Abstract
Introduction
Standard management of open fractures includes irrigation and debridement of the wound followed by skeletal stabilization and often skin grafting over the defect. Skin grafting is associated with complications such as infection, hematoma, contracture, and potential failure. A novel alternative is acellular fish skin substitute, derived from North Atlantic codfish, requiring very minimal processing. We sought to explore it's use and effectiveness in the management of an open mid-foot dislocation.
Case Info
A 35 year old man with notable history including class II obesity and a previous left tibia fracture presented to the emergency department after suffering multiple injuries in a motorcycle crash. Imaging and operative findings identified a complex open right midfoot/forefoot fracture-dislocation (Lisfranc injury) classified as Gustilo-Anderson Type I/II open fracture along with compartment syndrome. He was immediately taken to the operating room for fasciotomies of the right leg and foot as well as skeletal stabilization with an external fixation device. Approximately 5 weeks following injury, the patient underwent open reduction and internal fixation of the fractures and acellular fish skin substitute was applied to the open wounds following sharp debridement. At this point the wounds measured 4 x 3 cm medially, 9 x 4 cm dorsally, and 3 x 5 cm laterally. The AFSS mesh was applied over each wound, secured with 3-0 Monocryl suture, and covered with a non-adherent dressing and a wound vac to facilitate negative pressure healing. Antibiotics were administered for 24 hours postoperatively. At his 1 week follow up appointment, the AFSS was incorporating appropriately and a second layer was then applied. Subsequent appointments continued to confirm appropriate incorporation and healing. Seven months after initial injury, complete re-epithelialization was achieved and the patient was continuing physical therapy exercises at home.
Disc Clinical
This patient suffered a devastating open fracture injury with extensive soft tissue defects. These injuries are a challenge to manage and in this case, extremity amputation was a concern from initial presentation. In contrast to the majority of these injuries, this patient did not require a skin graft. There was no infection, hematoma formation, scar contracture, or other complications throughout the healing process.
Conclusion
Acellular fish skin substitutes are a novel tool in the management of open fractures and this case demonstrates an excellent outcome. The major benefits of this product include its ease of application, long shelf life of nearly three years, room temperature storage, low risk of viral or prion disease transmission, and affordability. Though there is no head to head comparison of total cost, skin grafting for open fractures costs over $25,000 on average in the US. AFSS costs approximately $127 per square inch, and shorter hospital stay. Surgeons managing these injuries should consider AFSS application before pursuing skin grafting.