Nail surgery advice for 93yr old

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Hi,

I have a 93 year old patient that wants a partial nail avulsion with phenolisation. She is in reasonable health and lives in a hostel. She couldn't remember he list of medications so I have contacted GP and hostel for health history. This is the first time I have seen her and she has been recommended by another podiatrist.

My question is how well does the doppler assess blood flow to the area? She has fragile skin - as you would expect at 93, but pulses are palpable and biphasic with doppler. Is this enough indication of healing ability??

thanks,

srd

 

Re: nail surgery

Arterial perfusion is but one aspect of the assessment that gives you an indication of liklihood to heal.

Palpable pulses without any claudication symptoms, and good general cardiovascular history (no MI or CVA) gives you confidence in peripheral perfusion. Good capillary fill times build on this. The best overall test, IMHO, is TcPO2 - but usually that is not warranted unless you feel the situation is marginal.

More important will be her medication review, look for steroids and any other factors that may compromise healing.

Her chronological age is by no means a reflection of her physiological age, but expect some delay in wound healing due to this. A healthy fit 93yo may sometimes be a better surgical candidate that an obese, smoker with other comorbidities in their 60's.

Careful tissue handling, gentle phenol application, and copious flushing with saline will minimise trauma to the toe - and perhaps this is the most important aspect when dealing with frail tissues.

LL

 

Re: nail surgery

Your Doppler assessment was at the ankle level and this may not give you a clear enough picture of the micro-circulation at digital level. Perhaps a Toe Brachial Pressure Index assessment would give you a better idea of the health of the microcirculation at the site of the proposed procedure. I would be very cautious in this case as the physical trauma and chemical trauma of the nail procedure may compromise the tissues and post-operative healing may prove problematic.

Overall, you must ensure that your patient’s health would not be compromised by the nail procedure.

Regards.

Footsie 100

 

I question the application of the phenol in this case. What about doing the procedure without phenolization of the nail bed? I realize the nail will grow back but regrowth will probably be slow at that age and the chance of causing a phenol burn which will be difficult to heal will be removed.

best of luck

Perry

 

:good:

You echoed my thoughts....I would probably perform the procedure without phenol for the reasons you state. This will also reduce the amount of time of exsanguination which is not ideal on a pt of this age.

Hope all goes well,

Cheers,
Bel

 

You also need to consider her risk of pressure sores from sitting after surgery.
Make sure she has an adequate pressure redistributing cushion for her chair at home.
You may also want to speak with her GP and consider the use of prophylactic anti-biotics.

 

I might consider an excisional partial matricectomy of the offending border if forced to deal with the nail. I have done them on people that age with skin that looked like cellophane, but only when they kept getting paronychias and had significant symptomatology otherwise. Then, you were, to quite our eminent colleague Lucky - f**cked either way because leaving then to keep getting infected with diminished vascularity was going to lead to gangrenous changes in all probability.

 

I'm with LuckyLisfranc on this matter. You need to perform a full vascular assessment, and use that and the general health status of the patient as your guide. In my experience, age isn't the major factor is deciding the risk:benefit for this procedure - the major question I always ask is: if I make a wound, will it heal?

I question the value of performing a PNA without phenolisation in chronic involution. If the healing potential of the tissue is impaired, I would find it hard to justify creating a wound where there isn't one already. If the toe is infected, then the playing field changes slightly.

I would add that you need to be sure about her self-care ability, and the amount of care she has at home, as those could also influence healing. In cases like this, I advise the patient that their healing time is likely to be longer than a younger person, and try make sure they understand the signs and symptoms of infection, and instruct them how to act if such consequences arise.