From crisis to closure: Early aggressive debridement and use of skin grafting in limb threatening necrotizing fasciitis

<h2>Abstract</h2> Necrotizing fasciitis (NF) in the setting of diabetic ketoacidosis (DKA) and septic shock presents a formidable challenge to limb preservation. This case describes a 64-year-old female with longstanding uncontrolled diabetes who presented in profound metabolic and septic compromise, with extensive soft tissue gas and polymicrobial infection of the right foot and leg. Emergent radical debridement and partial foot amputation were performed within hours of arrival, with vascular surgery consulted for below-knee amputation (BKA) due to concern for non-salvageability. This case highlights the impact of early aggressive debridement, serial washouts, and strategic wound optimization, culminating in successful split-thickness skin grafting. Despite the severity of infection and systemic compromise, amputation was limited to the first ray and second digit. At 2.5 months postoperatively, the patient regained ambulatory function and expressed high satisfaction with limb preservation. The graft healed fully, and no further surgical intervention was required. This outcome underscores the critical role of interdisciplinary coordination, surgical persistence, and timely decision-making in complex NF cases. <h3>Level of evidence</h3> IV