(CS-111) Upper and lower extremity limb salvage with the use of the reconstructive elevator

Introduction: The reconstructive ladder has been modified with the use of skin substitutes to an “elevator” to minimize morbidity of donor site grafts and free flaps, decrease recovery time, minimize hospital stays and improve function. Upper extremity hand wounds complicated with deep infections generally require local tissue rearrangement with local or regional perforated flaps and/or skin grafts. Implementing standard wound care principles – eradicating infection, optimizing blood supply, covering exposed deep structures or instrumentation, offloading, controlling exudate and optimizing range of motion, wound healing and return of function can be achieved in a timely fashion. Skin substitutes have given wound care specialists another tool in their armamentarium to stabilize an open wound and utilize the reconstructive elevator to achieve wound healing.

Methods: A sixty-four-year immunocompromised male presented 5 days after sustained a “bite” to the dorsal hand. The patient was admitted for IV antibiotics, diagnostic imaging, wound cultures and pain management. Upon inspection, extensor tendons were exposed, no bony changes were identified on imaging and he was neurovascular intact. The patient underwent several debridements, application of a skin substitute with NPWT and application of split thickness skin graft (STSG).

An eighty-three-year-old female sustained an acquired distal third and dorsal left lower extremity wound status post open reduction internal fixation (ORIF) after sustaining a fall 3 months prior. The patient received several debridements, application of two skin substitutes with NPWT.

Results: Both patients completely healed with restoration of range of motion. Both patients received post operative physical therapy. Neither patient had a complication nor an extended hospital stay. Both patients healed within 12 weeks of presentation.

Discussion: Skin substitutes, specifically fish skin graft, Kerecis is a xenograft with similar biologic properties to allografts. Evidence shows that is the ability to revascularize over tendons and works synergistically with adjuvants therapies such as negative pressure wound therapy and split thickness skin grafts. Lower limb salvage was achieved in an octogenarian that wound have otherwise needed free tissue transfer or an amputation. In the immunocompromised patient, the fish skin graft demonstrates the same efficacy and augmented neovascularization the skin thick skin graft without contracture and return of full range of motion. There is evidence to demonstrate that utilization of the fish skin graft minimizes hospitalization, reduces donor site morbidity, decreases the economic burden of acquired wound healing and can be used in conjunction with other advance wound modalities on the reconstructive elevator.