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Hi,
I have a 17 year old boy who has had an ingrown toe nail for a couple of months. He had seen a general surgeon who had booked him in for total nail avulsion. He saw me as a second opinion as he was unsure he wanted to permanently loose his nail at such a young age. The surgeon told him it was neccessary to remove the whole nail rather than partial so as to prevent the nail folding back on its self and peeling off. I haven't heard of this before ??

There is excessive periungual inflammation with hypergranulation tissue in medial and lateral sulcus of affected hallux nail. It is certainly a mess BUT why would you choose a full nail avulsion as the initial surgery and not go for a partial avulsion and then resort to full avulsion if needed, especially in a teenager ??

Srd

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Hi, just thinking....If partial avulsion you can still get some scarring as the nail grows back leaving 2 ridges through the nail? Perhaps that is why? Generally I would not take the whole nail though. Look forward to hearing others thoughts.
cheers

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Heather J Bassett
137 Wheatsheaf Road
GLENROY VICTORIA 3046
AUSTRALIA
03 9306 8557

Hi srd
I hate to say it but IMO general surgeons should not do nail surgery unless there are underlying complications such as a neoplasm or an exostosis. I have never heard of or seen the nail fold back on itself!
I would do PNAs with phenolisation and try and save the nail considering his age. Should that fail you can then go on to full nail avulsion.
I have done total nail avulsion without phenol and allowed the nail to grow back with success a couple of times, where the ingrowing was down to very bad self cutting!
Regards
Cornmerchant

Hello. Ingrown toenail procedures are what hooked me to podiatry in the first place. This young Pt should have the WHOLE nail plate removed but temporarily. I would suggest just a partial but given your description (both borders involved, the length of time and the marked inflammation) clean and complete nail avulsion would increase the chances that a healthier whole nail plate would grow back and allow surrounding tissues ample time to heal and appear more normal. If the process does not improve; that is the ingrown nail returns, then more permanent processes may need to be implemented. Good luck and I am pretty sure your young patient will appreciate your decision no matter what because you are the expert.
Dr Brooks

Hi

i have come across this a couple of times and what i have done is actually done a total but just phenolise the lateral and medial sides. If it does not heel up then you know you have to do a total. Has seemed to work well and the nail has grown back fine. However, normally would do a partial

chris

G'day Srd,

I do heaps of these procedures with very good results for my patients. I fail to see how removing good healthy viable nail in the middle of the nail will be of any assistance at all. Minimal trauma for faster healing!
As a result, I suggest 2 partial nail avulsion with phenolisation procedures, one for each side of the nail, with as much nail plate as possible left untouched in between. Once the offending sides of nail have been removed, remove the hypergranulation tissue and any hyperkeratotic tissue which may have formed (using arterial forceps, not a scapel so as to keep it all superficial). I have found that suturing is not necessary at all (well in the 100+ procedures I have performed). Phenolisation of the exposes matricies as well as the sulci following this generally yields a quick healing rate as well as a good cosmesis after healing.
Regrowth rates are almost non existant if the phenolisation has been sufficiently adequate (2x2 mins I use, with flushing of alcohol, then betadine then alcohol after each 2 minute application. I also apply with a blacks file to massage it sufficiently into the matrix and sulcus tissues). Post op infection rates are also minimal, and usually come about due to poor patient complience with redressing procedures.
Hope this helps!
Cheers!

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Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?

Adrian,

I agree with you on this one. The only time I will do a total phenol nail is for severely curved nails that would look like a claw if you removed the offending sides.
I would not do a total avulsion, as the nail matrix can become traumatized resulting in a thickened nail.
I perform this procedure with a digital tourniquet for more consistent results. I will use a tissue nipper for the granulation tissue, followed by the use of Monsel’s solution as a styptic agent for both the granulation tissue and the matrix. Then, I will use an cotton applicator to clean the Monsel’s from the matrix area. After this I will apply phenol.

Regards,

Stanley

Cheers Stanley!

Never heard of Monsel's solution before. What is it? I also use a digital torniquot and find that after it is removed, if there is no bleeding, I'm happy that the pheonolsaition has fully taken. This is under the pretence that all the small blood vessels have been cauterized by the phenol. I've also found that the little nociceptors also get cauterized which helps with post op pain and they grow back with no change in sensitivity.

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Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?

Hi Adrian,

http://en.wikipedia.org/wiki/Ferric_...fate_solutionv

Monsel's is the strongest styptic agent we use in podiatry. The only drawback is you need to clean the bottle frequently. As the water evaporates there is crystallization. Also use some vaseline around the stopper.
I agree about the nocioceptors, as all larger alcohol molecules have this property.

What is especially nice about Monsel's is that a phenol nail procedure can be performed on a patient taking coumadin. As I said above, before I phenolize, I use one application of Monsel's and then remove the excess with a cotton tip applicator.

The most effective part of the Monsel's solution is the goop on the bottom of the bottle. This is part crystal part solution.
Anyone that has a dog and has trimmed the nails too deep can tell you how they bleed. The yellow powder that is sold as a pet styptic is the powder form of Monsel's.


Regards,

Stanley

Hi

In addition to the advice given. It should be remebered that the nail is protective to the underlying anatomical structures. Therefore the conservative approach of partial avulsion of both sides with phenolisation should be the first choice. Unless the merits of the case reveal an underlying pathology/complication.
From what has been presented here however, that does not appear to be the case.

