Research Article| Volume 61, ISSUE 2, P323-326, March 2022

Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema

Published:September 08, 2021DOI:


      Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lipsky BA
        • Berendt AR
        • Cornia PB
        • Pile KC
        • Peters EJ
        • Armstrong DG
        • Deery HG
        • Embil JM
        • Joseph WS
        • Karchmer AW
        • Pinzur MS
        Senneville, Infectious Disease Society of America.
        Clin Infect Dis. 2012; 54: e132-e173
        • Stevens DL
        • Bisno AL
        • Chambers HF
        • Everett ED
        • Dellinger P
        • Goldstein EJ
        • Gorbach SL
        • Hirschmann JV
        • Kaplan EL
        • Montoya JG
        • Wade JC
        Infectious Disease Society of America.
        Clin Infect Dis. 2005; 41: 1373-1406
        • Anaya DA
        • McMahon K
        • Nathens AB
        • Sullivan SR
        • Foy H
        • Bulger E.
        Predictors of mortality and limb loss in necrotizing soft tissue infections.
        Arch Surg. 2005; 140: 151-157
        • McHenry CR
        • Piotrowski JJ
        • Malangoni MA.
        Determinants of mortality for necrotizing soft-tissue infections.
        Ann Surg. 1995; 221: 558-563
        • Bonne SL
        • Kadri SS.
        Evaluation and management of necrotizing soft tissue infections.
        Infect Dis Clin North Am. 2017; 31: 497-511
        • Elliott DC
        • Kufera JA
        • Myers RA.
        Necrotizing soft tissue infections. Risk factors for mortality and strategies for management.
        Ann Surg. 1996; 224: 672-683
        • Lauerman MH
        • Scalea TM
        • Eglseder WA
        • Pensy R
        • Stein DM
        • Henry
        Physiology, not modern operative approach, predicts mortality in extremity necrotizing soft tissue infections at a high-volume center.
        Surgery. 2018; (PMID: 29685635. online ahead of print)
        • Madsen MB
        • Skrede S
        • Perner A
        • Arnell P
        • Nekludov M
        • Bruun T
        • Karlsson Y
        • Hansen MB
        • Polzik P
        • Hedetoft M
        • rosen A
        • Saccenti E
        • Bergey F
        • Martins Dos Santos VA
        • INFECT Student Group
        • Norrby-Teglund A
        • Hyldegaard O
        Patient's characteristics and outcomes in necrotizing soft-tissue infections: results from a Scandinavian multicenter, prospective cohort study.
        Intensive Care Med. 2019; 45: 1241-1251
        • Ahn J
        • Raspovic KM
        • Liu GT
        • Lavery LA
        • La Fontaine J
        • Nakonezny PA
        • Wukich DK
        Lower extremity necrotizing infections in diabetic and nondiabetic patients.
        Int J Low Extrem Wounds. 2019; 18: 114-121
        • Brucato MP
        • Patel K
        • Mgbako O.
        Diagnosis of gas gangrene: does a discrepancy exists between the published data and practice.
        J Foot Ankle Surg. 2014; 53: 137-140
        • Tan JH
        • Koh BTH
        • Hong CC
        • Lim SH
        • Chan GWH
        • Wang W
        • Nather A.
        A comparison of necrotizing fasciitis in diabetics and non-diabetics: a review of 127 patients.
        Bone Joint J. 2016; 98-B: 1563-1568
        • Martinez M
        • Peponis T
        • Hage A
        • Yeh DD
        • Kaafarani HM
        • Fagenholz PJ
        • King DR
        • Moya MA
        • Velmahos GC.
        The role of computed tomography in the diagnosis of necrotizing soft tissue infections.
        World J Surg. 2018; 42: 82-87
        • Fernando SM
        • Tran A
        • Cheng W
        • Rochwerg B
        • Kyeremanteng K
        • Seely AJ
        • Inaba K
        • Perry JJ.
        Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging, and LRINEC score: a systematic review and meta-analysis.
        Ann Surg. 2019; 269: 58-65
        • Wong CH
        • Khin LW
        • Heng KS
        • Tan KC
        • Low CO.
        The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections.
        Crit Care Med. 2004; 32: 1535-1541
        • Hayeri MR
        • Ziai P
        • Shehata ML
        • Teytelboym OM
        • Huang BK.
        Soft-tissue infections and their imaging mimics: from cellulitis to necrotizing fasciitis.
        Radiographics. 2016; 36: 1888-1910
        • Tso DK
        • Singh AK.
        Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls.
        Br J Radiol. 2018; 9120180093
        • Wysoki MG
        • Santora TA
        • Shah RM
        • Friedman AC.
        Necrotizing fasciitis: CT characteristics.
        Radiology. 1997; 203: 859-863
        • Sansosti LE
        • Crowell A
        • Choi ET
        • Meyr AJ.
        Rate of and factors associated with ambulation after unilateral major lower-limb amputation at an urban US tertiary-care hospital with a multidisciplinary limb salvage team.
        J Am Podiatr Med Assoc. 2017; 107: 355-364