(CS-159) Observational etiologies in extensive wounds from patients with fentanyl and xylazine use disorder in the Philadelphia region.

Katherine Zabel, Assistant – Zabel Plastic Surgery

Introduction: Self injection of fentanyl and derivatives has been referred to as “krokodil” and may lead to wounds characterized by black scaly necrosis reminiscent of crocodile skin. Defined wounds at injection sites are thought to be secondary to chemical necrosis from organic solvents. More recently these drugs of abuse have been mixed with a non-regulated veterinary drug for sedation, xylazine (“tranq”). Dosages and exact combinations of these drugs are difficult to quantify. In our greater Philadelphia level-one trauma center, we have observed a change in the types of wounds over the course of years as drug populations experiment with different formulations. We describe our observations and treatment strategies for limb salvage in this challenging drug exposed population

Methods: We retrospectively reviewed all patients in a single plastic surgeon’s practice from March 2019 produce to May 2023. We identified 37 patients with wounds secondary to fentanyl, fentanyl derivative and xylazine use.

Results: Thirteen forearm amputations were performed for extensive wounds and open fractures that were unable to be salvaged. Twenty-four patients had a range of wound treatments including local flaps and cellular tissue products that were used after debridement for limb salvage. Eight patients had mirror image wounds on contralateral body sites. Twelve patients were lost to follow up. In patients with xylazine use, extensive wounds were identified in areas of the body where no injections were performed.

Discussion:

There is a paucity of literature to describe wounds caused by fentanyl and xylazine¹. Wounds vary from superficial ulcers to extensive wounds with necrotic muscle compartments and open pathologic fractures of long bones with osteomyelitis. The observation of mirror image wounds in the extremities independent of injection sites may suggest a metabolic or autoimmune etiology that is poorly understood. As this new atypical drug use formulation spreads to other areas of the United States, physicians should be prepared for the spectrum of wounds these drugs produce. The patient population has very poor compliance and follow-up. Patients have been observed to continue fentanyl use, despite bilateral forearm amputations.

Trademarked Items:

References: 1. Xylazine induced skin ulcers in a person who injects drugs in Philadelphia, Pennsylvania, USA. Malayala, SV et al. Cureus, 20221.