Filling Dead Space in Lower-Extremity Wounds with Fish Skin Grafts

Medical education note: This article is for clinicians. Always follow device IFUs and your institution's protocols.

Quick Take

Residual tissue voids after aggressive debridement are a major reason complex lower-extremity wounds stall or relapse. A podiatry service at UT Health San Antonio reports that packing these voids with an acellular fishskin graft (FSG) derived from North Atlantic cod supported rapid granulation, no graft rejection or adverse reactions, no interval infections or wound breakdown, and closure of all treated wounds—without additional surgery.

Why Dead-Space Management Is Mission-Critical

Unaddressed voids become reservoirs for fluid, bioburden, and recurrent breakdown, driving delays, repeat operations, and even major amputation—especially after large debridements for infection, ischemia, or trauma. Traditional approaches (bolster dressings, simple packing, or coverage alone) often fail to fill the space effectively. The piscine acellular dermal matrix offers a biologic 3D scaffold that supports cellular infiltration and angiogenesis, with a microarchitecture and omega-3 content that may create a more favorable healing environment.

What the Team Did

Population. High-risk patients with complex lower-extremity wounds and substantial dead space after aggressive debridement (etiologies included infection, ischemia, and trauma).

Intervention. After sharp debridement, fishskin graft was packed into the void and secured with standard secondary dressings. Patients were followed weekly for progression, granulation, infection surveillance, and time to closure.

Product. Kerecis® acellular fishskin graft (North Atlantic cod).

Outcomes That Matter

Integration & tolerance. No local adverse reactions or signs of graft rejection were observed.

Infection control. No interval infections or wound breakdown occurred during follow-up.

Surgical burden. No patient required additional procedures to obtain closure.

Healing. All wounds progressed to successful closure.

Practical Bedside Workflow

1. Debride Decisively

Remove all non-viable tissue to healthy margins and irrigate the cavity. Voids are best addressed after a proper debridement.

2. Pack the Void With FSG

Place the acellular fishskin graft into the dead space to fill and contact cavity walls; secure with your clinic's standard secondary dressings.

3. Follow Weekly

Monitor for granulation, dimensional fill, and signs of infection; adjust dressings as needed.

4. Stay Conservative When Possible

In this series, no additional surgery was required—an important win for limb-salvage patients with frail physiology.

Where This Fits in Limb-Salvage Algorithms

For wounds with high-risk profiles—diabetes, PAD, chronic infection, traumatic losses—filling the void is often the missing step. The authors conclude that FSG is a valuable adjunct for dead-space management that accelerates granulation and may reduce complications and reinterventions; they recommend its use within reconstructive limb-salvage protocols, while calling for larger studies to define comparative effectiveness.

Clinical Pearls

• Dead space is a diagnosis. Treat it intentionally, not as an afterthought to coverage.
• Biologic fill plus weekly oversight can keep high-risk patients moving steadily toward closure without escalation.
• Expect a quiet course. In this experience, there were no infections, breakdowns, or graft-related events, and every wound closed.

Limitations

This is a single-team series without a control arm; the poster calls for larger, comparative studies. Nevertheless, the consistent closures and absence of complications across varied etiologies are compelling signals for practice.

Clinician FAQ

When Should I Consider FSG for Voids?

After aggressive debridement leaves a cavity that simple dressings won't effectively occupy, especially in infectious, ischemic, or traumatic wounds.

How Often Do I Reassess?

This series followed patients weekly to document fill, granulation, and infection checks.

Did Anyone Need More Surgery?

No. None required additional procedures to achieve closure.

Any Graft Intolerance or Infections?

None reported—no rejection, local adverse reactions, or interval infections.

Bottom Line

When residual dead space threatens your lower-extremity cases, pack the cavity with acellular fishskin after debridement. In this series, that single step correlated with no infections or reoperations and closure in every case, and RCT data suggest intact fish-skin grafts can improve healing outcomes compared with standard care alone in deep diabetic foot ulcers.

References

1. Kerecis. Kerecis Fish-Skin Technology to Make a Splash at SAWC Fall 2025 – poster list. Press release, Sept 3, 2025.
2. Outos M, Nussbaumer P. Use of Fish Skin in the Treatment of Chronic Lower Extremity Wounds: A Case Series Report. J Surg. 2022;7:1468.
3. Oliver RA, Lovric V, Christou C, et al. Development of a Novel Model for the Assessment of Dead Space After Surgical Debridement. PLoS One. 2015;10(8):e0136514.
4. Patel M, Lantis JC II. Fish Skin Acellular Dermal Matrix: Potential in the Treatment of Chronic Wounds. Chronic Wound Care Manag Res. 2019;6:59-70.
5. Tickner A, Aviles F, Kirsner R, et al. Consensus Recommendations for Optimizing the Use of Intact Fish Skin Graft. Wounds. 2023;35(11):E376–E390.
6. Zhao C, Feng M, Gluchman M, et al. Acellular Fish Skin Grafts in the Treatment of Diabetic Wounds. J Diabetes. 2024;16(5):e13554.
7. Gage MJ, Liporace FA, Egol KA. Dead Space Management After Orthopaedic Trauma. J Orthop Trauma. 2016;30(3):64-70.
8. Dardari D, Piaggesi A, Potier L, et al. Intact Fish Skin Graft to Treat Deep Diabetic Foot Ulcers. N Engl J Med Evid. 2024;3.