What is the recommended treatment protocol for wounds using Atlantic Cod Acellular Dermal Matrix (ADM)?

Atlantic Cod Acellular Dermal Matrix (ADM) Wound Therapy

Critical Evidence Gap

There is no guideline or research evidence specifically addressing Atlantic cod-derived acellular dermal matrix in the provided literature. The evidence base focuses exclusively on human-derived ADM (HADM), porcine-derived ADM (PADM), and bovine-derived ADM (BADM), with no mention of fish or Atlantic cod-derived products 1, 2.

General ADM Wound Therapy Protocol (Based on Available Evidence)

Since Atlantic cod ADM is not addressed in current guidelines, the following represents the evidence-based approach for ADM products in general, which would theoretically apply if Atlantic cod ADM demonstrates similar properties:

Wound Bed Preparation (Essential First Step)

• Perform aggressive surgical debridement of all necrotic, nonviable tissue before ADM application 3, 4, 5. This converts chronic wounds to acute wounds and is fundamental to success 4, 5.
• Ensure adequate revascularization of ischemic wounds prior to ADM placement 3, 5.
• Control infection with appropriate antimicrobial therapy and surgical debridement when abscess, gas, or necrotizing fasciitis is present 4.
• Maintain moist wound environment with physiologic dressings while controlling exudate 3, 4, 5.

Indications for ADM Application

ADM should be considered when wounds fail to show ≥50% reduction after 4 weeks of appropriate standard wound management 3, 4, 5. This includes:

• Diabetic foot ulcers that remain chronic despite offloading, debridement, and infection control 3, 6
• Contaminated or high-risk abdominal wall defects where synthetic mesh is contraindicated 3, 7
• Complex tissue defects with compromised host extracellular matrix 1

Application Technique (Based on Human ADM Evidence)

• Apply ADM directly to adequately debrided wound bed 6, 7
• For injectable micronized ADM formulations: single-stage application allows outpatient treatment with moldable matrix to fit any wound shape 6
• For sheet ADM: place in sublay extra-peritoneal position when possible in abdominal wall reconstruction, as this reduces wound complications compared to other placements 3
• Always use non-adherent interface layer to protect exposed organs in open abdomen scenarios 3

Contaminated Field Considerations

ADM can be safely used in contaminated surgical fields, though recurrence rates are higher than with synthetic mesh 3. Specifically:

• Wound infection rates with ADM in contaminated fields are similar to synthetic mesh 3
• However, pooled hernia recurrence rates are 27.2% with biological mesh versus 3.2% with synthetic non-absorbable mesh 3
• ADM successfully resists infection in high-risk wounds, with 96% healing without event despite 45% postoperative wound occurrence rate 7
• ADM is effective even in infected diabetic foot wounds, with 84% showing positive tissue cultures at application 6

Expected Outcomes and Follow-Up

• For diabetic foot wounds: expect statistically significant reduction in wound size of 45% at 2 weeks and 59% at 4 weeks post-treatment 6
• For abdominal wall defects: 89-90% successful primary closure with one surgery, with mean follow-up of 182 days 7
• Repeated wound assessment allows evaluation of biofilm, infection, and need for frequent debridement 4

Critical Pitfalls to Avoid

• Do not apply ADM without first addressing the five basic wound care principles: offloading, debridement, revascularization, infection management, and physiologic dressings 3, 5
• Do not use ADM as first-line therapy before attempting 4 weeks of standard wound management 3, 4, 5
• Do not neglect evaluation for osteomyelitis in non-healing ulcers before ADM application 5
• Do not apply compression therapy with ankle-brachial index <0.6 without revascularization in venous wounds being considered for ADM 4

Atlantic Cod ADM Specific Considerations

Without specific evidence for Atlantic cod-derived ADM, clinicians should demand the same level of evidence (robust RCTs or systematic reviews) that exists for human, porcine, and bovine ADM products before routine clinical use 3, 5. The processing protocol, antigenicity, vascularization capacity, and stability as a dermal template must be characterized 8 before Atlantic cod ADM can be recommended with the same confidence as established ADM products 1, 2.