Closure of a Diabetic Foot Ulcer with a Fish Skin Graft in a patient with multiple co-morbidities and vascular compromise

Introduction: This is a 66 yr old female who is a noncompliant diabetic and smoker with PAOD, PVD, HTN, and history of MI x 2 with PTCA and stent placements.  This patient presented to the ER in October with cellulitis of her right foot due to a gangrenous right great toe.  She had an open wound to her right lateral foot from walking to avoid ambulating on her black toe.  CTA showed bilateral SFA occlusions.  Due to her labs being normal and the fact that she was not bacteremic, antibiotics were started as an outpatient and a right SFA stent was placed within 2 weeks.   She was then taken to OR for a right great toe amputation.  The right lateral foot wound was debrided surgically in OR and wound care resumed in clinic.Methods:FSG applications were started in December after SOC with serial debridements, dressings, compression, glucose management, and offloading.  The FSG was applied once weekly in the Wound Clinic and secured with a veil, then backed with an absorbent silver hydrofiber (Aquacel), foam borderless dressing, kerlex, and ACE wrap.  She required weekly debridement to prep the wound bed for FSG application with each clinic visit.  A total of 7 applications of decellularized fish skin graft was applied to her right lateral foot ulcer over 3 months.  She refused compression wraps after 2 visits and eventually only wore a diabetic shoe due to refusing a walking boot as well.Results:Within 1 month of 3 applications of FSG to her right lateral foot wound, her ulcer size reduced in width by 50% as she developed granulation tissue that filled in the defect quickly.  Drainage decreased as well.   6 applications and 2 months later, her foot ulcer was 90% healed.  She closed after 7 applications of FSG by end of March.Discussion: North Atlantic Cod fish skin was effective at healing her right lateral foot DFU despite her co-morbidities, heavy tobacco use, and noncompliance with offloading.  She went on to receive 3 more FSG applications for a right heel ulcer that developed 12 months later which also healed without complications.  She remained closed with soft pliable tissue, no contractures, no pain, and minimal scarring.  No further skin injuries occurred over the next 1.5 years and she is now deceased.References: