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Granuloma dilemma

Discussion in 'Foot Surgery' started by mazbaa, Apr 27, 2014.

  1. mazbaa

    mazbaa Member


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    Some advice would be so helpful please...
    20 year old patient attends my clinic with a severe ingrown toe nail and a granuloma (have posted attachment, hopefully you can see it).

    GP referred and was just prescribing NSAID's and antibiotic topical cream! I removed the offending nail and destroyed the nail matrix. At this point I must point out that I am a biomechanical pod who deals with 98% biomech cases..but this guy was in so much discomfort something had to be done asap.
    I was hoping the granuloma would reduce, scab over and ultimately fall off!
    The picture is 1/12 post op and still only mild reduction in size. No pain now but still discharging an bleeding! He lives a fair distance away and do not want to ask him to drive up for me just to ponder the situation.
    Can anyone help or advice please
     

    Attached Files:

  2. W J Liggins

    W J Liggins Well-Known Member

    Even with the causative factor (the onychocryptosis) dealt with, a granuloma of this size will become organised and fibrosis will result. The only solution is excision and ideally, a Winograd excision would have sorted the problem out initially. The Department of Health, BUPA and PPP all state that the latter form of surgery can be carried out in a 'clean room' ie. a surgery setting, so there is no reason that you should not undergo training in these techniques - if you so desire.

    All the best

    Bill Liggins

    PS. Do you have any objection to my copying the pic for my database of IGT?
     
  3. mazbaa

    mazbaa Member

    thanks Bill for your input. Of course, go ahead and copy the picture. As I do not have the experience in this procedure, do I refer him back to his Gp for a Pod Surgery consult or a general surgical opinion?
    Thanks again
     
  4. W J Liggins

    W J Liggins Well-Known Member

    Ideally to a podiatric surgeon. In the Worcester area this may mean paying a private fee, but if he is within travelling distance of Hereford, M/S Galloway and Gilbert are still, I believe in NHS practice and I would thoroughly recommend their service.

    All the best

    Bill Liggins

    PS. Thanks for the permissions!
     
  5. David Smith

    David Smith Well-Known Member

    Mazbaa

    How large is the base? is it only situated in the nail groove? Admittedly it is about 4 times as big as the largest Pyo Granuloma we usually see but why cant you remove it at its base with a pair of tissue cutters or Scalpel under LA? Apply some silver nitrate and pack and dress tightly to stop further proliferation.

    Regards Dave
     
  6. mazbaa

    mazbaa Member

    Hi Dave, I just feel I'm alittle out of my comfort zone..if the base is not to large then yes I can cut it off and apply silver nitrate or phenol. My concern is the size the blood flow to the area will simple chemical cauterising and pressure slop the flow of bleeding?
    Thanks again
     
  7. David Smith

    David Smith Well-Known Member

    If your not comfortable fair enough leave it to someone else but if you used a torniquet before you quaterize and pack with Kaltostat and several layers of non adherent dressing and tape it down tight without restricting the blood supply with the tape, then you should be ok. Leave him sitting in the waiting area for 15 mins to make sure there's no bleed thru and send him home with emergency contact number and extra dressing pack to add to the orignal if bleed thru occurs and see him again in 3 days to review and redress. Pretty much the same aftercare as you might do for a nail avulsionwith pheolisation.

    Dave
     
  8. Paul Bowles

    Paul Bowles Well-Known Member

    ...may possibly want to consider pathology after removal as well.
     
  9. blinda

    blinda MVP

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