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Hello, I have a pt (diabetic) who had B1st TNA with phenolisation approx 1 year ago. Unfortunately she has had regrowth to R1st which she would like removing again. The issue is that following the procedure she developed tenderness and pain to both hallux, how would this respond to further LA and nail surgery ? Anyone got any top tips or experience with this ?

 

Hi Cpye:

Can you be more specific concerning the post op pain?
These are not painless procedures and depending on the patient's pain threshold, activity level, shoe type, etc...some are going to hurt more than others.

If it was immediate post op pain you can give a Marcaine block. ALso the more "gentle" you are with removal, the less pain afterwards.

Steve

 

The pt reports tenderness along the digit. There is no impact from the nail and she has been wearing sandals since procedure as she cannot face wearing closed in shoes. As part of our consent we inform pt of possible post op pain, but I am concerned about administering a LA for further nail surgery given the symptoms she has suffered since previous procedure, just over 1 year ago. Appreciate your input.

 

Are you saying that one year post nail procedure she still is having pain?
If so, you may want to reassess her underlying etiology, perhaps she has other pathology.

I have seen pain in diabetic patients that does not correlate to the amount of work done. This may be secondary to peripheral neuropathy or even ischemic type pain. Fibromyalgia patients also have altered pain perception.

If it was immediate post op you may want to assess digital circulation. A digital block will, to a certain extent, decrease blood flow to the digit due to pressure of the volume of solution on small vessels.

In any event, if you cannot account for her symptoms I would not rule out the possibility of a repeat on a second procedure.

Steve