A Novel Concept for Treating Large Soft Tissue Defects After Necrotizing Soft Tissue Infection

March - April 2023

Dr Marcus F. Yarbrough Alpha Wound Care Solutions and Wellness

A Novel Concept for Treating Large Soft Tissue Defects After Necrotizing Soft Tissue Infection of the Back

Editorial Summary

Necrotizing fasciitis, a life-threatening subcutaneous soft-tissue infection, requires a high index of suspicion for diagnosis. It is vital to consider the diagnosis wherever there is a soft-tissue infection that appears to have rapidly progressing characteristics presenting with edema and erythema, or systemic signs of infection. However, necrotizing fasciitis can be easily missed because the patient may present earlier in the disease process with non-specific signs and severe pain (disproportionate to the clinical findings or anaesthesia over the site of infection). If necrotizing fasciitis is suspected, the patient should immediately be referred for urgent surgical debridement. Necrotizing fasciitis is a clinical diagnosis. Surgical debridement should be repeated as necessary until the patient has no necrotic tissue remaining. Adjunctive antibiotic therapy and supportive care are crucial, as well as starting intravenous empirical antibiotics as soon as blood cultures have been taken. Once culture results are available, antibiotics can be modified to target the causative organism. This article explores the surgical strategy of acellular fish skin in wound bed restoration post necrotizing fasciitis in a case of a diabetic patient diagnosed with extensive necrotizing fasciitis.

Introduction

Necrotizing fasciitis (NF) is defined as a severe and lethal bacterial infection that occurs with a rapid onset resulting in extended soft tissue and fascial necrosis with relative sparing of skin and muscle.1 Necrotizing fasciitis is a destructive infection of the skin and subcutaneous tissues associated with significant mortality and morbidity.2 Survival from the condition often necessitates patient referral for appropriate reconstructive surgery and supportive medical management. The mortality rate is high, ranging from 11% to 22%; this rate is even higher with mortalityassociated risk factors such as diabetes mellitus. Management is complex and multimodal, beginning with early identification and multiple surgical debridement with resultant large soft tissue defects.2,3

Post necrotizing fasciitis reconstruction can prove a challenge for the reconstructive surgeon. With a large amount of tissue debrided during the early process, the challenges vary depending on the anatomical location.

Methods

This case is that of a 64-year-old AfricanAmerican female with diabetes mellitus type 2 who was initially treated at a hospital for a back wound, developed NF, and was diverted and transferred to the burn unit with involvement extending from bilateral upper back to the bilateral gluteal area. The wound was initially treated with wide surgical debridement and reconstruction of the large back and gluteal soft tissue defect with intact

fish skin in combination with hyperbaric oxygen therapy and negative pressure wound therapy (NPWT). On assessment the total body surface area (TBSA) of the posterior back was approximately 18%. She underwent early debridement on day 2 of admission, with application of negative pressure wound VAC therapy for 3 days to stimulate a granulating wound bed. Subsequent surgical debridement ensued with the first application of intact fish skin graft (FSG). A method of a 3 layer ‘stacked’ intact FSG was used to ensure adequate coverage and to minimize tissue deficits. A ‘rolled’ configuration of the FSG was placed between the wound bed and skin flaps located on the superior, lateral and inferior edges, which was sutured in place with PDS® II (polydioxanone) Suture, (Ethicon (Johnson and Johnson), Raritan, New Jersey, United States).

A NPWT was put in place for 7 days. After the 4th debridement and fish skin application with NPWT, debridement and excision of the sacral tubercules was completed due to a concern for osteomyelitis. The intact FSG was then stacked on the sacrum. On the 45th hospital day, a split thickness skin graft (STSG), meshed at a ratio of 4:1 was performed along with autologous skin cell suspension. This was buttressed in place with burn mesh gauze and inspected on post-operative day 7. The intact fish skin was re-applied to residual areas where the graft had not taken. On day 63 of hospitalization, a STSG meshed at 2:1 was placed on the sacrum and bilateral gluteal defect.

