surgical matricectomy - post procedure pain

[stoic]

hey guys -

i'm a second year medical student and long time SDN'er. i've got a quesion about the amount of pain pt's experience post surgical partial matricectomy w/partial nail bed removal. it's my understanding that if they can do the procedure with chemical/electro matrix ablation that it's not nearly as painful but if a true surgical matricectomy w/nailbed removal is required that the first few post-op days are very painful.

i ask for personal reasons; this is a procedure that i need done and am trying to fit into my schedule. i'd like to get the scoop from you guys so that i can figure out just how much this will slow me down. how long are patients usually on narcotics? how powerful of narcotics are needed (ie will i be able to get any studying done at all while on them).

anyway, i appriciate any info you can give me. i'm also not entirely clear on the indication of for the chemical nail matrix ablation vs. surgical matrix excision?

thanks again,
dave

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[psionic_blast]

hey guys -

i'm a second year medical student and long time SDN'er. i've got a quesion about the amount of pain pt's experience post surgical partial matricectomy w/partial nail bed removal. it's my understanding that if they can do the procedure with chemical/electro matrix ablation that it's not nearly as painful but if a true surgical matricectomy w/nailbed removal is required that the first few post-op days are very painful.

i ask for personal reasons; this is a procedure that i need done and am trying to fit into my schedule. i'd like to get the scoop from you guys so that i can figure out just how much this will slow me down. how long are patients usually on narcotics? how powerful of narcotics are needed (ie will i be able to get any studying done at all while on them).

anyway, i appriciate any info you can give me. i'm also not entirely clear on the indication of for the chemical nail matrix ablation vs. surgical matrix excision?

thanks again,
dave

I would recommend that you have a pod did it. Most general practioners will do what called an infiltration that hurts like the dickens. Pods use other techinques mercado block, v block, ring block etc. I had one done myself no narcotics need in my case. Are you sensitive to pain? I was right back on my foot the next day. Chemial abalation is what I had done on myself It has not grown back. If you have constant problems have the nail bed killed with phenol. (chemical ablation). Good luck trust me infiltration hurts like hell, they use to use this as a from of torture in the middle ages.

 

[dpmgrad]

hey guys -

i'm a second year medical student and long time SDN'er. i've got a quesion about the amount of pain pt's experience post surgical partial matricectomy w/partial nail bed removal. it's my understanding that if they can do the procedure with chemical/electro matrix ablation that it's not nearly as painful but if a true surgical matricectomy w/nailbed removal is required that the first few post-op days are very painful.

i ask for personal reasons; this is a procedure that i need done and am trying to fit into my schedule. i'd like to get the scoop from you guys so that i can figure out just how much this will slow me down. how long are patients usually on narcotics? how powerful of narcotics are needed (ie will i be able to get any studying done at all while on them).

anyway, i appriciate any info you can give me. i'm also not entirely clear on the indication of for the chemical nail matrix ablation vs. surgical matrix excision?

thanks again,
dave

The goal of both chemical nail matrix ablation and surgical matrix excision is to prevent nail from grow in the section of nail matrix that had undergone surgical intervention. Many people prefer chemical ablation because the recovery time is faster than surgical excision. In surgical excision, you will have stitches, which would need to be removed in 7-14 days. No stitches are involved with chemical ablation. Most people do have very good results with chemical ablation. However, surgical excision (if done properly) is more accurate since you are physically removing the affected nail matrix portion out. On the other hand, in chemical ablation, you are relying on chemicals (phenol, sodium hydroxide, etc...) to kill off that portion of the nail matrix.
Both procedures usually involves partial nail avulsion only and leaving the underlying nail bed intact. However, if one wishes to have a partial excision of the underlying nail bed, this is usually done with the surgical matrix excision procedure. If you were to get this partial excision of nail bed done with the chemical ablation procedure, you are looking at a surgical procedure where you will have stitches.

As for pain, it is a very subjective matter. Everyone's pain tolerance is different. I can say that there is some degree of discomfort with both procedures. However, most people do not require narcotics after the procedure.

Since the surgical excision of nail matrix requires sutures, the recovery time is usually longer than chemical ablation.

Hopefully, this answer some of your questions.

 

[IlizaRob]

hey guys -

i'm a second year medical student and long time SDN'er. i've got a quesion about the amount of pain pt's experience post surgical partial matricectomy w/partial nail bed removal. it's my understanding that if they can do the procedure with chemical/electro matrix ablation that it's not nearly as painful but if a true surgical matricectomy w/nailbed removal is required that the first few post-op days are very painful.

i ask for personal reasons; this is a procedure that i need done and am trying to fit into my schedule. i'd like to get the scoop from you guys so that i can figure out just how much this will slow me down. how long are patients usually on narcotics? how powerful of narcotics are needed (ie will i be able to get any studying done at all while on them).

anyway, i appriciate any info you can give me. i'm also not entirely clear on the indication of for the chemical nail matrix ablation vs. surgical matrix excision?

thanks again,
dave

Narcotics?? If you need narcotics after a procedure like this one, then you are either extremely sensitive to pain, or the doc didnt do the best job. Ive had my nail removed many times and I was on it right after the procedure for each one of them. I dont remember much pain after the local wore off. It will be tender though. As far as Chemical vs surgical methods, I have never heard of a noninvasive matrixectomy. You must be refering to chemically killing the nail bed with phenol after the nail is taken out. That way, it wont grow back. So either way, the procedure will be invasive. But some techniques require an incision. Just make sure the doc does an H block rather than an infiltration block. Good luck.

