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Outcomes of Surgical Reconstruction of Xylazine-Associated Upper Extremity Wounds: A Retrospective Case Series
Joseph G Bartolacci, MD PhD; Matthew Delancy, MD; Parker H Johnsen, MD; Katharine T Woozley, MD
Cooper University Hospital, Camden, NJ
Introduction: Illicit opioids in the United States are increasingly contaminated with xylazine. Xylazine causes profound local tissue vasoconstriction and blood vessel and lymphatic damage as a sclerosant. Hand surgeons are often engaged to manage the resulting severe necrotic wounds. To date, no clinical guidelines exist to direct surgical management of these wounds. We present the results of 21 patients who underwent surgical management of xylazine-associated wounds of the upper extremities and their complication rates and propose surgical management recommendations. Materials and Methods: IRB approval was obtained for a retrospective review of electronic health records. A query of all health records for patients with admission for intravenous drug use with xylazine-associated extremity wounds at our single urban tertiary care hospital over a 7-year period (2016-2023) was performed. Keyword searches included intravenous drug use, xylazine, and tranq. 55 patients met inclusion criteria, of which 21 underwent reconstructive surgery. Demographics, laboratory findings, and surgical complications were compiled and analyzed. Results: Post-operative outcomes for 21 patients that underwent surgical management of xylazine wounds were evaluated. Upper extremities were the most affected body site. In patients with upper extremity wounds, 45% were bilateral, and 22% of patients also had wounds in other areas such as lower extremities or trunk. Patients with xylazine-associated wounds had multiple comorbidities: 64% had Hepatitis C, 82% used tobacco products, 36% were homeless, and 32% had comorbid psychiatric diagnoses. Laboratory values on admission were notable for elevated inflammatory markers, including WBC count of 11.9 + 5.9, ESR 75.2 + 27.3, and CRP 8.0 + 6.3. Patients underwent an average of 7 procedures; however, one outlier underwent 28 procedures. The most frequently performed reconstructive procedures were split thickness skin grafting (STSG, 8 performed), amputation (8), flap-based reconstruction (5), and dermal substitute placement (2). Complications occurred in nearly 60% of cases. Notably, just 63% of STSG and 50% of dermal substitutes were successful, while flap-based reconstruction had a mere 20% rate of flap survival. The majority of reconstructive failures occurred during xylazine use relapse. Patients with successful remission were associated with higher rates of skin graft take than patients who relapsed (100% vs. 37.5%). Conclusions: Results show that surgical management of xylazine-associated wounds was associated with high rates of reconstructive failure. Data show that patients with xylazine-associated wounds have numerous comorbid conditions that impact wound healing. Xylazine use remission improved surgical outcomes, suggesting a possible direct drug effect on wound healing.
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