory parameters, timing of surgery, and 30-, 90-, and 180-day mortality rates were compared. Results: Patients with confirmed necrosis showed significantly higher LRINEC scores (7.5 vs 5.6; p = 0.004), blood glucose (223.6 vs 154.9 mg/dL; p = 0.031), and urea levels (75.4 vs 50.4 mg/dL; p = 0.019) at admission. Advanced clinical signs, including bullae or crepitus, were strongly associated with necrosis (OR = 4.82; p = 0.007). These patients were more frequently admitted to the ICU (82.8% vs 42.4%; p = 0.002) and underwent earlier surgery (<24 h; OR = 0.19; p = 0.002). No significant differences were observed in infection site, microbiology, hospital stay, or mortality (6.9% vs 12.2%; p = 0.676). Conclusion: Elevated LRINEC scores and advanced clinical signs predict confirmed necrosis but not mortality. The timely decision to perform fasciotomy, regardless of confirmed necrosis, appears to be critical for improving outcomes. This suggests that relying on clinical judgement and early surgical exploration is critical for a timely and effective response to highly suspected cases of NF.