Matrixectomy aftercare of choice

[BlueMerlin]

Hey, wanted to throw out a questions about what you guys like to do for your aftercare of matrixectomies to minimize post-procedure inflammation. I typically have done topical cream and daily warm soaks in salt and warm water, and have them clean out the gutter. However, while this works great *when* people do it, I have found that only about half of people in the demographic I serve will do this.

I've heard that Hydrogel w/Oakin works great, but never tried it myself. What are your thoughts on easier treatments people that patients tend to be compliant with?

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[air bud]

Take dressing off later that night. Soak in Epsom salts for week or so. Antibiotic ointment and bandaid. See me in 2 weeks. Generally not antibiotic unless diabetic then duricef 500mg BID 5 days. See them in 2 weeks.
If healthy and think will do well, I tell them if redness no pain at 2 weeks it's ok, likely due to irritation of skin from phenol not infection. I try not to clog up my clinic with meaningless visits so I have room for new people. I have a partner and she is busier than me, but I try to hog as many NP as I can so more spots means more new patients and better stuff than level 2 visits .


PS make sure they have intact pulses....

 

[dtrack22]

Hey, wanted to throw out a questions about what you guys like to do for your aftercare of matrixectomies to minimize post-procedure inflammation. I typically have done topical cream and daily warm soaks in salt and warm water, and have them clean out the gutter. However, while this works great *when* people do it, I have found that only about half of people in the demographic I serve will do this.

I've heard that Hydrogel w/Oakin works great, but never tried it myself. What are your thoughts on easier treatments people that patients tend to be compliant with?

I’m not sure what is easier than OTC abx ointment and a band aid.

You expect the patients in the “demographic you serve” to fork over $25 for some Amerigel? That’s 3 packs of cigarettes.

My patients get a sheet telling them to do daily foot soaks and abx ointment with a band aid. I do a lot of avulsions and matrixectomies and haven’t seen any complications from this. I honestly couldn’t even tell you which patients were following the instructions perfectly and which were taking shortcuts. They all pretty much look the same after a few weeks.

 

[air bud]

My patient demographic is pretty tough as well.

Correctly said by every doctor everywhere always forever

Like dtrack says, if you think they have money for amerigel then you are are basically practicing in Beverly Hills

 

[msuDPM]

I’m not sure what is easier than OTC abx ointment and a band aid.

You expect the patients in the “demographic you serve” to fork over $25 for some Amerigel? That’s 3 packs of cigarettes.

My patients get a sheet telling them to do daily foot soaks and abx ointment with a band aid. I do a lot of avulsions and matrixectomies and haven’t seen any complications from this. I honestly couldn’t even tell you which patients were following the instructions perfectly and which were taking shortcuts. They all pretty much look the same after a few weeks.

Pretty much agree with this. I have them leave bandage on overnight, start soapy water soaks twice daily the next day. Bacitracin and a bandaid in between soaks. See me in 2 weeks. Should probably do vinegar soaks instead as I use NaOH instead of phenol, but haven't seen bad enough results to change. Almost all do well at 2 week. Have had occasional DM nail bed wound, but typically heal pretty quickly.

 

[janV88]

My practice uses naoh not phenol. Much less swelling and drainage afterwards. Just as effective.

For aftercare. Abx x 7 days. Amerigel, gauze, coban. Leave for 24hrs. Then remove. May shower and rinse with warm soapy water. Dry. Amerigel and small dressing daily. See back in 1 week. Maybe see back at 3 week mark

 

[air bud]

My practice uses naoh not phenol. Much less swelling and drainage afterwards. Just as effective.

For aftercare. Abx x 7 days. Amerigel, gauze, coban. Leave for 24hrs. Then remove. May shower and rinse with warm soapy water. Dry. Amerigel and small dressing daily. See back in 1 week. Maybe see back at 3 week mark

Not trying to stir up trouble or critique, but if less swelling and drainage with NaOH, why are you seeing at 3 weeks other than for an office visit? Don't get me wrong, I see at 2 weeks (at least 10 days out ...) But I don't know why you would want to see at 1 and 3. I don't want to be busy seeing patients for the sake of seeing patients.

Also, is amerigel something the patients purchase? I honestly have no exposure to amerigel. I didn't spend much time in clinic in residency and when I did nobody used it. I vaguely remember from rotations

 

[heybrother]

My anecdotal experience is any patient seen before 2 weeks will likely result in an additional office visit.

 

[janV88]

Not trying to stir up trouble or critique, but if less swelling and drainage with NaOH, why are you seeing at 3 weeks other than for an office visit? Don't get me wrong, I see at 2 weeks (at least 10 days out ...) But I don't know why you would want to see at 1 and 3. I don't want to be busy seeing patients for the sake of seeing patients.

Also, is amerigel something the patients purchase? I honestly have no exposure to amerigel. I didn't spend much time in clinic in residency and when I did nobody used it. I vaguely remember from rotations

I usually don’t see them at the 3 week mark. Just if it’s needed. By 1 week they are usually 90-95% healed. I review signs of infection and tell them to see me as needed.

