Hi Jad,

Thank you for your question! Scott, Gene, Cathy and I chatted about it, and compiled a few questions on the patient and the wound that hopefully might be helpful:
- Does the patient have any underlying condition that led her to develop necrotizing fasciitis after a laceration? 
- Would there be any info on her CRP levels prior to her developing necrotizing fasciitis? (meaning, was it elevated to begin with?)
- Are there any other comorbidities/ factors that might be impeding wound healing? The ulcer is over 1 year old, and it might be worthwhile reassessing the patient and the wound (e.g. nutrition, smoking habits, comorbidities, need for biopsy, etc)
- Where is the wound located? Would chronic osteo be a possibility? 

As for CRP: 
- CRP is non-specific, may indicate an inflammatory process and can also be elevated in many non-infectious processes such as ischemic heart disease, rheumatoid arthritis, etc. 
- In terms of CRP levels and chronic wounds, here is some info: 
* Wright and Khan evaluated levels of serum CRP following local and free-tissue reconstructions for traumatic injuries or chronic wounds of the lower limb and found that: CRP peaks on day 2 following soft-tissue coverage and falls thereafter. Peaks after day 4 post surgery indicate infective complications or further surgery. Patients with chronic wounds show a slower decrease in their CRP. Persistently elevated CRP following surgery is associated with infection and nonunion.https://pubmed.ncbi.nlm.nih.gov/19758848/
* Liu et al evaluated 20 patients with trauma-related chronic wounds (that failed to heal after 6 weeks of conservative local wound care). They found that the baseline medium serum CRP level was 66.4mg/L (range IQR, 41.3–122.9 mg/L), that is, 22 times higher than the reference range. Their wounds eventually developed healthy granulation tissue after debridement and NPWT. Authors noticed a significant drop in level of CRP - the median CRP was 10.4 mg/L on the last day of NPWT. https://www.o-wm.com/article/prospective-pilot-study-evaluate-wound-outcomes-and-levels-serum-c-reactive-protein-and

I appreciate your reply so much. So the wound is on her anterior left foot and ankle. She does not have any chronic medical conditions that have yet been identified. She does not smoke, but has some alcohol use. She was playing college soccer prior to her injury. I am concerned about underlying osteo and am planning a MRI. I don't yet have previous CRP levels as she was previously treated elsewhere, but I have old records so I can review those. I am also going to order TCOM's which I feel silly about as she is twenty but I am really stumped

Jad:

We never feel silly about following a protocol or looking outside the box when we have carefully examined the box. So, based on your information, occult osteomyelitis is a higher priority differential. I would suggest ESR as well. If both are elevated, I’m more sure of my diagnosis. My guess is that the MRI will be ... ahem ... ready? Ready? Inconclusive.

If the wound is still open, does it track to bone? If so, would your foot and ankle surgeon think about debriding and culturing the bone at the base of the wound? Aggressive debridement of the entire wound ... and negative pressure therapy following the debridement. That’s probably what I would do.

Based on what you find in the operative debridement, would you consider Inf Disease consult and empirically treating her for osteo? This is certainly a judgment call ... I’m just thinking about ramping up the aggressiveness of therapy.

Regardless of the above, I would also think about reducing any chance that edema plays a part in this. Consider a 2-layer, moderate compression wrap, changed with the VAC changes. At the least, two layers of “moderate” level Tubigrip compression ... wear all the time while awake.

Like you said, she is 20 years old and shouldn’t have any difficulty with wound healing. Then, my mind points me to occult osteomyelitis, especially given the location.

I think you are right on the money! I do plan to get infectious disease involved and surgery. I've ordered the MRI and will get the SED rate. I appreciate your advice very much.
Jad

By the way ... what was the original mechanism of injury?

They made a home made slip and slide with a tarp and a hose. She was wearing an ankle bracelet and lacerated her leg. Developed necrotizing fasciitis and spent over a month in the hospital. Had two split thickness skin grafts that failed and one full thickness graft that failed. I don't know why they failed.

Hmmm ... I’m sticking with my first diagnosis. However, you might debride and send the materials for culture. I’ve seen some unusual mycobacterium species cause wound healing failure.

In Missouri, we call that hillbilly engineering. Never really works out well in the long run.

When skin grafts fail, to me it means that the wound bed wasn’t properly prepared enough, local hypoxia, infection, edema, or ... in rare cases, the patient manipulates the wound for secondary gain.

Thanks again. I think you are right. Appreciate your assistance.