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Management of Xylazine-Induced Soft Tissue Necrosis – A Review of 20 cases
Helene Retrouvey, MD PhD1, Maximilian Meyer, MD2, Kyros Ipaktchi, MD2, Andrew Maertens, MD2, Matthew Folchert, MD1 and Alexander Lauder, MD3, (1)University of Colorado, Aurora, CO, (2)University of Colorado School of Medicine, Aurora, CO, (3)Denver Health Medical Center, Denver, CO

Introduction: The illicit injection drug use of xylazine has recently been designated as an emerging public health threat. Xylazine is an alpha-2 adrenergic receptor agonist, a non-opioid sedative, analgesic, and muscle relaxant not approved for human use. The use of this drug is associated with fatal overdoses and devastating soft tissue necrosis that may lead to subsequent limb amputation. This study aimed to (1) summarize the available literature related to xylazine-related soft tissue necrosis, (2) report additional cases of soft tissue injury from xylazine, and (3) develop a staging system and management algorithm for wounds related to xylazine use.

Methods: A retrospective review was performed to identify patients treated with xylazine-related soft tissue necrosis at a Level 1 trauma center. Clinical cases, treatment strategy, and available outcomes were presented. Additionally, a comprehensive literature search was performed using the keywords “xylazine� and “soft tissue� to report similar cases in the published literature.

Results: The management of seven patients with xylazine-related upper extremity soft tissue necrosis were included in addition to summarizing findings of five studies reporting on thirteen additional cases. These cases were managed with local wound care (2 patients), surgical debridement (7 patients), osseous reconstruction (1 patient), skin graft reconstruction (3 patient), flap reconstruction (1 patient), and limb amputation (10 patients).

Conclusion: Acute treatment of xylazine-related soft tissue necrosis is ideal to minimize morbidity. Management strategies of these wounds should be based on tissue depth of involvement. Superficial ulceration involving the skin and subcutaneous tissue (Stage 1) should be managed with local wound care. Deeper ulceration involving tendons and/or muscle but superficial to bone (Stage 2) require surgical debridement and soft tissue reconstruction. Deeper ulceration involving bone (Stage 3) require bony debridement and reconstruction. Lastly, when all tissues in the extremity are involved (Stage 4), amputation may be the only option.

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