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Hi, I am looking for a little help with a difficult case.

Patient:- 25 yr old male, obese, Idiopathic Hypo Pituatism.
Medications:- cortisone acetate, testosterone, thyroxine

Patient has history of chronic ingrown hallux nail, and a partial nail avulsion with phenolisation off nail matrix was performed May 2007 with no complications. Oct 2007 spicule regrowing, and conservatively removed. Jan 2008, spicule continues to grow and patient is feeling the pain again.

Any ideas as to what may be causing this regrowth? Any chance the medication or disease may be interfering with the phenol causing it to be ineffective? Is obesity an issue?

Should I redo the surgery? Not sure why it is regrowing? Haven't had to redo a surgery out of the last 50 procedures that I have done over the last few years. Thanks for any advice anyone is able to give me.

 

The 2 most likely reasons for re-growth are due to the following:

1. A small portion of the nail matrix was left behind after extracting the nail.
2. The phenolisation procedure was inadequately performed.

Unfortunately, not every toenail is immune to re-growth after having a chemical matricectomy. However, when I perform this procedure, I always make an assertive effort to thoroughly inspect the cavity after the nail has been extracted. Sometimes, after the nail has been cut with the thwaites nail clippers, the distal portion of the toenail will appear nice and straight, however, sometimes, upon closer inspection, just inferior to the eponychial margin, the nail matrix can appear slightly curved or skew. Obviously, this will have to be rectified. When I am inspecting the cavity, I usually flush the cavity with saline solution and probe around using a blacks file.

As far as redoing the surgery, I suppose it depends on the presentation and how much of the spicule you have to work with. Personally, I would wait again for a bit of regrowth so that I would have enough nail to work with. I don’t see any objections to not doing the surgery, however, if you have doubts, then you should refer them. If you do decide to do it, make sure that you have extracted absolutely everything and then thoroughly apply the phenol.

I hope this helps,

Daniel