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Just a query in regards to carrying out a TNA with LA and phenolisation of a man aged 40 with an acute episode of gout and cannot take allopurinol.
He needs the procedure ASAP and we could be waiting months for the gout to die down.
Has anyone had any experience of contraindications etc with this presenting complaint before we go ahead??

Many thanks.

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First; The acute attack should not last months.

May I ask why the rush to perform a nail avulsion? Haven't heard of many emergency nail procedures.

It's bad enough having an acute gout attack without adding insult to injury by performing a total nail procedure and phenolization.

I'm assuming that the gout attack is in the 1st MTPJ and the offending nail is on the same toe.
Correct?


If he is having an acute gouty attack I would treat with Indocin along with a Post. Tibial N. block using 2% xylocaine/plain. The vasodillatory effect of the xylocaine will help clear the acute flare-up fairly quickly.

Once he's feeling better go ahead and do the nail. It will still be there in 10 days.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Many thanks for your interest,
Ok so a little more about the patient..
He is seen regularly by his gp regarding the gout in both 1st mpj's as he can only take certain medications when the flare arises only, and is sometimes non compliant hence the extended flares. So if we assume his gp is treating the gout and I am treating the igtn.

He presented with a very deep, very painful involuted first nail which he's been hacking away at for sometime and has left a very large spicule ( largest and deepest I have seen!) deep in the sulcus arising from near matrix, hence any attempts of conservative treatment is both difficult to remove and extremely painful.

Unfortunately due to policy and lack of PGD's the procedure will be digital block using mepivicaine.

The reason for posting was to find out whether anyone had any known reactions worth acute gouty flares and LA or Phenol or increased risk of infection with this presentation.

Thanks

How about removing a section of nail under LA without phenolisation. Gives you a few months breathing space. Come back and do Nail surgery later?

I would imagine having Gout and an ingrowing nail together not being a pleasant experience

Hi Mac
I'm still a bit confused re: the acute gout. Any local with vasodillatory effect will also resolve the Acute gout (if that is what it is) - just give him a PT block along with the digital.
I totally agree with Toughspiders (a.k.a....??) why not wait to perform the phenol procedure, just do a simple I&D and call it a day.

As far as aggravating the acute gout with another procedure: patients with gout will, of course, be prone to an acute flareup after a trauma (such as surgery) although I would not think a simple nail procedure would be invasive enough to cause this.

If he is already having an acute attack then it's a moot point isn't it.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Acute inflammation in the area may undermine the effectiveness of LA, but assuming anaesthesia is achieved using digital block, electrosurgical ablation of the matrix is one solution. This avoids having to repeat the procedure, results in a faster healing time with no need to use phenol.