Application of Fragmented Fish Skin Graft* on a Nonhealing Diabetic Foot Ulcer for a Diabetic, Bedbound Patient with Neuropathy and ESRD

Introduction:  Fish skin graft (FSG) is a xenograft derived from Atlantic cod that augments wound healing1. This case evaluates FSG* in a patient with non healing diabetic foot ulcer (DFU) which had not responded to conservative wound care. Patient is a 70-year-old, bedbound male on dialysis for end-stage renal disease (ESRD) with PMH of diabetes, neuropathy, depression, hyperlipidemia, and cardiomyopathy. Need for non-conservative treatment arose as the wound persisted for over one month.Methods:The patient is a 70-year-old, bedbound male who presented with a necrotic arterial ulcer on the hallux of the left foot. At initial visit, wound was 1.0 cm x 1.0 cm, depth unknown. Imaging indicated bilateral arterial plaquing and vascular calcifications. Twelve days later, the wound measured 1.0 cm x 0.9 cm, depth unknown. Rivaroxaban was prescribed to improve blood circulation. After one week, the wound measured 1.0 cm x 1.0 cm x 0.1 cm and underwent full-thickness biopsy and debridement; culture was negative. FSG was determined necessary as the wound had persisted for over one month. Nine days later, wound size was 1.0 cm x 0.5 cm x 0.1 cm and first FSG was applied. The following week, the wound measured 0.5 cm x 0.5 cm x 0.1 cm and a second FSG was applied. Two weeks later, the wound measured 0.4 cm x 0.2 cm x 0.05 cm. Patient reported less pain and the wound was predicted to be able to achieve closure without FSG, however a third and final FSG was applied to expedite healing. Wound was noted to be fully healed two weeks later.Results:Three applications over four weeks augmented complete wound closure. This demonstrates the efficacy of using FSG on a nonhealing, necrotic arterial foot ulcer.Discussion: This case illustrates clinical efficacy in treating non healing DFU using FSG in a bed bound, neuropathic male patient on dialysis for ESRD. FSG proved safe and effective in augmenting healing. More extensive studies should investigate FSG efficacy in treating DFU in bedbound, neuropathic, and ESRD patients on dialysis.References:Di Mitri, M. (2023). Plastic & Reconstructive Surgery - Global Open, 11.