September - October 2022
Surgical Applications of Intact and Fragmented Fish Skin Grafts and NPWT for Lower Extremity Wounds: A Case Report
Editorial Summary
Introduction
Compartment syndrome, acute or chronic, occurs with increased pressure within a confined space in the body, affecting areas of the body known as fascial compartments. Formed by a special tissue that forms a membrane layer around muscles, fascial compartments are highly sensitive to pressure changes. Increased pressure significantly reduces blood flow to the area, impairing oxygen delivery, ultimately causing nerve and muscle damage. Compartment syndrome can occur in the hand, forearm, upper arm and buttocks, commonly occuring in the anterior fascial compartment below the knee. Fractures, burns, bites and crush injuries can cause acute compartment syndrome where there is significant damage to the blood vessels and tissues. Repetitive tissue injury and overuse can also lead to chronic compartment syndrome. Symptomatically, severe pain (even at rest), tightness, reduced mobility, decreased function and difficulty weight bearing are are all pathognomonic of this condition.
Fasciotomy is the definitive treatment for acute compartment syndrome to decompress the involved compartments, decreasing the risk of amputation of the affected limbs. Although this is a life-saving procedure, patients are often faced with complications including long hospital stays, wound infection, and osteomyelitis due to the challenges associated with healing full-thickness wounds. With no clear consensus regarding the best methodology for closure of fasciotomy wounds, the technique applied each time is largely the surgeon’s preference.
In these case reports, the feasibility of an intact fish skin graft for definitive fasciotomy wound closure in a patient with multiple wounds is assessed, and a second case involves multiple nonhealing venous ulcers with extensive soft tissue loss and exposed tendons.
Lower limb reconstruction remains a pivotal but challenging aspect of a wound care clinician’s workload. This article offers an overview of surgical applications of intact and fragmented fish skin grafts and Negative Pressure Wound Therapy (NPWT) for lower extremity wounds. Dr Deepali Darji Northern Illinois Foot & Ankle Specialists Cleveland OH, United States Dr Joseph D. Rundell Northern Illinois Foot & Ankle Specialists Philadelphia PA, United States Dr Rimvydas P. Statkus Northern Illinois Foot & Ankle Specialists74 Wound Masterclass - Vol 1 - September 2022
Chicago IL, United States
Dr Patrick A. McEneaney
Northern Illinois Foot & Ankle Specialists
Crystal Lake IL, United States
Surgical Applications of Intact and Fragmented Fish Skin Grafts and NPWT for Lower Extremity Wounds:
First Patient
A male patient presents with compartment syndrome of the right leg and secondary rhabdomyolysis a week after surgery. The patient received multiple fasciotomies of the leg, resulting in five wounds. The wound beds were debrided three days after the procedure
and meshed fish skin grafts were sutured in place, followed by a non-adherent dressing, before continuous NPWT (negative pressure wound therapy) at 125 mmHg setting with bridging between wound sites. The patient received four applications of Omega3 fish skin grafts to all sites, including a single application of fragmented intact fish skin graft into the larger area wounds.
Figure 1: Reconstructive steps.
1a: S/p fasciotomy. Wound bed preparation/ debridement prior to first application of Omega3 fish skin grafts.
1b: 3:1 ratio meshing of fish skin Complete wound closure of all sites achieved graft.
1c: Meshed fish skin graft sutured over wound base.
1d: Non-adherent dressing placed over the graft prior to application of NPWT with bridging between wounds.
1e: Application of fragmented fish skin graft as wound size decreased and discontinued the use of NPWT.
1f: Complete wound closure of all sites achieved.
A Case Report
1d 1e 1f Wound Masterclass - Vol 1 - September 2022 75
1a 1b 1c
Surgical
Second Patient
aggressive wound debridement and advanced wound care due to deterioration and active infection. After resolution of infection, the wounds were debrided prior to placement of grafts and NPWT.
Applications of Intact and Fragmented Fish Skin
NPWT
Lower
Wounds: A Case Report
The second case involved a male patient with chronic venous insufficiency and three large ulcers encompassing the right ankle. The patient was referred to the surgeon for 2a: Extensive soft tissue loss with multiple venous ulcers to the right ankle. 2b: After treatment of infection and debridement of non-viable tissue, a clean granulating base was achieved prior to application of graft tissue. 2c: Application of fragmented Omega3 fish skin graft. 2d: NPWT with bridging between multiple ulcers. 2e: After serial debridements and multiple graft applications, all sites were epithelialized soon after this photo was taken. 2a 2b 2c 2d 2e 76 Wound Masterclass - Vol 1 - September 2022
Grafts and
for
Extremity
Figure 2:
“Previously published clinical trials showed that full-thickness acute wounds treated with fish skin healed significantly faster than wounds treated with porcine tissue.”1-3
Discussion
Most wound sites were epithelialized within two months. The average wound surface area reduction across the five wounds one month after the application of fish skin was over 7%. The wounds showed an earlier buildup of granulation tissue. The results had good cosmetic and functional outcomes for the patients.
Previously published clinical trials showed that full-thickness acute wounds treated with fish skin grafts healed significantly faster than wounds treated with porcine tissue.1-3
References
1. Lullove EJ, Liden B, Winters C, McEneaney P, Raphael A, Lantis Ii JC. A Multicenter, Blinded, Randomized Controlled Clinical Trial Evaluating the Effect of Omega-3-Rich Fish Skin in the Treatment of Chronic, Nonresponsive Diabetic Foot Ulcers. Wounds. 2021 Jul;33(7):169-177. doi: 10.25270/wnds/2021.169177. Epub 2021 Apr 14. PMID: 33872197.
2. Magnusson S, Baldursson BT, Kjartansson H, Rolfsson O, Sigurjonsson GF. Regenerative and Antibacterial Properties of Acellular Fish Skin Grafts and Human Amnion/Chorion Membrane: Implications for Tissue Preservation in Combat Casualty Care. Mil Med. 2017 Mar;182(S1):383-388. doi: 10.7205/MILMED-D-16-00142. PMID: 28291503.
3. Kirsner RS, Margolis DJ, Baldursson BT, Petursdottir K, Davidsson OB, Weir D, Lantis JC 2nd. Fish skin grafts compared to human amnion/chorion membrane allografts: A doubleblind,
Animal studies have shown that Omega-3 fatty acids in the fish skin graft have an inhibitory effect on bacterial growth, improve epithelial cell migration, angiogenesis and accelerated blood perfusion in the wound bed.4,5 By incorporating aggressive wound debridement/ preparation and application of NPWT, as well as applying the standard tenets of wound management (reduction of bioburden/ infection and adequate offloading), these wounds can heal considerably faster compared to conventional wound care.1
prospective, randomized clinical trial of acute wound healing. Wound Repair Regen. 2020 Jan;28(1):75-80. doi: 10.1111/wrr.12761. Epub 2019 Oct 25. PMID: 31509319; PMCID: PMC6972637.
4. Kotronoulas A, Jónasdóttir HS, Sigurðardóttir RS, Halldórsson S, Haraldsson GG, Rolfsson Ó. Wound healing grafts: Omega-3 fatty acid lipid content differentiates the lipid profiles of acellular Atlantic cod skin from traditional dermal substitutes. J Tissue Eng Regen Med. 2020 Mar;14(3):441-451. doi: 10.1002/term.3005. Epub 2019 Dec 30. PMID: 31826323.
5. 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. PMID: 33557424; PMCID: PMC7915828.
A Case Report
Surgical Applications of Intact and Fragmented Fish Skin Grafts and NPWT for Lower Extremity
Wounds:
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