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First of all regards! and hope you all have had a wonderfull christmas. I would like some information on the proper surgical procedure which is best used for removing a pyrogenic granuloma on the lateral border of the hallux
Regards
Claudina

It depends how far the flames shoot out of it.

lets put it that way it is inflammed and there is pus production a previous pna with phenolisation has already been performed, as igtn was suspected, i found the frost procedure, but i dont know if it is correct or if there are other procedures which can be better.

If there is granuloma formation, I would anesthetize the toe and first suspect that there is still some nail spicule that is still present. Often following a partial nail avulsion, I have seen that a small piece of nail or nail spicule may break off or be missed and left in the nail border. Most often, this presents at the extreme tip of the nail groove and has often been broken off prior to the patient entering your office. It is often a small spicule that almost is growing out the distal nail groove and out the end of the toe.

The patient attempts to cut the nail and leaves the small spicule behind. By the time the patient enters the office, the entire nail groove is inflamed, and when the nail border is avulsed or a P & A is performed, this small spicule is often left behind.

Therefore, I would excise/curette the granuloma (expect bleeding) and use a small curette to carefully explore the ENTIRE nail groove, especially the extreme distal groove for a small spicule. After the granuloma has been curetted and/or sharply excised, it can often be chemically cauterized with silver nitrate applicator sticks or electrically cauterized.

It is rarely necessary to perform a Frost type procedure for a granuloma. Please remember that a granuloma USUALLY occurs as a result as a reaction to some irritant. That's why I'd explore the area carefully.

Hope this helps.

After a P&a possible that you just not have allowed it to drain however always take an x-ray to rull out osteo i would start with a culture open and allow to drain then do the procedure that you are best at frost winograd zadik

Hi Claudia

I think Lee's message was a merry Christmas joke over a typo. 'pyrogenic' for pyogenic.

It is possible that the granuloma is caused by an inclusion cyst. Unusual after phenolisation but it is possible that matrical cells are still producing some nail under the eponychium. Having gone through the good advice already given - and a C & S should return a positive result if the problem is infective, I would go along with the Frost or Winograd procedure.

All the best

Bill Liggins

thanks very much you were very helpful with all the info you gave me
Cant thank you enough
Regards
Claudine

if the pyogenic granuloma re occurs after it is curetted and chemically cauterized, would it be best to do a frost procedure or a winograd ? the lesion is on the fibular border of the hallux

thank you

anne marie ( 3rd year BSc(Hons) podiatry student at the univeristy of malta)

In my opinion, if any lesion recurs, in addition to considering the next procedure to perform it is imperative to also perform a biopsy. The results of the biopsy may dictate the next procedure to perform!

Hi Claudina

I found an article on pubmed that details a study that successfully removed pyogenic granulomas using cryosurgery. Enter pyogenic granuloma into the search facility at pubmed and you should be able to find it. A possible alternative to the suggestions in other posts.

Cheers
Rob

Hi Claudina:
I feel motivated to add a post here since apparently you've been going back and forth.
Re-read Dr DSW's first post (even though I hate agreeing with him! hahaha <------a joke)
he's exactly right.
These are not uncommon and almost always due to continued infection from a missed spicule.
Find the offending nail, remove the granuloma and wrap it up good.
Steve

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

Now that Steve (Dr. Arbes) has agreed with me, we can definitely put this subject to rest!!!

Claudia:
How did it go?

Steve

Dr. DSW is correct.
Very common, most likely a nail spicule.
Antibiotics after procedure, post-op shoe.

__________________

Dr. John G. Fasick
LSUHSC New Orleans
Clinical Insructor, LSU School of Medicine
jfasic@lsuhsc.edu

Claudia

Regarding pyogenic granulomas, I'm not a surgeon but granulomas are very common presentation in everyday podiatry clinic and are simple to get rid of.

After removing the nail spike I usually take the bulk off with a pair of tissue cutters and then trim with a scalpel if necessary. I then pack with Seasorb and tightly dress, as also indicated by DrSarbes, with instructions to leave dressed for 5 days. I tend to avoid silver nitrate at first since people don't like a big black mark left on their toe and plus it stings like mad. I find this very successful but sometimes Silver nitrate is required.

Cheers Dave

__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.