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Dharmendra (Drummond) Goven

Just a quick thought...... Have you considered the cause of the ingrown?. I know we all get caught up in the action side of things....thats what we are here for. Recently discovered that alot of 17 yold teenage boys are on roaccutane which causes excessive granulation tissue. Redo his medical history. If this is the case, removing any part of the toenail until he has finished the course of roaccutane will actually increase granulation tissue. Let me know how you go.
Di

I think I agree with Dr Brooks, initially I would consider a TNA without phenolisation (assuming the cause was poor cutting technique rather than a significantly involuted nail plate). All of the hypergranualtion/inflammation should have resolved by the time the nail grows back theoretically. Obviously easy to advise without seeing it - everyone is different I guess.

Let us know what you decide and how it goes

Ian,

Is it actually possible to perform TNA without any damage to the nail matrix? Any trauma to teh matrix may lead to possible chauxic nail development and further problems. I'd suggest remove just what needs to, phenolise it, and there shouldn't ever be a problem again?

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Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?

Adrian,

That is a fair point regarding nail matrix damage - I can't disagree with you. Regarding future growth of the nail I also agree, and would have to councel the patient pre-operatively to ensure they understood this and were happy to proceed.

I dont do a terrible amount of nail surgery anymore but have had cases previously which sounded very similar to this 17 year old chap, and when I recommended a bilateral PNA with phenolisation it was not something the patient always liked the sound of (the vanity within horrified at the thought of a permanently narrower nail plate perhaps?). Therefore I discussed a TNA as an option (including all risks etc) and in the 2 or 3 I have performed good results were obtained. Again I suppose more of an illustration of individual management plans on a patient by patient basis. By no means did I mean to suggest that this was a first line procedure for all bilateral onychocryptoses in teenagers.

Hope that explains my earlier post with greater clarity

If I could ask a question rather than make a suggestion, I would be grateful (4th yr student):

Would a bilateral PNA without phenolisation be indicated in a case where recurrence could be avoided by proper trimming technique, or would the risk of complications (eg. chauxis) due to matrix damage be inhibitive ?

Greatly appreciated,

Andrew

I personally wouldn't due to risk of matrix damage. I think a bit of very careful clipper wok with a mosquito nipper, a scapel and a blacks file should be able to remove an acure ingrown toenail and round off the nail edge sufficiently so that it will grown out safely. Even better, most times I have been able to do this without the use of LA, as careful scapel work on the nail spike and then removal by pulling it out the way it went in is not all that painful, and once it's out the rest of the area can be cleaned up quite easily. Rarely have I found to much hypergranulaton tissue to be able to do this, so stick in a bit of LA and debride the hypergranulation tissue, and make sure you dress it with an alginate dressing. If it's to infected for this, then it's too infected for a PNA or TNA anyway, so off to the GP for bug thumpers.
Hope this helps

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Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?

Andrew,

I think there may be some instances where a bilateral PNA would be performed without phenolisation, but again all the aforementioned implications exist - and you would need to consider the likelihood of recurrance, taking factors (such as nail involution, cutting technique etc) into consideration. Again it may not be a good idea for all patients, but i dont think you can ever rule it out completely.

Just my thoughts.

Ian

Hi Srd & All,

Seems like everyone is on the same track - which is good to know.

My suggestion would be to do a simple bilateral NWR (phenolisation technique), trim the hypergran tissue and apply Agn3 (Silver Nitrate) to co-agulate and shrink Hyper gran tissue. TNA last resort for cosmetic reasons mainly.

I would not waste my time with temporary removal as i can't see any benefit in this other than possible faster healing time and maybe better cosmesis. Always a pain (and somehwat embarassing to have to repeat a simialr procedure and risks the pateint thinking you failed (even with the best communication) - which is typically why the end up in our doors after GP's tried to solve the problem. In such cases often the pateint tends to think that they have had a permanent procedure when in fact they have not.

Having said that I am doing more 'temporary TNA's (and Permanent) for chronic and nasty onychomycotic nails - with good results as the nail regrows with topical anti-fungals and use of a product called phytonail! Intersted if anyone else has a similar experience.

My philosphy in clinical practice is if it is re-occurring in any way and is clearly involuted then fix it once and for all - I also rarely do uni-lateral procedures for the same reason and for the fact that most people are not going to thank us if they have to return for the same procedure in a few months and incur the same inconvenience and costs to do the other side.

Thanks for everyone feedback good to read and review what everyone else is doing.

Ps. Has anyone ever experienced a BAD BATCH of LA where nerve blocks were simply not working - I had a period a couple of years back where this was found to be the case - which was a relief as I thought after doing 1000's of these procedures over the years I was losing my touch!

Another thing to be mindful of is post operative dermatological reaction and allergys to betadine or even Fungal infections that can provide for slower healing and simulate bacterial infections when they are not.

Cheers!
TJ

Dear All,
Thanks so much for the replies - it's so great to have so much input!!!!!!

In the end I went with PNA (removal and phenolisation of both medial and lateral edges of nail.)

Initial outcome looks good with hypergranulation tissue resolved and nail edges clear and healthy. (Did end up having to advise antibiotics after 1st week though)

Patient has been pleased with results so far and had very little post-op pain.

Interesting to see long term outcome.

Thanks again
SRD