PNA procedure question please

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Hello,

Am brushing up on my PNA procedure, which I have not done in a while.

I would be grateful of some tehcnical tips/advice in relation to the followoing two questions please.

1. After disecting through to the nail matrix with the 61 blade, and applying the forceps, do you rotate the split nail MEDIALLY (toward the midline of the toe) or LATERALLY ?

2. When applying the phenol, do you rotate the cotton tip Medially or Laterally ?

Many thanks,
HC

 

HC - is this a serious question? It doesn't matter which way you do it. Personally, I would like to rotate the forcep/ nail section around the axis of my thumb (similar to a gunslinger in an old western) and throw the phenol applicator from behind my back in to the sulcus with the other hand for dramatic effect. As long as you remove the nail section whole and apply the phenol to the area, you can't really go far wrong.
Bob

 

I remember the medial/lateral clockwise/counter clockwise thing being an issue at uni. Every time I do a surgery a small voice in my head asks which was it, because i have forgotten?? I must have fluked all of my surgeries since, the correct way, because they all come out. As pointed out i dont think it makes a difference. I would recommend contacting a colleague near you and sitting in on one for a refresher. No shame in it if you havent performed one for a while.
Bob - would you video one of your surgeries and post it, I would like to see the behind the back to sulcus phenol application. Does it improve your surgical outcomes??
Cheers

 

Absolutely! 100% hit rate with no re-growth. I have tried a variety of techniques and the 'cowboy' seems to provide the most consistent results. Some years ago I did a small study in my practice comparing 3 methods of nails avulsion:
- the 'cowboy' technique
- applying the phenol to the wound with a blacks file but rotating my entire body around the axis of the file rather than moving the file (similar to a cartwheel around the long axis of the file)
- the standard technique whilst chanting 'kabaddi' constantly until I was unable to breathe
The 'cowboy' technique was far more successful than the other two methods.

 

Wow. i know its just an avatar. But i instantly got visions of Boba Fett cartwheeling around a podiatry clinic. Great stuff. Your clinical studies must be something else to take part in.

 

I can go a long way back to the very dawn of phenolisation in the UK. Personally, I have found the @@@@@@@@@ (name withheld to protect a well known British lecturer) technique the most successful. This is similar to Bob's body rotation technique but crucially involved moving widdershins whilst chanting "This is serious stuff, will the orthopods allow us to do it" throughout the procedure, and then spending a sleepless night.

Cheers

Bill

 

I find them quite boring. Personally, I would rather be back on Tatooine making real money as a bounty hunter, but since Princess Leia killed Jabba the Hutt that line of work dried up considerably. The only movement in the second study arm was around the long axis of the file (using a trick that a Sith lord taught me when we were out drinking one night) - cartwheeling around the clinic is just dangerous and ridiculous.

 

Thanks Derek, yes you are right it is that little voice from uni which I can't remember!!!
Which way do you rotate the nail and then the phenol?
A pod surgeon once told me it did make a difference, as you don't want to rotate the phenol applicator medically into viable nail tissue...

 

We were always taught to rotate towards the midline of the toe. I think this was thought to cause less extra soft tissue from being removed with the nail. As far as which way to rotate the phenol? I've never given it any thought.

 

We were taught to rotate both nail and phenol towards the midline

 

So the Inglish are to blame for the current mood of subservience, eh? North of the border, under the close watch of the RCS we didn't rotate but simply yanked, dipped the toe in phenol then flushed with urine, which for the most part was usually alcohol anyway. Never had any regrowths. Never had any patient returns either.

 

Thanks.. So it seems rotating both nail and phenol towards the midline is the consensus.. Craig Payne do you agree?

 

"So it seems rotating both nail and phenol towards the midline is the consensus......."

"consensus" surgical skills ! Yikes.

All I have to say is that this entire thread makes me think "WTF"

 

Perhaps you could offer some input then Sarbes?

 

Agreed.... Steve to a large degree - "rotating" the nail with forceps in either direction will get the job done, so will getting under with and applying pressure inferiorly to superiorly with a blacks file and easing it out. So will grabbing it with a pair of clippers and pulling it. As Steve said above this is about surgical skills. The best Pods I have ever worked with all did it their own way and got great results anyhow. Its all about a-traumatic tissue handling and care.

As for failure rates the literature is somewhere divided between 3% and 10%. There is no way it is 0% - that is not possible. There is no surgical procedure in the world that has a predictable 100% success rate.

The "old" thing taught at Uni about rotating the nail "medially" towards the midline of the nail was to expose the connective tissue on the medial sulci surface. This could then be visualized and excised with a beaver or scalpal if required. Others just keep rotating and "pluck" it out!

Careful visual inspection of the nail and more importantly the nail sulcis should be done and the area inspected with a blacks file looking for any erroneous nail pieces or tissue which you may want to remove.

