When Treatment Including a Piscine Acellular Dermal Matrix Results in Limb Preservation

In a poster presented at SAWC Fall, Ian Barron, DPM, FACFAS, showcases a case where piscine acellular dermal matrix (ADM) had an impact for a patient with necrotizing fasciitis.

A 70-year-old female with type 2 diabetes and end-stage renal disease began treatment for necrotizing fasciitis, as identified via subcutaneous emphysema surrounding the fourth and fifth rays of the right foot on radiographs and computed tomography. She then underwent emergent fourth and fifth ray amputation with application of negative pressure wound therapy with instillation (Veraflo, 3M) of 0.25% diluted sodium hypochlorite solution (Dakin’s solution, Century Pharmaceuticals). Subsequent bone biopsy results, and repeat debridements took place, resecting part of the cuboid. After the third debridement, the surgeon applied an intact piscine ADM (Kerecis) to the wound bed, including exposed, partially resected cuboid bone. Negative pressure wound therapy was not resumed due to skin maceration.

This first graft completely incorporated within 10 days, including covering the exposed remaining cuboid bone. Local wound care with silver alginate managed exudate. Due to persistent tunnelling of the wound, a second piscine ADM application took place following debridement. The surgeon fragmented the matrix and packed the tunneling wound, also covering the ulcer base, including exposed third metatarsal head.

This addition application resulted in significant granulation and depth coverage within one week, including that of tendon and bone. Application of skin graft substitute did allow for complete closure and resulting limb preservation 16 weeks after the second piscine ADM application.

Dr. Barron, the Assistant Director of Research at the Grant Medical Center Foot and Ankle Surgery Residency Program in Columbus, OH, says he was inspired to present this case for multiple reasons, but primarily due to the extent of the initial infection and deficit.

“Other services wanted to take the patient for a below-knee amputation (BKA), but I felt a BKA would ultimately lead to a quick decline for the patient,” he explains. “The salvage success allowed for custom bracing, which has given the patient her independence back.” 

He points out that even though some may not consider the foot functional given the extent of the amputation, it has allowed continuation of independent daily activities. He adds that he also feels it could decrease risk of BKA-associated mortality.

Dr. Barron discloses he is a paid consultant for Kerecis.