A Novel Concept for Treating Large Soft Tissue Defects After Necrotizing Soft Tissue Infection of the Back

Figure 1: 64 year old female presenting with necrotizing fasciitis of the back TBSA of 18%.

1a: Initial presentation.

1b: Pre-operative appearance: pre-excision and debridement.

1c: Post-debridement.

1d: Placement of wound VAC to stimulate granulation tissue.

1e: Pre-operative: pre-excision.

1f: Post excision: area of concern was the sacrum which was debrided using a rongeur until punctate bleeding was observed.

1g: Application of the intact fish skin using the multilayered stacked approach on the sacrum 3 layers (blue arrow), as well as rolled product to tunneling areas (green arrows, NPWT applied).

1h: Healthy granulation and ready for grafting. Note the sacrum with granulation tissue. Tunneling incorporated from ‘rolling the intact fish skin’ between lateral skin flaps and primary closure, although one area on the right remains.

Results

After multiple surgical debridements, Application of intact FSG resulted in a viable granulation and neo-dermis. Utilization of intact FSG allowed for reduction in fluid, protein loss and minimized microbial invasion. The ‘stack and roll’ method allowed for contraction of the large soft tissue defect from 45cm x 50cm to 35cm x 30cm.

The adjuvant use of NPWT allowed for over 90% intact fish graft incorporation and good wound bed formation. Incorporation of the intact fish skin over the sacral bone was observed on day 36 of the hospital stay. On the 45th day of hospitalization the incorporation of autologous skin cell with a ratio of 4:1 STSG was applied. The graft was inspected on the 51st hospital day and over 80% take was observed to the gluteal, upper and lower back areas. Despite our efforts, the patient unfortunately succumbed to her injuries.

A Novel Concept for Treating Large Soft Tissue Defects After Necrotizing Soft Tissue Infection of the Back

Conclusion

To conclude, intact fish skin should be considered a safe and efficient treatment modality to achieve a viable wound bed, as well as wound contraction and ultimately autograft, in patients with soft tissue defects caused by necrotizing fasciitis.

As demonstrated in published clinical trials, full-thickness acute wounds show faster healing time when treated with FSGs compared to those treated with porcine tissue.4-6

Research studies involving animals have demonstrated an inhibitive effect on bacterial growth due to the Omega-3 fatty acids in the FSG; also shown was improvement of angiogenesis, epithelial cell migration, as well as accelerated blood perfusion in the wound bed.7-8

By the incorporation of aggressive wound debridement and/ or preparation and application of NPWT, when combined with standard practice in wound management aiming for reduction of bioburden and infection, and appropriate offloading, healing time in these wounds can be increased significantly compared to conventional wound care.9

References

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8. Stone R 2nd, Saathoff EC, Larson DA, Wall JT, Wienandt NA, Magnusson S, Kjartansson H, Natesan S, Christy RJ. Accelerated Wound Closure of Deep Partial Thickness Burns with Acellular Fish Skin Graft. Int J Mol Sci. 2021 Feb 4;22(4):1590. doi: 10.3390/ijms22041590.

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9. Wound healing grafts: Omega-3 fatty acid lipid content differentiates the lipid profiles of acellular Atlantic cod skin from traditional dermal substitutes. Kotronoulas A, Jonasdotir H, Siguroardottir, Halldorsson S, Haraldsson G, ROlfsson O. J Tissue Eng and Regen Medicine. 2019 Dec 11.

10. Patel et al (2019). Fish skin acellular dermal matrix: potential in the treatment of chronic wounds. Chronic Wound Care Management and Research.

11. Mortality in patients with necrotizing fasciitis. GolgerA, Goldsmith CH, Pennie RA, Bain JR. Plastic Recontr Surg. 2007; 119: 1803-1807. (PubMed)

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Figure 2: STSG meshed at 4:1 and recell and re-application of fish skin graft Figure 3: