HbA1c and nail surgery

Members do not see these Ads. Sign Up.

Hi everyone,

I'm trying to find some information (papers, policies etc) relating to performing nail surgery on patients with a high HbA1c.

Our policy (NHS) currently states that we will only perform nail surgery if a patients HbA1c is <9.0%, however we will occasionally get prophylactic antibitoics from a patients GP if the nail is particularly bad and their HbA1c is higher than this to try and reduce risk of infection post op.

I'd be interested to see what other podiatrists think about the use of prophylaxis in patients with a high HbA1c, and also what level of HbA1c you think is too high to perform nail surgery?

Thanks for reading and I look forward to your replies.

 

Hello

Less than 9.0 is OK from the diabetic point of view but there are many more factors to consider, mainly what is the state of the PVS, what is the mobility, what is the history of healing, plus social situation etc. etc. Prophylactic antibiotics are not a universal panacea and should only be used in appropriate circumstances; also you (or someone in your department) should be able to 'prescribe' anyway. If you are considering phenol ablation, why stick your neck out and put the patient more at risk when an incisional technique would be more appropriate?

Bill Liggins

 

As my rt hon colleague says.

To set an arbitrary level at which you will do surgery, and above which you will not is IMO a silly way to consider it because it places the hba1c on only one side of the risk assessment.

When considering whether to do surgery one must consider the short medium and long term risks of surgery, AND the short medium and long term risks of NOT doing surgery.

For example, if you have a brittle diabetic with an hba1c of 12, who has a chronic, infected OC which has a chronic infection which is unlikely to resolve without surgery then the risk of not doing surgery is higher than the risk of doing it. There's an open wound and infection already! Now it might be that the most low risk approach short term is an oblique wedge under La with no phenol. Lower risk than leaving it and lower risk than phenolising. However mid and long term risks are higher for regrowth.

As with all things clinical, one cannot make rules and pigeon holes for every if x then y situation. Clinical judgement and FULL risk assessment (including the risks of inaction) are the way forward, not arbitrary levels and pathways.

 

When the patient has an infected nail border the nail portion must be removed whatever the A1C level because the ingrown nail is causing the infection, followed by p.o. antibiotics. I never do phenol when infection present in diabetic because the phenol creates a burn which can worsen the infection and delay healing.. so I just take out the nail border ...let the toe heal then return in 2-3 mon when no infection and if the A1c under 9 then I will perform a phenol on the ingrown nail border.

 

All surgical decisions should be patient centred and full assessment and if in doubt seek advice from the patients diabetologist .That is what MDT are for to make informed and patient based decisions hope this helps

 

The philosophy is interesting. Medicine would hold that co-operative working with the physician to lower the HbA1C prior to surgery would be the norm. In surgical terms, prophylactic antibiosis followed by a rapidly healing incisional technique would be the most appropriate procedure. The rationale being that the physician can medicate accordingly and only one, rather than two surgical procedures are carried out.

Of course, this is my experience of working in a hospital environment only, and it seems that others may prefer a different route.

Bill Liggins

 

Lots of really sensible points already made. A patient with an infected nail does require intervention no matter what the HbA1c however, I am interested in the original posting regarding prophylaxis. Nlmbu do you mean performing surgery on patients with non infected but painful sulci? Or recurrent minor infections? Controlling HbA1c is vital no matter what, also assessment of vascular and neurological status. Neuropathic pain or aching may be interpreted as an ingrown nail by patients and Gp's. Also microvascular disease can mislead the unweary. Your local High Risk Foot Clinic is possibly you best bet if you are in any doubt. Patients with rip roaring infections may require IV antibiotics and stabilisation by an endocrinologist. Plus careful evaluation for osteo myelitis. You may decide an incision would increase the risk of OM and go for a total removal with no incision. Very difficult to make hard and fast policies for patients who are far from hard and fast
Ros

 

Reducing A1C prior to surgery is fine for non infected elective cases because it is not urgent and it can take significant time for A1C reduction for outpatients. Inpatients have strict diet control and iv insulin so glucose levels are reduced immediately. Hence, the reason for severe infections best treated w/ hospitalization. The toenail infection treated as an outpatient cannot wait for A1C reduction as it is an urgent condition that must be treated now. The A1C measures average glucose levels over the last 3 months. If your patient presents with A1C of 12 and you somehow convince them to control their diet for a few days before your planned toenail surgery the A1C will still be over 11 because it is averaged over 3 months even though they may have normal glucose the day before the surgery. You might get the A1C down to 8 with diet control for a month but by then the toe will have gangrene because the ingrown nail was not removed at the first signs of infection. You do not need a diabetologist, physician, or endocrinologist. Take out the ingrown nail causing the infection then get the patient some antibiotics. Think of the problem like stepping on a nail. You have to take out the nail first before doing anything else.

 

Hence, a patient with unstable diabetes and a severe infection should clearly be t/t as an I/P with input from the endocrinologist (physician) and the podiatric surgeon with the capability of carrying out the appropriate surgery. It is wrong, in my view, in any case, to put the patient at risk by carrying out any form of surgery in such cases without prophylactic antibiosis.

Primum non nocere

 

Consider the hypothetical case of a diabetic presenting with an abscess on the bottom of their foot from stepping on a foreign body(ie. thorn). Nobody gives antibiotics and waits a few days before doing I & D. The incision and drainage is done immediately because we all know that the I & D surgical procedure facilitates healing of the infection. This is true for any abscess in any patient. After the I & D the patient receives abx , referral to physician, wound care or whatever they need to treat the wound or out of control DM. The same philosophy goes for ingrown nails.