As for amerigel and if patients buy it. I’ve had almost all my patients buy it. I’m sure some don’t even follow my directions even though we print out a sheet. Is it better than baci? Not sure. It’s what my partners use and they’ve never had any issues.

 

[dtrack22]

What air bud (I think) is getting at is...why are you seeing a patient that usually doesn't have problems first during the global period where you get $0 for them taking up a chair in your clinic and then again at 3 weeks when you're realistically billing a 99212 instead of filling it with a new or established patient that will reimburse more?

Even if you don't typically see them at 3 weeks, I can't make any sense of why you see them at 1.

Heck, in your situation its easy to defend the 3 week appointment. As a new practitioner your clinic schedule likely isn't full (well mine isn't but maybe I shouldn't project on others). So even a 99212 isn't preventing other patients from getting in to see you. If every slot in air bud's schedule is full, then not seeing matrixectomy patients twice makes sense. If he has openings then he's losing money by not filling them with even a $42 visit.

 

[Carbon13]

If much drainage is present = PO ABX 7 days / betadine soaks, matrixectomy the next week.
If drainage is STILL moderate = nail avulsion to further calm things down, continue soaks -> Matrixectomy in next few weeks, once nail is big enough to grab. (I've had cases of wound drainage diminishing effects of chemical agent)

NaOH
Silver Sulfadiazine, 2x2, coban after procedure. Change bandage next day and begin soaks
3 days Vinegar / 3 days Betadine
F/u in 2 weeks. Expect to see stable eschar.

I've seen Tobradex drops used with success to speed things up.

For the ischemic / diabetics, I've seen the dead space of the proximal fold get clogged with junk & try to abscess as the edge closes over. In these instances I've had good luck with sending a sterile OR scrub brush home with the patient and having them use it to agitate the wound during soaks to keep things fresh.

Also, I've had some serious messes come into the office after having the PCP perform IGTN removal on the same digit / multiple attempts. Not worth it for them to mess with IMO.

 

[janV88]

What air bud (I think) is getting at is...why are you seeing a patient that usually doesn't have problems first during the global period where you get $0 for them taking up a chair in your clinic and then again at 3 weeks when you're realistically billing a 99212 instead of filling it with a new or established patient that will reimburse more?

Even if you don't typically see them at 3 weeks, I can't make any sense of why you see them at 1.

Heck, in your situation its easy to defend the 3 week appointment. As a new practitioner your clinic schedule likely isn't full (well mine isn't but maybe I shouldn't project on others). So even a 99212 isn't preventing other patients from getting in to see you. If every slot in air bud's schedule is full, then not seeing matrixectomy patients twice makes sense. If he has openings then he's losing money by not filling them with even a $42 visit.

Good point with seeing follow ups after global and not filling your schedule with no pay visits to increase revenue. I guess for me it’s the way it’s done at my office. Patients are all told from the beginning that 1st visit is done 1 week out cost included in the procedure...etc. So I just follow along to prevent confusion. Then at 1 week 95% of them look great so after that I just see them prn.

Question about soaks. Do patients actually do them? My protocol is daily bandaid with amerigel. This is written on a sheet... easy. But I still get about 20% who come in with no band aid. They even spent the money on the amerigel and dressings.

 

[dtrack22]

I guess for me it’s the way it’s done at my office.

I know we are in different situations, and when specifically dealing with matrixectomies this may not apply, but be careful (in general) following this line of logic when you work for podiatrists. If I did things because its the way they were done in my office, I would be making up stress fractures, telling patients they have "pre-broken" bones, neuromas, etc. to justify treatment. This isn't directed at janv but many of you will find that you are better equipped to diagnose and treat many pathologies compared to your bosses. i.e. When your boss tells you to use a tourniquet for an I&D on a post-op infection case because they put tourniquets on everything, and then states how hard it is to tell if some of the tissue is viable or not...that's a true story from a colleague

Just be careful with doing things a certain way because that's how its done at your office

 

[streetsweeper]

My post procedure protocol is similar to Airbud..same logic with the follow ups. I use NaOH. No tourniquets. I don't routinely prescribe Abx, not even for diabetics unless it is obviously infected. I can recall twice this year where I had to prescribe Abx based on a judgement call. Haven't had problems for past 3 years in practice.

Keep it simple.

 

[BlueMerlin]

Lots of good ideas, guys. Thanks for the responses. I'm still new in practice and have been wanting to stretch my legs and see if I can do better in a few areas.

 

[ExperiencedDPM]

I have never seen the need for oral antibiotics. Most edematous and erythematous reactions are from the phenol, not an infection. You are using a caustic agent and it’s unlikely for an organism to thrive in that environment.

A hydrogel, silvadene (if not allergic) or Bacitracn. Stay away from Neo/polysporin.

Soaks are fine but many patients don’t comply. The biggest factor in my opinion is the use of a gauze pad and NOT a band aid. It allows for better absorption with no possible reaction to the adhesive on a band aid. And this opinion is based on performing the procedure thousands of times.