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Unmet Challenges: Assessing Non-healing Xylazine Wounds and the Paucity of Effective Treatment Options. A Retrospective Review with Illustrative Cases.
Genoveffa R Morway, DO1, Parker H Johnsen, MD2, Aaron Jackson, DO, DPT1, Pietro Gentile, BS2 and Katharine T Woozley, MD2, (1)Philadelphia College of Osteopathic Medicine, Philadelphia, PA, (2)Cooper University Hospital, Camden, NJ

The increasing prevalence of the veterinary tranquilizer, xylazine, in the illicit intravenous drug market has led to severe soft tissue wounds, often found on the upper extremities. This sedative analgesic is increasingly found in seized fentanyl samples in certain areas of the country, particularly in the greater Philadelphia area. The unique cutaneous manifestation of xylazine use consists of large deep angulated ulcerations, typically with eschar formation which often persist for months-to-years. The goal of this study is to describe the nature of and review the treatment options for these relatively new and difficult-to-treat wounds.

Materials & Methods
A retrospective chart review was performed at a level one trauma center located in an area with significant xylazine adulteration of fentanyl supply. International Classification of Diseases, Tenth revision (ICD-10) codes were used to identify adult patients hospitalized with upper extremity wounds. Chart review verified xylazine use via history obtained from the patient. Clinical data was collected and analyzed, including demographics, laboratory values, hospital readmissions, attempted treatments, and outcomes.

One hundred and ten patients met the inclusion criteria for the study. The use of xylazine was confirmed via patient history as, at the time these patients were seen, there was no commonly accepted laboratory test for presence of xylazine. While there was a trend towards elevated inflammatory markers, patient’s did not regularly present with leukocytosis. The wounds varied from superficial to deep necrotic wounds with exposed bone, often with eschars.
Treatments included intravenous antibiotics, local wound care, and for many patients, surgical procedures. Surgeries performed include irrigation and debridement, split thickness skin graft, groin flap, and amputations. A significant percentage of patients required multiple procedures, indicating failure of index procedures. No single procedure showed any increased likelihood for healing. A clinical observation noted at this institution, not specifically elucidated in the data, was that once patients stopped using xylazine, their ability to heal seemed to improve significantly.

Xylazine use in humans has led to distinctive soft tissue lesions, often seen on the bilateral upper extremities. A wide array of treatments have been attempted from conservative measures to surgical procedures of varying levels of invasiveness, none of which appeared to heal or improve outcomes.. A multidisciplinary approach is likely necessary to coordinate addiction medicine, social work, infectious disease, and hand surgery to best help these patients in need.

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