Ingrown toenail surgery question

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shezadeh

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Mods, please delete if not allowed. Pre-pod here, but posting to learn more. I remember seeing a video for a procedure for ingrown toenails, but it was a bit invasive. There was a significant amount of "flesh" removed from the sides and front (end of toe) of the nail, almost 1/3 deep, to allow the nail to grow out. What is the name of this procedure? Is this still done?

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The vast majority of permanent nail surgery is going to rely on phenol. If you polled enough podiatrists you'd find someone who does "sharp" for everything but they'll be the exception. I do some variation of 3-5 sharp procedures a year on people who've undergone plural failed matrixectomies. Look up Frost, Winograd etc.

Interestingly, the first thing I saw when I looked up Frost in Google was a variation being performed in the operating room. Every single sharp procedure I've done as an attending has been done in my clinic. These are not big deal procedures. They require a blade, a pickup, a curette (?), some suture and marcaine. I don't write pain medication for them.

This is just a random aside - the CPT code for matrixectomy includes all variations of the procedure ie. sharp, chemical, laser - whatever and wherever ie. OR or clinic. There is no special magically increased reimbursement for taking the patient to the OR. In fact, you are reimbursed at facility rate which is substantially less.
 
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Thanks, but there was one particular surgery that was even deeper than the Frost procedure. I just can't find the video or the name anymore. Basically, the surgeon cuts both sides (and front) of the nail, but very deep, to allow the nail to grow outwards. There is a ton of bandaging at the end. Does this ring a bell with anyone?
 
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You are probably talking about a subungual exostosis (benign bone growth under the nail). That is seldom even necessary (can just trim the nail or remove the nail) and should be an OR procedure typically when it rarely is actually needed (OR due to depth down to bone, significant bleeding and suturing which most patients are not too comfortable with being awake for, elective procedure and not ER injury that needs to be done asap, etc). Subungual exostectomy is over-performed in the office, especially by older practitioners, since it is probably a good paying code. You can always take an xray and find this ridge of bone or small outgrowth on most highly curved toenails, but that doesn't mean it is necessary or wise to do a fairly aggressive procedure.

It would be figure 3 in link below for a subungual exostosis removal... basically make sideways incision across the tip of the toe and flap up the nail side of the toe's skin to expose and remove bone, then remove the nail and sew it all back up (yeah, not medical terms but he is pre-pod). Not common at all... especially should not be common to do in the office and not the OR.

 
Nope. That isn't it. Let me see if I can find the video clip...
 
At the end, basically halfway deep, there is a "horseshoe" of skin/flesh removed.
 
Maybe a Zadik then. That's where you raise the proximal border as a flap and excise the matrix down to bone.

That said, Feli's post is overall pretty solid concerning dynamics and that article on pincer nails is interesting albeit I'll just probably stick with matrixectomy.
 
Strange, I really can't find this video. It was a "horseshoe" cut/removal from the sides and front of the toenail. No flaps.
 
You are probably talking about a subungual exostosis (benign bone growth under the nail). That is seldom even necessary (can just trim the nail or remove the nail) and should be an OR procedure typically when it rarely is actually needed (OR due to depth down to bone, significant bleeding and suturing which most patients are not too comfortable with being awake for, elective procedure and not ER injury that needs to be done asap, etc). Subungual exostectomy is over-performed in the office, especially by older practitioners, since it is probably a good paying code. You can always take an xray and find this ridge of bone or small outgrowth on most highly curved toenails, but that doesn't mean it is necessary or wise to do a fairly aggressive procedure.

It would be figure 3 in link below for a subungual exostosis removal... basically make sideways incision across the tip of the toe and flap up the nail side of the toe's skin to expose and remove bone, then remove the nail and sew it all back up (yeah, not medical terms but he is pre-pod). Not common at all... especially should not be common to do in the office and not the OR.


Maybe a Zadik then. That's where you raise the proximal border as a flap and excise the matrix down to bone.

That said, Feli's post is overall pretty solid concerning dynamics and that article on pincer nails is interesting albeit I'll just probably stick with matrixectomy.


Just found it, it is called the Vandenbos procedure.
 
Just found it, it is called the Vandenbos procedure.
I promise you will do tops 1 in your career. Forget it exists. Look it up when you need to
 
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I promise you will do tops 1 in your career. Forget it exists. Look it up when you need to
I guess that answers the question as to how common it is
 
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I guess that answers the question as to how common it is
You have to take McGlamry (at least older versions ) with a grain of salt. So much academic stuff in terms of procedures etc. Depending on residency etc a million things you never need to know. I don't know academic the kids are these days, but just so much unnecessary stuff. Do you need to know all the different ways you can screw up someone doing a lateral ankle stabilization by sacrificing good anatomy? No. Brostrom and internal brace (honestly I do IB on everyone these days....). Do you need to know all the ways to do am ingrown nail....no. might you find some jerk who wants to pimp you on those? Yeah...
 
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I promise you will do tops 1 in your career. Forget it exists. Look it up when you need to
You're only going to do that one if you don't have OR privileges to do Winograds at the ASC or hospital at the beginning of a block of real surgery.

I would never do that Vandenbos type dissection in the office unless it was a real infection control situation or the pt had no insurance and was in a real jam. What a mess. That is crazy to intentionally leave those huge bovied wounds, haha. I am sure they are also told to soak in epsom 5x daily afterwards (total TFP non-EBM rule #1).

.... Do you need to know all the different ways you can screw up someone doing a lateral ankle stabilization by sacrificing good anatomy? No. Brostrom and internal brace (honestly I do IB on everyone these days....). ...
Yeah, I made a fool of myself on one of my clerkships talking about Crisman, Lee, etc... they were like "yeeeeeah, so those were some of our older articles."

I do IB for ATFL on all of them (and scope on 90% of them, the v-shaped IB for ATFL+CFL when needed) basically ever since residency also... I used cadaver tendon on a few before IB. It's just fast and more predictably awesome than just Brostrom or any anchor or spiderweb stitch Brostrom magic can hope to be.
 
You're only going to do that one if you don't have OR privileges to do Winograds at the ASC or hospital at the beginning of a block of real surgery.

I would never do that Vandenbos type dissection in the office unless it was a real infection control situation or the pt had no insurance and was in a real jam. What a mess. That is crazy to intentionally leave those huge bovied wounds, haha. I am sure they are also told to soak in epsom 5x daily afterwards (total TFP non-EBM rule #1).


Yeah, I made a fool of myself on one of my clerkships talking about Crisman, Lee, etc... they were like "yeeeeeah, so those were some of our older articles."

I do IB for ATFL on all of them (and scope on 90% of them, the v-shaped IB for ATFL+CFL when needed) basically ever since residency also... I used cadaver tendon on a few before IB. It's just fast and more predictably awesome than just Brostrom or any anchor or spiderweb stitch Brostrom magic can hope to be.
yes, IB is awesome use 100 percent of the time. I never look at an ATFl and say yeah, that looks like good tissue, Imma just do vest over pants (pants over vest...). Agree scope 90 percent as well. The few times i have done CFL has been on more active patients and did 2 IBS (my rep loves me...) to maintain more anatomic orientation...at least that is what I tell myself. Have done IBs on 16 year olds a few times. Turns out great. Have on coming up that was some old proceudre (waiting on MRI) where the did a tendon through the fibula etc....planning on cutting out and hopefully revise with IB. Repeat IB is great. Uh check out the research on it.
 
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I would never do that Vandenbos type dissection in the office unless it was a real infection control situation or the pt had no insurance and was in a real jam. What a mess. That is crazy to intentionally leave those huge bovied wounds, haha. I am sure they are also told to soak in epsom 5x daily afterwards (total TFP non-EBM rule #1).
Funny thing was that a few of the YouTube videos for the Vandenbos procedure were in-office...
 
(1) Everyone has their own considerations of what is appropriate to perform in the office. Some people do "sharp" nail surgery at the surgery center. I've done all of mine in my clinic. I also do partial toe amputations in the office when the need arises. Everyone will have their own level of comfort based on their expectations of bleeding, sterility, patient tolerance.

(2) I watched a video of the Vandenbos and this is just a much more gruesome version of the procedures already described above. You watch that procedure and think "neat" - I watch that video and think, I can accomplish the same or better with 1/3rd the tissue injury. The patient doesn't know better but they likely had an unnecessary monstrosity performed on them. I briefly scanned the literature on this procedure and some of the return to work/healing times seemed outrageous compared to other procedures we do. I routinely send anyone I perform surgery on back to work same/next day. Certain activities/procedures can be associated with longer recovery ie. total matrixectomy + steel toed boots may be a no go but most people after a partial avulsion/partial matrixectomy should feel better than they did before surgery within a day.

(3) IB is growing on me a lot. Just had a teenager walk in a boot at 1 week and tell me they are pain-free. That said - I don't want to use all of their extra anchors etc. I deploy to the talus, prepare the fibula, repair with suture tape or the extra strand, and then deploy to the fibula. I saw a few cases in residency where patients had ridiculous reactions to anchors so I am to be a minimalist whenever possible.
 
