(CS-124) Fragmented Fish Skin Graft (FSG) to Heal Deep Heel Wounds

Deep heel wounds are notoriously difficult to heal due to a confluence of anatomical and physiological factors. The heel bears significant weight and pressure during ambulation, which impairs perfusion and contributes to sustained tissue damage (Lipsky et al., 2020). The constant pressure and weight-bearing stress on the heel, even with offloading techniques, can disrupt the delicate healing process and lead to further harm (Armstrong et al., 2018). Moreover, the plantar heel’s subcutaneous tissue has limited blood supply, which is crucial for delivering oxygen and nutrients necessary for tissue regeneration (Thomas, 2020). 

One of the most unique properties of the Icelandic codfish skin graft is that unlike the majority of other dermal substitutes, the fish skin graft (FSG) can be applied in layers onto itself. This makes it an ideal graft for deep wounds in which an entire cavity needs to be built up with granulation tissue.

Methods: In the two presented cases, the patients initially had a deep heel wound which was deep to subcutaneous tissue with a hard end feel. Due to the depth of the wound being dangerously close to bone, it was imperative to treat it in an aggressive manner. An initial incision and drainage was performed after which a serial debridement was performed a few days later. The fragmented FSG was packed into the wound cavity and Negative Pressure Wound Therapy (NPWT) was applied.

Results: At the two week follow ups, there was significant build up of granulation tissue in the wounds that the bone was no longer palpable. Incorporating caramelized graft tissue was fenestrated to allow for sanguineous saturation into the graft for continued incorporation. Serial debridements were performed in the clinic on a weekly basis and NPWT was re-applied. FSG was then reapplied onto the wounds as needed, when the wounds showed signs of plateauing.  Ultimately,  the wounds were completely healed and the patients returned to all activities.

Discussion: Packing the wound up to the brim with FSG serves as the necessary scaffolding the wound needs for migration of the body’s own cells throughout the entire surface area of the wound. Further replication of use of the graft in this particular manner is necessary to solidify its place as an appropriate standard of care for not just deep heel wounds, but for deeper cavitational wounds in general.