Limb salvage of xylazine associated wounds: a case series and technique paper

Background: Xylazine is an alpha-2 adrenergic agonist that causes central nervous system depression and direct vasoconstriction of peripheral blood vessels. Due to its synergistic effects, illicit drugs such as fentanyl and heroin are often adulterated with xylazine. This has led to an increased incidence of skin ulcerations and necrosis associated with xylazine injection. The purpose of this case series and technique paper is to present a limb salvage approach and expected outcomes in the management of this challenging condition. Materials and methods: A retrospective chart review was completed of nine adult patients who underwent serial debridement and eventual free tissue transfer for upper extremity wounds associated with xylazine injection. Demographic, surgical, and clinical outcome data was collected. Results: Eleven forearms in nine patients were included. Each patient was debrided a minimum of two times before definitive soft tissue coverage. All patients had successful healing of their wounds, which were ultimately covered with either an anterolateral thigh or latissimus dorsi free flap. Two patients had peripheral flap dehiscence requiring repeat debridement but no further soft tissue coverage. No patients had an amputation. Four patients returned to the operating room for additional staged reconstructions such as tendon transfer and contracture release. Conclusion: Despite the challenges of this condition, we prefer to take a limb salvage approach that encompasses surgical debridement, free tissue transfer, and secondary reconstruction. Social, psychiatric, and addiction medicine counseling is paramount to mitigate the risk of treatment elopement, repeat injection, and poor wound care.