(1) Everyone has their own considerations of what is appropriate to perform in the office. Some people do "sharp" nail surgery at the surgery center. I've done all of mine in my clinic. I also do partial toe amputations in the office when the need arises. Everyone will have their own level of comfort based on their expectations of bleeding, sterility, patient tolerance...
Absolutely.

I think the patient tolerance is my typical guide. I don't like things that bleed a lot or take awhile or need sutures, cautery, etc in the office if it's not absolutely necessary (ingrowns never are emergent despite what the NPs in Urgent Care seem to think). I used to think I could just tell who the patients that would be ok to do 3:1 lesion excis, sharp ingrown, aggressive wound care with a fair amount of bleeding, lac repair without a visual barrier, etc on... but then I had enough 'tough' looking/sounding patients who still syncopized and slumped out of the chair or even came very close to having to be sent to ER for eval of basically glorified panic attacks. I guess that stuff can happen even from suture removal or injections, but it seems more common with longer or more bloody procedures in my exp. Even if the patient is ok, I also don't love it when I've clearly alarmed my new MAs, hah. Plus, as if the procedure didn't get me an appoint slot or two behind, the damage control for the fainting and sending your MA for orange juice and then checking on them again gets your clinic flow even a bit more backed up (kidding... kinda).

Toe amps are debatable depending on the cellulitis/abscess and urgency, but I like to cut the mid or prox phalanx as opposed to disarticulations... so that's an OR thing in my hands also and not bedside/office unless some rare circumstance (maybe huge pt deductible and/or bad cellulitis pt in office... where I may open amp and then send to hospital for IV, closure in OR after office or next morning). I do tendonotomies on lesser digits in office if I think they might work, but I use 18ga and that's over in less than an minute with a pressure wrap, no sutures and basically less time and bleeding than ingrown. I realize I'm on the conservative end. Conversely, I think some other guys still do plantar fascia releases, MIS, 3-stab TALs, and other stuff in office, so again, it's all about personal preference. As long as nobody's crashing off the guard rails of local standard of care (or sterility, as you said), it's personal pref.

I will do some reasonably messy or painful I&Ds, reductions, lac repairs, etc at ER or hospital bedside +/- IV sed, but I feel that stuff is immediately necessary for perfusion/sepsis/etc reasoning... I don't feel it's really a choice unless you could get to OR immediately.
 
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Absolutely.

I think the patient tolerance is my typical guide. I don't like things that bleed a lot or take awhile or need sutures, cautery, etc in the office if it's not absolutely necessary (ingrowns never are emergent despite what the NPs in Urgent Care seem to think). I used to think I could just tell who the patients that would be ok to do 3:1 lesion excis, sharp ingrown, aggressive wound care with a fair amount of bleeding, lac repair without a visual barrier, etc on... but then I had enough 'tough' looking/sounding patients who still syncopized and slumped out of the chair or even came very close to having to be sent to ER for eval of basically glorified panic attacks. I guess that stuff can happen even from suture removal or injections, but it seems more common with longer or more bloody procedures in my exp. Even if the patient is ok, I also don't love it when I've clearly alarmed my new MAs, hah. Plus, as if the procedure didn't get me an appoint slot or two behind, the damage control for the fainting and sending your MA for orange juice and then checking on them again gets your clinic flow even a bit more backed up (kidding... kinda).

Toe amps are debatable depending on the cellulitis/abscess and urgency, but I like to cut the mid or prox phalanx as opposed to disarticulations... so that's an OR thing in my hands also and not bedside/office unless some rare circumstance (maybe huge pt deductible and/or bad cellulitis pt in office... where I may open amp and then send to hospital for IV, closure in OR after office or next morning). I do tendonotomies on lesser digits in office if I think they might work, but I use 18ga and that's over in less than an minute with a pressure wrap, no sutures and basically less time and bleeding than ingrown. I realize I'm on the conservative end. Conversely, I think some other guys still do plantar fascia releases, MIS, 3-stab TALs, and other stuff in office, so again, it's all about personal preference. As long as nobody's crashing off the guard rails of local standard of care (or sterility, as you said), it's personal pref.

I will do some reasonably messy or painful I&Ds, reductions, lac repairs, etc at ER or hospital bedside +/- IV sed, but I feel that stuff is immediately necessary for perfusion/sepsis/etc reasoning... I don't feel it's really a choice unless you could get to OR immediately.
I don't think that's unreasonable. Priority number 1 is doing right by people. People are skittish and that includes MAs.
 
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