Time to Surgical Closure of Complex Infectious Wounds

A Single-Center Retrospective Cohort Study

Sara Yumeen, MD; Mélissa Roy, MDCM, MSc, FRCSC; Fatima N. Mirza, MD, MPH; Sarah Rehou, MS; Shahriar Shahrokhi, MD, FRCSC, FACS


Wounds. 2022;34(8):e51-e56. 

In This Article

Abstract and Introduction


Introduction: Surgical management of NSTIs can result in complex wounds, and closure of these wounds is often difficult or complicated. Although surgical factors influencing mortality and LOS have been well described, little is known about patient, wound, and surgical factors associated with time to closure.

Objective: The purpose of this study is to identify patient, wound, and surgical factors that may influence time to closure of NSTIs.

Materials and Methods: The records of patients who presented to a tertiary care center over an 11-year period (2007–2017) with an NSTI requiring surgical closure were retrospectively reviewed.

Results: Forty-seven patients met the inclusion criteria. The average time to closure was 31.1 days, with an average of 4.8 procedures. Most patients were middle aged (mean, 50.3 years; range, 20–81 years), immunocompetent, and nondiabetic upon admission. Closure was achieved mainly with autograft. The percent TBSA was described in 19 cases (40%). There was no association between substance use (alcohol, smoking, or other), anticoagulant medication use, or medical comorbidities and time to closure. On multivariable analysis, flap closure (P =.02) and increased number of surgical procedures (P =.003)—the latter reflecting the need for an increased number of debridements—were associated with increased time to closure.

Conclusions: The data in this study suggest that use of local flaps for wound closure and increased number of surgical procedures (particularly debridements) may be predictors of time to closure in patients with an NSTI.


A simple, effective algorithm guides clinicians when determining the optimal means of wound closure.[1] This algorithm, traditionally known as the reconstructive ladder, provides a framework for reconstruction that attempts coverage with the simplest, least morbid technique possible to optimize the delicate balance between risks and benefits.[2] Overall, the objective is to achieve timely and adequate wound closure.

Traumatic soft tissue injury and NSTIs are a significant health care burden. Necrotizing soft tissue infections encompass infections of the soft tissue compartment, including dermis, subcutaneous tissue, superficial fascia, deep fascia, and muscle. Management of NSTIs requires fluid resuscitation, antibiotics, and complete surgical debridement.[3] In particular, early surgical debridement is a significant determinant of morbidity, mortality, and clinical outcomes.[4,5] Surgical management of necrotizing infections and traumatic injuries can result in complex wounds for which primary wound closure is often impossible. Patients can require multiple surgical procedures for further debridement and eventual closure; an average of between 2 and 7 procedures have been reported in the literature to achieve adequate infection control.[4,6,7] Additionally, patients often have associated injuries or hemodynamic instability, and therefore require a longer hospital LOS and considerable resources (financial, operational, and human).

Both patient and wound factors influence healing and selection of wound closure technique, especially when surgical intervention is considered. Such factors include patient comorbidities such as diabetes, peripheral vascular disease, age, body mass index, immunosuppression status, and alcohol use.[8,9] Local factors to consider include bacterial burden, maceration, necrosis, trauma, pressure, and edema.[10]

The primary objective of this study is to describe the sociodemographic factors of and time to closure for patients who required surgical wound closure owing to an NSTI. The secondary objective is to identify possible predictors of time to closure.