Im not sure phenol does anything besides cautery - successful resection of the nail matrix should provide permanent results anyhow. Regardless we continue to use phenol however we undertook a study (unpublished) a few years back looking at phenol less procedures, 15 patients, 1 regrowth at 12 months. Similar results to phenol based procedures I would argue.

Irrigation should be performed but there is no data I know of saying when or why - at least none that makes any sense. We leave the phenol in wound until the tissue blanches white and the wound appears cauterized. Phenol is a carcinogen when inhaled - something to think about generally if you are a Podiatrist using it alot! The study we performed (I think we presented the poster at the APodC Gold Coast Conference) used histo-acryl to close the wound with no phenol. Outcomes were similar to PNA at 12 months I believe if I remember correctly.

All Podiatrists should be extremely proficient in PNA's and all nail/skin surgery generally. If you arent maybe spend some time with your local Pod who is or your local Pod Surgeon - the skills you can pick up will change your habits for the better!

 

Yes... but it does smell nice... does anybody else think so, or is it just me .

Oh, nearly forgot...

Hi HC (BTW, it's nice to have a name).

A few pointers (as per your above points):

1. Avoid cutting the eponychium (see diagram below) as you make your way down to the root... make sure you go all the way with the beaver blade (61) to just beyond the root... sometimes you feel a 'give' (no resistance) so as you have cut the nail all the way through. This makes way for a nice clean job & easy/quick removal. Keep your cut straight & clean - looks better (cosmetically) .

Apply the forceps as close to the base as possible i.e. going under the eponychium - clamp on nail & lock securely (important, as sometimes force is required to rotate nail & you don't want the nail to break). Gently (or with controlled force) rotate medially (yep, it works for me) & keep on rotating till you feel the nail release - don't tug/yank it out. The offending little fella (with its root) should just slide out (whole/complete) leaving a nice clean cavity inside (particularly if you have tourniquet the toe appropriately ). You may want to have a scalpel blade handy just in case any tissue comes with the nail of which you want to cut away.

2. As with that nice smelling phenol . Make sure the applicators aren't too large for the area you wish to cauterize, as you want to avoid phenol spilling over onto the surrounding skin (later causing burn irritation). I apply glycerine around the sulcus/skin to prevent this off-chance occurrence. Once there, it doesn't matter how you apply (i.e. medially/laterally); just make sure you cauterize the op site for a couple of minutes where you will notice the area blanch whitish.

Flush area with alcohol (i.e. chlorhexidine)... & dress up.

The above is a general guideline as not all cases are the same - i.e. some may be heavily infected with swelling & a lot of granulating tissue present in which case removal could be a wee bit more complicated.

Anyway, that's how I do it . Hope it helps.

 

Thanks a lot Ben-Hur and Paul. Very much appreciated, thanks for taking the time to give me some pointers, very grateful and useful tips.
Again, many thanks.

 

Great response! I do the same...probably been a little guilty of tugging too much though (keep your minds out of the gutter)....

 

Hello HC

Mathew aka Ben Hur gives great advice, the way I do it (as taught at Glasgow southern General) is like this:
Use a small blacks file slid under the nail along the nail groove until you feel a little give as you push past the distal nail root this will loosen the underside. Then do the same on the top edge, push the blacks file under the eponichium until you feel it give, then work back into the centre of the posterior nail fold a few millimetres. Now take your forceps and slide them along and under the nail edge and grip and lock. Then, assuming your on the left edge of the nail (either right or left foot doesn't matter) then rotate anticlockwise, if on the right side of the nail then rotate clockwise. This will lift out the whole nail edge free and clear. Remove the forceps and using appropriate type nipper, cut the nail edge off along its full length in one clean cut.
When using phenol, apply the lightly soaked, appropriately sized cotton bud deep into the nail groove under the eponymous and rotate, then side back and forth along he length of the nail groove. Which way to rotate? Well by my experience, if you rotate anticlockwise (on the left side nail edge) then some phenol may be pushed out onto the healthy skin of the toe - so use a sterile swab to wipe away any excess and then flush away with sterile water. If you rotate clockwise then, if the edge is not bound down to the nail bed, some phenol can get under the remaining nail edge and will result in an extra area of nail bed being destroyed an you may have to remove an extra bit of nail edge at a later follow up to make it look tidy.
So it's your choice and may depend on how you assess each patient and their nail status.
Hope this helps, regards Dave Smith

 

Thanks David Smith .

 

David said it. I was taught that rotating a phenol soaked cotton tip 'upwards' against the newly created nail border can mechanically force the phenol under the remaining nail (especially where the nail has had chronic infection and softening) and cause prolonged inflammation post op (especially as your flush wouldn't clear the trapped subungual chemical) and inadvertent chemical damage to the nail and nail bed. Wonky end result!

 

It seems to me that there is a fine line between getting enough Phenol to cauterize the exposed nail bed to prevent any nail growing back without burning the surrounding tissue and delaying healing. Sliding the swab back and forth seems to me to be the most logical way with a swab to wipe away any excess like David Smith said.