Filling Dead Space in Lower-Extremity Wounds with Fish Skin Grafts
Filling the Void: Using Acellular FishSkin to Eliminate Residual Dead Space in Complex Lower-Extremity Wounds
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.[1,2]
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.[3,4]
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).[1,5]
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.[5,11]
Product. Kerecis® acellular fishskin graft (North Atlantic cod).[2,8]
Outcomes that matter
Integration & tolerance. No local adverse reactions or signs of graft rejection were observed.[1,2]
Infection control. No interval infections or wound breakdown occurred during follow-up.[1,7]
Surgical burden. No patient required additional procedures to obtain closure.[1,2]
Healing. All wounds progressed to successful closure.[1,2]
Practical bedside workflow (replicable steps)
Debride decisively. Remove all non-viable tissue to healthy margins and irrigate the cavity. Voids are best addressed after a proper debridement.[11,12]
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.[4,5]
Follow weekly. Monitor for granulation, dimensional fill, and signs of infection; adjust dressings as needed.[1,5]
Stay conservative when possible. In this series, no additional surgery was required—an important win for limb-salvage patients with frail physiology.[1,2]
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.[5,10]
Clinical pearls
Dead space is a diagnosis. Treat it intentionally, not as an afterthought to coverage.[3,9]
Biologic fill + weekly oversight can keep high-risk patients moving steadily toward closure without escalation.[2,10]
Expect a quiet course. In this experience, there were no infections, breakdowns, or graft-related events, and every wound closed.[1,7]
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, mirroring the broader acellular fish-skin literature, which still emphasizes the need for more randomized, head-to-head trials.[4,6]
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.[5,9]
How often do I reassess?
This series followed patients weekly to document fill, granulation, and infection checks, consistent with consensus guidance for complex lower-extremity wounds treated with intact fish-skin grafts.[1,5]
Did anyone need more surgery?
No. None required additional procedures to achieve closure, echoing other lower-extremity fish-skin series that report complete healing without re-operation.[1,2]
Any graft intolerance or infections?
None reported—no rejection, local adverse reactions, or interval infections—similar to trauma and chronic-wound case series where acellular fishskin was well-tolerated and free of graft-related complications.[1,7]
Cite-as-you-read
All methods, outcomes, and conclusions above are anchored in the “Addressing Residual Tissue Voids in Lower Extremity Wounds with Acellular Piscine Skin Substitute Graft” poster experience and corroborated by peer-reviewed fish-skin literature in diabetic and other chronic wounds.[1,6]
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.[1,10]
References
(Each number matches the bracketed citations in the text.)
[1] Kerecis. Kerecis Fish-Skin Technology to Make a Splash at SAWC Fall 2025 – poster list including “Addressing Residual Tissue Voids in Lower Extremity Wounds with Acellular Piscine Skin Substitute Graft.” Press release, Sept 3, 2025.
Link: https://www.kerecis.com/kerecis-fish-skin-technology-to-make-a-splash-at-sawc-fall-2025/ kerecis.com
[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. Case series of chronic lower-extremity wounds treated with Atlantic cod fish-skin showing complete healing and no major side effects.
Link: https://www.gavinpublishers.com/article/view/use-of-fish-skin-in-the-treatment-of-chronic-lower-extremity-wounds-a-case-series-report
[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. Describes how unobliterated dead space rapidly fills with hematoma/exudate that provides ideal conditions for bacterial growth.
Link: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136514
[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. Reviews histologic structure, omega-3 lipid content, and clinical data for acellular fish-skin matrices in chronic wounds.
Link: https://www.dovepress.com/fish-skin-acellular-dermal-matrix-potential-in-the-treatment-of-chroni-peer-reviewed-fulltext-article-CWCMR
[5] Tickner A, Aviles F, Kirsner R, et al. Consensus Recommendations for Optimizing the Use of Intact Fish Skin Graft in the Management of Acute and Chronic Lower Extremity Wounds. Wounds. 2023;35(11):E376–E390. Provides expert guidance on indications, timing, and follow-up for intact fish-skin grafts in limb-salvage algorithms.
Link: https://pubmed.ncbi.nlm.nih.gov/38048615/
[6] Zhao C, Feng M, Gluchman M, et al. Acellular Fish Skin Grafts in the Treatment of Diabetic Wounds: Advantages and Clinical Translation. J Diabetes. 2024;16(5):e13554. Review of mechanisms (collagen, omega-3 fatty acids) and clinical data for acellular fish-skin grafts in diabetic wounds.
Link: https://pubmed.ncbi.nlm.nih.gov/38664883/
[7] Cole W. Use of Acellular Fish Skin Graft to Decrease Pain and Inflammation While Speeding Healing in Trauma Wounds. Poster, American College of Foot and Ankle Surgeons (ACFAS) 2019. Lower-extremity trauma case series in which all patients healed without reported adverse events.
Link (PDF): https://www.acfas.org/getattachment/79555451-01a2-4cb4-be89-365084a75ce6/POST2019_CS-1003.pdf
[8] Kerecis. Fish Skin for Wound Healing. Product and science overview of intact Atlantic cod fish-skin grafts, indications, and key clinical studies including the Odinn RCT.
Link: https://www.kerecis.com/fish-skin-for-wound-healing/
[9] Gage MJ, Liporace FA, Egol KA. Dead Space Management After Orthopaedic Trauma: Tips, Tricks, and Pitfalls. J Orthop Trauma. 2016;30(3):64-70. Discusses how dead space and fluid collections drive infection and failure in limb-salvage trauma cases.[9] (PDF via Orthobullets upload) https://upload.orthobullets.com/journalclub/free_pdf/26429404_26429404.pdf
[10] 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. RCT showing higher healing rates and faster time to closure vs standard care for deep DFUs treated with intact fish-skin grafts.
Link: https://pubmed.ncbi.nlm.nih.gov/39365895/
[11] Nowak M, Reed M, Pugliese D, et al. Wound Debridement Products and Techniques. Int Wound J. 2022;19(5):1081-1097. Review emphasizing sharp removal of devitalized tissue and irrigation as foundations of wound bed preparation.
Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC9326937/
[12] Wound Debridement – Physio-pedia. Overview of sharp and mechanical debridement, indications, and infection risk when devitalized tissue is not removed.
Link: https://www.physio-pedia.com/Wound_Debridement
