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Presence of localised infection - a definite contra-indication to nail surgery?

Discussion in 'Foot Surgery' started by Berms, May 20, 2008.

  1. Berms

    Berms Active Member


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    I have recently seen many patients who have presented with an infected, painful, ingrown nail. The area is usually inflamed and I am almost always able to drain some pus from the site... For those patients that are surgical candidates, my practice thus far has been to wait, treat the infection and then perform the partial nail avulsion and phenolisation procedure.

    My questions are; what is considered best practice?

    1. Do the procedure immediately, and then treat the infection?
    2. Treat and clear the infection first, and then perform the procedure?
    3. What level / degree of localised infection is considered clinically significant?
    4. What level / degree of localised infection requires antibiotic therapy as opposed to topical antiseptics.

    Thanks for any advice, it is appreciated.
    Adam
     
  2. drsarbes

    drsarbes Well-Known Member

    Re: Presence oflocalised infection - a definite contra-indication to nail surgery?

    Hi Berms:
    I never do the P&A when an infection is present.
    When infected, I just do the I&D and wait a minimum of 2 weeks to do the P&A (if they give a Hx of repeated infections) - in fact I tell them that they can wait up to 3 or 4 months following the I&D (removal of the offending nail border) without worries of a recurrent infection.

    I also rarely find a need for antibiotics. Once the offending nail border is removed (or the entire nail if needed) along with bid soaks for a few day, the infection normally subsides very nicely. Once in a while I get a long standing paronychia (months or even years) then I may place them on antibiotics and check for osteo.



    Steve
     
  3. Adrian Misseri

    Adrian Misseri Active Member

    Re: Presence oflocalised infection - a definite contra-indication to nail surgery?

    G'day Adam,

    I generally don't refer for antibiotics either unless the toe looks heavily infected. If it is infected, I'll remove the nail spike then do the procedure about a week later if i can. If it's any longer, I'll tell my patients that it's vital that they keep it cleaned and dressed so that no infection gets into the area prior to surgery. that being said, I have done one or two procedures on mildly infected ingrown nails, and since the area is getting a good clean up and there's adequate phenolisation, I generally don't ahve too many problems. Remember, phenol has been used a a strong disinfectant for years, should kill just about any topical bugs in the area. The main concern with the PNA and infection will be the local anastetic not taking properly in teh toe. With infection, the pH of the tissues increases, and short acting local anastetics such as lignocaine will not take properly on the nerves, leaving little or no anastesia.
     
  4. Berms

    Berms Active Member

    Re: Presence oflocalised infection - a definite contra-indication to nail surgery?

    Thanks for the advice drsarbes, thats very helpful. I'm not familiar with the term "I&D" - could you explain this a little more? Do you anaesthetise the toe for the I&D? Most of the cases I am referring to are too painful and too inflamed for me to adequately get to the the offending nail border with just the "regular" techniques.

    Thanks,
    Adam
     
  5. Lee

    Lee Active Member

    Re: Presence oflocalised infection - a definite contra-indication to nail surgery?

    Adam,
    I think Steve was referring to Incision and Drainage (I&D). Basically, you're allowing an encapsulated collection of pus to drain by removing the offending nail spike and sometimes debriding any localised necrotic tissue. In your average healthy young guy who often presents with an acute ingrowing toenail, this might suffice (along with saline soaks, etc..) in clearing it up until you do your PNA.
    As for the injecting into infected tissues bit, why not just do a more proximal block (eg. mayo, ankle) so you're far enough away for it to work?
     
  6. Berms

    Berms Active Member

    Re: Presence oflocalised infection - a definite contra-indication to nail surgery?

    Thanks Lee. That makes sense.
     
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