Electrosurgery and nail Surgery

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Dear All,

There is a distinct possibility that within 2 years that the use of Phenol BP in nail matricectomies could be withdrawn.

Looking at the recent edition of the Podiatry Now and BJP there were 2 articles on this topic.

One organisation opting for Sodium Hydroxide and the other suggesting Liquid nitrogen.

I have recently spoken to our risk manager about this.

He is adamant that we do not replace Phenol with Sodium Hydroxide.

So we are left with UREA, Liquid Nitrogen and Electrosurgery.

I personally am keen on Electrourgery especailly since the cost of the equipment has become affordable.

I spoke to our clinical director today and she says the capital cost is reasonable and would probably be successful with a decent bid for the sums required based on a decent plan of implementation.

SO

Does any body have experience with Electrosurgery and how it compares to Phenol?

Any advice and information would be gratefully received.

regards David

 

David

Like most things there are a few papers discussing this technique but little research testing the efficacy of the technique against the standard phenolisation. Have you seen the article at:

http://www.aafp.org/afp/20020615/2547.html

This is a "procedural" paper more than an evidence based account but it give an insight into the technique. Liquid Nitrogen also seems to be effective and I would say also needs investigating as cost, training and timewise it may be more efficient than using electrosurgery but that is just personal opinion not fact!

Soton Pod

 

David

I am not at all convinced that phenol will be withdrawn as the agent of choice for matrixectomies. Having read the article in the BJPM, I have to say that I am not in complete agreement with the authors' conclusions. In my experience, sodium hydroxide is more problematic than phenol as an agent for ablation - healing times are longer; there is a greater incidence of post-op discomfort and pain; and there is a greater rate of regrowth.

One of my considerations is the post-operative cosmetic results, and to that end I am not convinced by the effectiveness of electrosurgery, which can produce marked scarring. Neither am I convinced that cryosurgery can be used to give equal or better results than phenol (although I am a great proponent of cryosurgery in the Rx of VPs). In addition, using LN2 as an ablative agent in digital surgery can be extremely painful for the patient when freeze times, necessary for destruction of soft tissue, are utilised.

The primary argument for changing from phenol to sodium hydroxide (or other methods) concerns the risks to the operator from inhalation of the fumes -something that can be mitigated against by the use of effective filtration systems.

Best wishes

Mark

 

Liquid Nitrogen

Mark

I would have to say, in response to your comments, that using liquid nitrogen as an alternative to phenol is viable. You mention the issue of pain. This has never been something I have encountered bearing in mind that the freeze times required are short when compared with plantar wart treatments. Matrix tissue is much more suseptable to cold injury than the plantar epidermis and so freeze times are brief. Also, immediate pain is less as the toe is already anaesthetised but of course as the anaesthetic wears off some discomfort may return but this needs to be properly investigated to make a fair comparison.

Soton Pod

 

Between 1987 and 1989, sixty-eight patients underwent bi-lateral (both hallux) nail surgery where phenol was used as the chemical agent on one digit, whilst LN2 (either by direct or indirect application of the cryogen) was used on the other. Post-operative care was provided up to eight weeks after surgery and an additional two review appointments were scheduled at six and twelve-month intervals following complete healing.

From those patients:

· With phenol, two patients reported mild to moderate post-operative discomfort (both TNAs)
· With LN2, twelve patients reported mild to moderate pain (8 TNAs and 4 PNAs) and nine patients reported moderate to severe pain (6 TNAs and 3 PNAs)
· With phenol, healing times were between 14 and 28 days for PNAs; 33 and 58 days for TNAs
· With LN2, healing times were between 13 and 21 days for PNAs; 28 and 48 days for TNAs (healing times were measured by closure of the wound with no exudate)
· With phenol there were no regrowths of nail at the 12 month review
· With LN2 there were 12 partial regrowths (with TNAs) and 1 regrowth (with PNA)

Phenol was applied by the standard three and four minutes irrigation via a cotton bud applicator. LN2 was applied as a direct cryogen through a fine spray for all TNAs (23 in total) and indirect application via a 4mm dia closed cryo-probe for all PNAs (45 in total) in two freeze/thaw cycles between 10 and 20 seconds (until the formation of a visible iceball at 3mm beyond the margin of the target tissue).

Post-operative discomfort/pain is difficult to measure objectively for comparative analysis as no two patients have the same pain threshold, however it was observed that there was an elevated level of discomfort when the cryogen was applied directly to the matrix and nail bed tissue and especially so when there was formation of a haemorrhagic bullae (5 TNAs and 1 PNA).

I would concur that freeze times are much less than those used in VP treatments, especially with planter verrucae, however it is very difficult to measure the iceball formation unless thermocouples are inserted into the adjacent tissue. If thermocouples are not used then you run the risk of inadequate iceball formation (leading to regrowth) or excessive iceball formation (leading to severe post-operative pain - and malformation of the remaining nail matrix when used for PNAs).

Mark Russell

 

Why on earth change from using phenol?? I don't understand. Phenol will always be available, how else will people have sympathectomies and other medical procedures?

Nevermind the evidence...

The Cochrane Database of Systematic Reviews 2005 Issue 4
Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Surgical treatments for ingrowing toenails
Rounding C, Bloomfield S

Plain language summary
Ingrown toenails occur when the skin at the side of a nail is punctured or traumatised by the growing nail. This causes inflammation and sometimes infection. After removing part or all of the nail causing the problem, options to prevent recurrence include removing the nailbed and/or applying phenol (a caustic liquid). The review of trials found that removing the ingrown nail and using phenol on the nailbed was more effective at preventing recurrence than nailbed removal. However, people whose nailbeds were treated with phenol were more likely to have infections than those whose nailbeds were untreated after the surgery.

 

Hi guys!

I am a final year university student looking to research and compare methods/agents used in matrixectomies during nail surgery.

At first I was planning to compare sodium hydroxide with phenol but this seems to have been done to death. I thought I would just ask if there is any gap in current understanding that I could attempt to fill?

Also, DAVOhorn, I am unfamiliar with the use of UREA nor can I find it on google. Could you provide a little more info?

Regards,

Gareth