Use of Intact and Micronized Fish Skin for Treatment of the Complications of Frostbite

Introduction: 68 year old male who presented on January 18, 2024 with shortness of breath. He has a positive history of tobacco and substance abuse. The patient has been intermittently homeless. He has insulin dependent diabetes which has been uncontrolled.Our service was consulted four days after admission once his renal and pulmonary statuses were stabilized. Initial examination revealed severe blistering to both feet with evidence of frostbite with multiple serous blisters present to the dorsal of both feet and ankles. Methods:Additional blisters developed over the next two days. These were incised and drained. Each foot was dressed with Adaptic, Chlorhexadine, and a compression dressing. He continued on IV Vancomycin and oral Metronidazole. Several additional incision and drainage procedures were performed for new blister formations. On February 4, 2024 the blisters had dried and the epidermis was blackened discolored with eschar formation to the dorsal of each foot, anterior ankle and all 10 toes were becoming gangrenous due to impairment of the microcirculation. Eight days later the patient was brought to the OR for frostbite to both feet with tissue necrosis and gangrene of the toes, 1-5, bilateral feet. Measurement of the Ulcers/eschars to the primary wound sites: 11cm x 12cm x 0.4cm to the right foot, primarily dorsum; left foot: 10cm x 9cm x 0.4cm There were multiple smaller secondary and tertiary ulcer/necrosis sites.  The patient was readmitted on February 28, 2024 as the dorsal wounds had stabilized and the toes were completely gangrenous, 1-5, bilateral feet. He underwent transmetatarsal amputation of each foot on March 1, 2024. The left foot plantar flap was brought dorsal and closed with 2-0 nylon simple sutures with minimal tension. 38 sq cm of micronized fish skin graft was applied to the wound bed in any areas of deficit. A 6 cm x 8 cm meshed Fishskin graft was then applied over the dorsal ulcer and opening of the incision. Results:The patient returned to the OR 11 days later for debridement of any new eschar tissue and application of additional micronized and fenestrated grafts to the open wounds to the dorsal and plantar aspects of the right and left foot. He was discharged to SNF the next day with the dressings intact. The patient was followed bi-weekly and then weekly monitoring the healing of the remaining ulcer sites.Discussion: The patient is scheduled for additional grafting on June 7, 2024.References: