The Reconstructive Ladder Meets Marine Biotechnology: Acellular Fish Skin Grafts and Negative Pressure Wound Therapy for Complex Pediatric Foot Trauma: A Two-Case Report and First Institutional Experience

Abstract

Background: Complex pediatric foot trauma with exposed deep structures presents a major reconstructive challenge. The classical answer—flap reconstruction—carries donor-site morbidity, long operative times, and intensive monitoring poorly suited to young children and to resource-limited public hospitals. Intact acellular fish skin grafts (AFSG) derived from Atlantic cod (Gadus morhua) are an omega-3–rich biomaterial that preserves a native three-dimensional extracellular matrix and promotes rapid vascularization and granulation, without the zoonotic risk or harsh chemical processing of mammalian substitutes. Case description: We report two boys treated at CHU Ibn Rochd, Casablanca, in what is, to our knowledge, the first use of AFSG at our institution. Case 1 was a 5-year-old with an 8 × 10 cm heavily contaminated dorsolateral foot defect after a motor-vehicle accident; after wound-bed conditioning, an AFSG was applied under continuous negative pressure wound therapy (NPWT) and a vascularized granulation bed was obtained within three days, allowing definitive split-thickness skin grafting (STSG), with closure approximately 18 days after injury. Case 2 was a 3-year-old referred with full-thickness dorsal necrosis after a failed degloving repair, with exposed navicular and cuneiform bone and extensor tendon loss; an AFSG under petrolatum gauze and NPWT produced granulation over bare cortical bone within four days, enabling immediate STSG and complete closure. Conclusion: In both children, AFSG combined with NPWT rapidly converted complex bone- and tendon-exposing wounds into graftable beds, markedly shortening the time to definitive closure and avoiding free-flap reconstruction. Its principal limitations are limited local availability and high cost, compounded by the absence of insurance or hospital reimbursement coverage, which currently constrain routine use in our resource-limited setting.