(CS-076) Limb Salvage Utilizing Omega3 Fish Skin Graft*

It is estimated that diabetic ulcerations and infections cost the U.S. $9-13 million annually¹. These ulcerations are insidious, extending themselves to morbidity and mortality². Four out of ten patients with diabetic ulcerations will undergo an amputation; within five years, seven out of ten will die². As such, limb salvage is critical to reducing mortality. Further, amputation is expensive. Thus, advanced therapies that augment limb salvage are needed. In this case study, the authors show that Fish Skin Graft (FSG), an acellular dermal matrix featuring omega-3 fatty acids, three-dimensional structure, and intact biological and mechanical properties like the host tissue, can promote angiogenesis, leading to faster healing and limb salvage.

Methods:

The patient initially presented with a diabetic foot ulcer (DFU) that was infected. Due to Covid and closures, the patient could not seek regular treatment at the local wound care center. Unfortunately, lack of treatment allowed the infection to migrate to the flexor tendon sheath, which later developed into a gas infection. The patient presented with a fever, became septic, and was transferred to the emergency room, where he was admitted. Due to the severity, the admitting physician recommended a below-knee amputation (BKA); however, the patient requested limb salvage. The patient was informed that a BKA was a faster alternative but that limb salvage was an option due to good vascular status. The patient underwent an incision and drainage followed by removing all devitalized tissue. A second surgery was needed four days postop to remove additional infected tissue. At four weeks, signs of infection had diminished, including erythema and swelling. FSG was selected due to its bacteriostatic properties and known cellular ingrowth. 

Results: The patient underwent several applications of the FSG and was able to reach full epithelization via secondary intent. The FSG rapidly regenerated the tissue and preserved the limb. Further, the patient had preserved function and could return to his place of employment.

Discussion:

In this single case, FSG significantly improved the patient's quality of life. FSG is minimally processed, preserving the native structure, biological components, and Omegga3 Fatty acids. The FSG augments cell ingrowth and angiogenesis, moving wounds through the wound healing cascade faster than competitive products^3,4. These properties, combined with the bacteriostatic properties and proven superior cosmetic outcomes, make FSG an excellent choice during limb salvage treatment^5,6. Future, more significant prospective studies should evaluate the effectiveness of FSG in complicated limb salvage patients.

Trademarked Items: *KerecisTM, Kerecis, Isafjordur, Iceland

References: 1. Raghav A, Khan ZA, Labala RK, Ahmad J, Noor S, Mishra BK. Financial burden of diabetic foot ulcers to world: a progressive topic to discuss always. Ther Adv Endocrinol Metab. 2018 Jan;9(1):29-31. doi: 10.1177/2042018817744513. Epub 2017 Dec 12. PMID: 29344337; PMCID: PMC5761954.
2. Winters C, Kirsner RS, Margolis DJ, Lantis JC. Cost Effectiveness of Fish Skin Grafts Versus Standard of Care on Wound Healing of Chronic Diabetic Foot Ulcers: A Retrospective Comparative Cohort Study. Wounds. 2020 Oct;32(10):283-290. PMID: 33370245.
3. 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.
4. 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.
5. Baldursson BT, Kjartansson H, Konrádsdóttir F, Gudnason P, Sigurjonsson GF, Lund SH. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: a noninferiority study. Int J Low Extrem Wounds. 2015 Mar;14(1):37-43. doi: 10.1177/1534734615573661. Epub 2015 Mar 9. PMID: 25759413.
6. Wallner, C.; Holtermann, J.; Drysch, M.; Schmidt, S.; Reinkemeier, F.; Wagner, J.M.; Dadras, M.; Sogorski, A.; Houschyar, K.S.; Becerikli, M.; Lehnhardt, M.; Behr, B. The Use of Intact Fish Skin as a Novel Treatment Method for Deep Dermal Burns Following Enzymatic Debridement: A Retrospective Case-Control Study. Eur. Burn J. 2022, 3, 43-55. https://doi.org/10.3390/ebj3010006