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The Natural History of Xylazine-Associated Necrotic Wound Progression: Insights from 34 Patients and 49 Upper Extremity Wounds
Jason C. Flynn, B.S.
1, Jacob H. Zeitlin, M.D.
2, Yehuda A. Masturov, B.S.
2, Sebastian D. Arango, M.D.
2, Adam B. Strohl, M.D.
2, Andrew J. Miller, M.D.
2; Tristan B. Weir, M.D.
2(1)Sidney Kimmel Medical College, Philadelphia, PA, (2)Philadelphia Hand to Shoulder Center, Philadelphia, PA
Introduction: Xylazine-associated necrotic (XAN) wounds have become increasingly common among people who inject drugs (PWID) in Philadelphia and other major cities. The purpose of this study was to characterize the natural progression of XAN wounds in the absence of surgical intervention.
Materials & Methods: A retrospective analysis was performed for 34 patients with active intravenous drug use presenting with XAN wounds at a single medical system between January 1, 2021, and December 31, 2023. Patients were included if they had at least two clinical images of a given XAN wound and documented physical examination on two separate dates. Patients with a prior surgery for the XAN wound at the time of initial presentation, and all clinical photographs after a surgical debridement, were excluded from the study. A comprehensive chart review captured encounter dates, demographics, comorbidities, patient-reported fentanyl bag count per day, and number of eventual surgeries. Patient wounds were graded based on the clinical photographs (
Figure 1) and documented physical examination findings at each encounter. Kaplan-Meier survivorship analyses were performed to evaluate the survivorship-free of wound and physical examination progression.
Results: Across the 105 encounters, 21 (20.0%) showed worsening of some aspect of their wound appearance or physical exam on subsequent follow-up. When compared to their initial visit, 30 (28.6%) wounds/exams had worsened. However, 16 (15.2%) showed interval improvement during their course of follow-up. A Kaplan-Meier survivorship analysis for wound appearance is shown in
Table 1. Wounds with swelling initially were more likely to worsen in appearance on subsequent visits (
P = 0.010). Those who worsened either based on wound appearance or exam findings had shorter length of stays during the previous encounter (mean ± SD: 5.5 ± 4.3 vs. 12.5 ± 16.8 days;
P < 0.001). In addition, those who worsened were less likely to be discharged to rehab on their previous encounter (
P = 0.026). There were no significant predictors for interval wound improvement (
P > 0.05 for age, length of stay, bag count, change in bag count, setting of encounter, and previous disposition).
Conclusions: XAN wounds generally progress slowly over weeks to months rather than hours to days. Developing treatment algorithms should emphasize substance abuse cessation prior to undergoing complex soft tissue reconstructive efforts. Collaboration among hand surgery, substance abuse, infectious disease, and social work teams is key to the optimal management of these patients.
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