The Use of Intact Fish Skin Grafts in the Treatment of Necrotizing Fasciitis of the Leg: Early Clinical Experience and Literature Review on Indications for Intact Fish Skin Grafts

Abstract

Background: Necrotizing fasciitis (NF) is a serious infectious disease that can initially place the patient's life in danger and, after successful surgical and antibiotic treatment, leaves extensive wounds with sometimes even exposed bones and tendons. Autologous skin grafts are not always possible or require adequate wound bed preparation. Novel intact fish skin grafts (iFSGs; Kerecis^® Omega3 Wound, Kerecis hf, Isafjördur, Iceland) have already shown their potential to promote granulation in many other wound situations. Faster wound healing rates and better functional and cosmetic outcomes were observed due to their additionally postulated anti-inflammatory and analgesic properties. Therefore, iFSGs may also be essential in treating NF. We present our initial experience with iFSGs in treating leg wounds after NF and review the literature for the current spectrum of clinical use of iFSGs.

Case presentations: We present two male patients (aged 60 and 69 years) with chronic or acute postsurgical extensive leg ulcers six weeks and six days after necrotizing fasciitis, respectively. Both suffered from diabetes mellitus without vascular pathologies of the lower limbs. A single application of one pre-meshed (Kerecis^® Graftguide) and one self-meshed 300 cm² iFSG (Kerecis^® Surgiclose) was performed in our operation room after extensive surgical debridement and single circles of negative wound pressure therapy. Application and handling were easy. An excellent wound granulation was observed, even in uncovered tibia bone and tendons, accompanied by pain relief in both patients. Neither complications nor allergic reactions occurred. The patients received autologous skin grafting with excellent functional and cosmetic outcomes.

Conclusions: iFSGs have the potential to play a significant role in the future treatment of NF due to the fast promotion of wound granulation and pain relief. Our experience may encourage surgeons to use iFSGs in NF patients, although high-quality, large-sized studies are still required to confirm these results. The observed effects of iFSGs on wounds associated with NF may be transferred to other wound etiologies as well.

Keywords: chronic wounds; fish skin grafts; gangrene; intact fish skin; necrotizing fasciitis; negative pressure wound therapy; skin substitutes; skin transplantation; wound healing; wounds.

Figure 1

Different physician modifications of solid iFSGs: (A) Most usual graft fenestration using a surgical scalpel blade no. 11. (B) Graft shredding to achieve wound bed contact, even in deep wound beds, such as a non-healing toe amputation zone. (C) Intraoperative meshing of a cut-to-shape and hydrated large iFSG using a Zimmer air dermatome (Zimmer Biomet^®, Warsaw, IN, USA) and fixation to the wound bed with a stapler.

Figure 2

Timeline of the treatment of a chronic leg ulcer caused by necrotizing fasciitis supported by an intact fish skin graft (iFSG). After initial presentation (A) followed by ulcer shaving (B) and few days of negative pressure wound therapy a physician-meshed 300cm² iFSG (Kerecis^® Graftguide) was applied (C). Wound granulation was excellent after 5 days (D) but due to a slow epithelialization over time (E), the wound was finally closed using a split skin graft with complete closure 3 months after iFSG transplantation (F).

Figure 3

Timeline of the treatment of a postsurgical acute wound supported by an intact fish skin graft (iFSG) after extensive tissue loss due to necrotizing fasciitis. After initial presentation (A) and immediate surgical extensive debridement, forefoot amputation (B) and few days of negative pressure wound therapy a pre-meshed 300cm2 iFSG (Kerecis^® Graftguide) was applied onto the remaining wound bed (C). After six weeks and two isolated reapplications on an uncovered tibia site, the wound bed granulation was excellent (D) and a split skin graft transplantation was performed (E) to achieve complete wound closure after another 5 weeks (F) and an aesthetically and functionally satisfying late outcome (G).

Figure 4

Salvage of a dry iFSG in a low exudating wound five days after its application (A) using hydrogel (Prontosan^®, B. Braun Medical, Bethlehem, PA, USA) with a good result, graft dilution and incorporation and wound bed granulation after another five days (B).

Figure 5

Treatment of a nearly uncovered tibia area with two applications of iFSGs at two-week intervals supported by hydrogel (Prontosan^®, B. Braun Medical, Bethlehem, PA, USA) and dressed with a silicone interface and sterile compresses (A–C). No local debridement was performed, and the periosteum was left untouched. Due to the local progressive granulation (D), the patient was scheduled for final meshed autologous skin grafting.