Advice needed on nail surgery failure

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Hi

I have a patient who has had a total nail avulsion with destruction of matrix with Phenol 3x and each time a portion of it has regrown. The same procedure was performed on the other foot (1st nail) and was a success.

The procedure was performed by the patients GP at his local surgery, and as it has been unsuccessful the patients GP has now talked about amputation the toe as he does not feel another procedure would be beneficial!!!!

The patient has now come to me (Im seeing him shortely) wanting a second opinion as he quite rightly only wants amputation as a last resort.

Has anyone else come across a situation like this? I know occasionally regrowth happens, but as it was successful on the other foot, Im assuming it is more likely to be a failure in technique rather than the patient.

I wasnt aware that GPs even did this procedure themselves?

Any advice would be most welcome

Thanks

 

GPs can do any surgery that is accepted by the Association of Surgeons in Primary Care, if they are a member of that body. This would certainly include PNA/TNA.

I agree that the problem was probably one of technique. So you are confronted with 3 choices:

1. have the GP send the patient for partial (Symes) or full amputation of the toe
2. attempt a further TNA yourself
3. have the patient referred to a podiatric surgeon colleague who may wish to carry our a Zadeks procedure

Whatever your decision, I suggest that you contact the GP as conventional protocol requires.

All the best

Bill Liggins

 

If PNA/TNA with phenol was unsuccesful, I would recommend a wedge resection way before discussion of amputation.

 

There are indications for amputation, a regrowth of a nail spicule is not one of them.
If phenolization has not worked, a matrixectomy can be done.
I have a question ....why would anyone allow the same doctor to perform a 3rd surgery when he was unsuccessful with surgery #1 and #2?
Luckily he was not undergoing a vasectomy.

Steve

 

Yeah- ask how many kids he has just of interest

 

In the original posting, no mention is made of any pain or discomfort consequent on the nail fragment regrowth, suggesting that a cosmetic problem is at issue. A revision TNA by another surgeon, same or alternative technique, should solve the problem. The suggestion that the toe is amputated is difficult to take seriously.

 

No doubt a technique fail. Most likely culprit being phenol applied sparringly for too little time and probably blood in the site preventing phenol from contacting the would surface adequately.
Suggest you do it properly and show them how it should be done.

 

Total nail removal and phenolization works well, but i always advise the patient they will need a second procedure as some aspect of the nail will regrow. Advise as such and you should be fine.

In your case i would block the toe, use a tourniquet, and debride the remaining nail tissue. Use a combination of phenol and electrocautery and wrap with an occlusive dressing.

 

All,
This talk of amputation sounds to me like taking a sledgehammer to crack a nut - I would be curious as the reasoning behind this drastic suggestion?

I would take this golden opportunity to solve your patient's problem and enhance your own reputation by doing the procedure yourself (properly).

It goes without saying that you should notify the GP first, out of courtesy.

regards

catfoot