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Ankle block for Multiple TNA's

Discussion in 'Foot Surgery' started by PodRon21, May 1, 2009.

  1. PodRon21

    PodRon21 Welcome New Poster


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    At lunch today a patient was discussed.

    Male
    35
    O/C nails (all of them) causing heavy infections.
    Pt keeps returning with same problem of reacurrent infection due to nails.

    Now podiatrist is suggesting one nail off at a time taking months, my idea was possible ankle block and removal of all nails at once?

    Logic says less LA needed for sensation loss so less chance of reaction however great infection risk.

    Was just think out loud, what do others think about that?
     
  2. Ryan McCallum

    Ryan McCallum Active Member

    I wouldn't be so concerned about the quantity of local anaesthetic required to give adequate anaesthesia provided you stay within limits of the MSD of your chosen anaesthetic agent. I would be thinking more about the number of injections the patient is going to be subjected to.

    My preference would be an ankle block if more than 2 toes were to be operated on.

    As for infection risk, that will depend on more than just the number of nails operated upon although that is a relevant factor. Weigh up risks vs benefits and also what the patient would prefer.

    Regards,
    Ryan
     
  3. Gibby

    Gibby Active Member

    Thank you for the discussion.
    I have done 8, 9, 10 nail avulsions at a time. Usually in children, always in response to chronic, painful paronychia.
    Prior to the surgery, make certain the patient has had comprehensive metabolic and nutritional analyses. Make certain the patient does not have an immune-deficiency issue. I agree with the ankle block. Expect some significant edema post-operatively, and give specific post-operative orders. Prophylaxis (abx) is recommended.

    -John in New Orleans
    confirmed cases of swine flu here are pending
     
  4. Paul_UK

    Paul_UK Active Member

    Ankle block would make sense if doing multiple procedures, as Ryan says above, less injections to deal with. Hoswever, more importantly would be the patients complience in dressing multiple wounds on one or both feet. There is no point doing all the toes at once if they wont dress them and they end up being in a worse state than they started.
     
  5. W J Liggins

    W J Liggins Well-Known Member

    Unless you have I/P hospital privileges I strongly suggest that you avoid dealing with both feet concurrently. Although it is entirely possible to carry out ankle blocks of both feet within Manufacturers recommended Maximum Safe Dose, if one or more of the blocks fail then 'top-ups' may take you over MMSD. Additionally, both the immediate post-operative recovery and the secondary are going to be difficult in an Out-Patient setting. The patient will be unable to walk unaided and you might be found liable for discharging an unfit patient if a fall resulted. Personally, I wouldn't worry greatly concerning the infection risk but you do not state whether you intend to cauterise the matrices or carry out any other procedure. If you are proposing an incisional procedure, then I agree with Gibby (above) that prophylactic antibiosis should be considered. Finally, whatever procedure is intended, I would suggest hospital follow-up at 2-3 days, 7 days and 12 weeks with written instructions concerning home management.

    Hope this is of some help.

    Bill
     
  6. drsarbes

    drsarbes Well-Known Member

    I recommend one foot at a time. Doing 2 feet makes a relatively simple matter into a somewhat painful and slow healing event.

    Toenail procedures should NOT be an "ordeal"

    If you are doing simple nail avulsions any type of anesthesia will work. I doubt you will use much less solution for a "foot block" at the level of the ankle than you will for five digital blocks.

    The above procedures normally require band aids one day post op, so I would not be concerned with dressing changes.

    The bigger question is - is this patient getting repeated Bacterial infections (pyogenic paronychia)?
    If so, simple nail avulsions will only give short term relief. When his nails grow back he will most likely have the same problem.

    It's not a question of how do anesthetize and perform a procedure, but one of performing a procedure correctly that is indicated.

    Steve
     
  7. W J Liggins

    W J Liggins Well-Known Member


    Given that the OP has already stated that the patient has suffered from frequent infections, and that it is intended to remove all the nails as a single episode, therefore the dressing will be larger than a band aid, I repeat my advice that the patient should ideally attend for re-dressing at 2-3 days and 7days (approx.) post op. Whether dressings are carried out by a nurse or the practitioner is not moot to the point, but it does mean that checks can be carried out on a patient who is known to be subject to repeated infection. You will therefore cover yourself against the possibility of charges of negligence (currently a 'hot' issue with the U.K. HPC.) I take it that most podiatric surgeons have a discharge f/u date, mine happens to be 12 weeks post-op. but that is a matter of choice/accepted procedure.

    I accept that practice may vary slightly in different parts of the world, but for what it is worth, that is my advice as requested by the OP.

    Bill
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi Bill:

    Well, whether you take one nail or 5, each digit should do well with a bandaid after 1 day.
    Nail avulsions, when done "gently" heal very quickly and shouldn't really need much attention.

    If they are all infected at the time avulsions, you may be correct that more will be needed, but perhaps not.

    I like the rest of the world comment..think this patient's toes knows where they are????? lol
    "it is what it is".....

    Steve
     
  9. W J Liggins

    W J Liggins Well-Known Member

    Hi Steve

    Thanks for your comments. Even though you are in Wisconsin and I am the other side of the pond, I do not think that our toes are too far away from each other!

    I think much depends on what procedure the OP intends to carry out. If it is simply a matter of plain avulsion, then I would tend to agree. If it is intended to carry out a Zadeks or other incisional procedure then it is a different matter and if a chemical ablation then it is different again.

    I don't want to bore you with 'political' problems here, but the registration board is being particularly aggressive at the moment and holding practitioners to account for such flimsy and subjective matters as whether the patient thinks hands were washed prior to treatment (naturally, they always are) and whether the practitioner spoke to a patient 'with pressure'. This is a very real problem, particularly within the national health service where individuals are having contracts terminated for such reasons as taking part in S & M in their own time, incorrect completion of notes etc. So assuming the OP works for that employer they would be well advised to look after their back.

    Cheers

    Bill
     
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