2736-LB: Diabetic Foot–Associated Necrotizing Fasciitis as a Decision-Driven Clinical Entity: Distal-Restricted Amputation Preserves Survival Despite High Amputation Rates

Introduction and Objective: Necrotizing fasciitis (NF) is traditionally managed under a survival prioritized paradigm, where extensive tissue sacrifice is justified to reduce mortality. In contrast, diabetic foot infection emphasizes limb preservation. When NF arises from diabetic foot lesions (DF/NF), these paradigms collide, and optimal surgical decision making remains undefined. We hypothesized that DF/NF represents a distinct, decision driven clinical entity in which early distal restricted amputation may maximize survival without increasing major limb loss. Methods: We conducted a retrospective cohort study of 86 patients with lower extremity NF (2015-2025), including 20 DF/NF and 66 nondiabetic NF cases. Clinical characteristics, microbiology, amputation patterns, and mortality were compared. Multivariable logistic regression was used to identify independent predictors of amputation. Results: Despite similar short-term mortality between DF/NF and non-diabetic NF (10.0% vs. 4.5%, P=0.329), DF/NF patients exhibited a substantially higher overall amputation rate (55.0% vs. 15.2%, P<0.001). This increase was almost exclusively attributable to minor, distal amputations (40.0% vs. 1.5%, P<0.001), while major amputation rates remained comparable. After adjustment, DF/NF status emerged as the only independent predictor of amputation (adjusted OR 7.55, P=0.008), whereas traditional severity markers, including LRINEC score and inflammatory biomarkers, were not independently associated. Conclusion: DF/NF is not merely a diagnostic subtype but a decision driven clinical entity. It follows a non-zero sum surgical paradigm in which early distal restricted amputation functions as trigger point elimination, preserving survival while avoiding unnecessary proximal limb loss. Recognition of DF/NF should prompt a distinct surgical decision framework beyond conventional severity scoring. Disclosure J. Zhou: None. H. Tang: None. X. Jiang: None. Funding Yantai Municipal Bureau of Science and Technology(ZR2025LZ047)