 

[stoic]

The goal of both chemical nail matrix ablation and surgical matrix excision is to prevent nail from grow in the section of nail matrix that had undergone surgical intervention. Many people prefer chemical ablation because the recovery time is faster than surgical excision. In surgical excision, you will have stitches, which would need to be removed in 7-14 days. No stitches are involved with chemical ablation. Most people do have very good results with chemical ablation. However, surgical excision (if done properly) is more accurate since you are physically removing the affected nail matrix portion out. On the other hand, in chemical ablation, you are relying on chemicals (phenol, sodium hydroxide, etc...) to kill off that portion of the nail matrix.
Both procedures usually involves partial nail avulsion only and leaving the underlying nail bed intact. However, if one wishes to have a partial excision of the underlying nail bed, this is usually done with the surgical matrix excision procedure. If you were to get this partial excision of nail bed done with the chemical ablation procedure, you are looking at a surgical procedure where you will have stitches.

As for pain, it is a very subjective matter. Everyone's pain tolerance is different. I can say that there is some degree of discomfort with both procedures. However, most people do not require narcotics after the procedure.

Since the surgical excision of nail matrix requires sutures, the recovery time is usually longer than chemical ablation.

Hopefully, this answer some of your questions.

thanks for the info. obviously this isn't exactly my field of expertise... i just assumed that the surgical method would be significantly more painful than it apparently is (i knew chemical/electric matrix ablation was not very painful - especially compared to a badly infected ingrown toenail!). and i'm definately going to a dpm (appt. this afternoon). though interestingly i've done a few partial nail avulsions electrocautery matrix ablations in the clinic (family med rotation). this is something i've have longggggg standing trouble with and i think it definately requires the know how of a dpm.

and thanks for not pulling the "don't fish for med advice on sdn" line. just a friendly discussion b/w future professionals about medical conditions . i am going to the dpm in a couple of hours.

for the sake of discussion, here's some more info. i have had problems with ingrown toenails for as long as i remember (both left and right). i've had spicules removed several times (under local), but never had a matricectomy. this current infected toenail is the worst i've ever had (left big toe). it's been infected for 3 weeks! it's an infection that sprung up while i was at the lake, likely from the pressure of waterski bindings pressing on my toes (i shudder to think about what sort of bugs are being cultured in the warm, summer lakewater). i even did a 10-day course of antibiotics (finished 5 days ago; erythromycin 500mg qid b/c i'm allergic to amox) that knocked the infection down quite a bit but didn't clear it completely. now the infection is back with a vengence (and probably resistance...). lots of granulation tissue and exudate with severe inflammation spreading from the medial border of the left toe all the way around the nail bed and even a little into the lateral border of the nail. oh, and a lot of pain. i can barely walk and can't wear a sock over the toe. it aches constantly and i can feel the sharp stabbing pain w/each pulse. touching it is like setting my toe on fire. you all ask about pain tolerance; i have an average tolerance. i'm not wimp nor a superman, but this thing really hurts. no systemic symptoms.

anyway, lets treat this like a case study. given that history - hypothetically of course - does it influence your management choices? does the infection need to be cleared before surgical intervention? given the amox allergy and failed tx with erythromycin, which antibiotic would you choose (my amox allergy is legit, do you worry about the cross reactivity between penicillins and cephalosporins?) send a C&S on the infection? will a surgical vs. chemical ablation +/- nail bed removal have the best result in terms of clearing the infection and relieving the pt's extreme discomfort?

thanks again guys. i see the podiatrist at 1:30pm central. i'll post the results of my visit when i get back.

 

[stoic]

so i saw the dpm and i have to say i was unfortunately not pleased with my experience. he came in the room, looked at my toe, and "said, yup, that's an infected ingrown toenail. we'll need to take that out. does sometime next week work for you?" brilliant. that cost $100. total bull****. $100.

he wouldn't even prescribe an antibiotic. this toe is infected! very infected! he pushed and a huge blob of pus popped out. oh and it hurts even i can't wear shoes (not that it seems to matter to dr. xxx). i ask about another antibiotic to settle it down before next week and he said "nope, we'll get to it soon enough next week; shouldn't need it."

wtf? it's a 3 week old infection that survived a full course of treatment with one antibiotic. over in my end of the medical world that needs another antibiotic. a strong one.

i had a funny feeling about how it was that i had to call 5 pods before i found one with an opening this week. strangely, the receptionist said that this one had "openings pretty much whenever it works for you... luckily he's able to see quite a few new patients" and I ask "ok, is he new to the practice" pause "no, Dr. xxx has been here for several years."

/rant off/

perhaps i'm enough out of my element that i don't understand the priniples in the treatment of this condition and should just roll with it. i'm not looking for answers here, just venting. sometimes we all need remeinders that if you're going to charge $100 dollars for an office visit, you'd better spend more than 5 minutes in the room and do something to make the patient feel like you've earned (and i'm not level blame at dpm in general here - all physicians are guilty of this from time to time)

 

[Dr_Feelgood]

Wow. I have shadowed few pods and they have never left an ingrown nail. This guy/gal must like you money. Sorry, but some pods are like any other doctor and it is about the cash you bring not the best for their patients.

Where do you live???

 

[IlizaRob]

so i saw the dpm and i have to say i was unfortunately not pleased with my experience. he came in the room, looked at my toe, and "said, yup, that's an infected ingrown toenail. we'll need to take that out. does sometime next week work for you?" brilliant. that cost $100. total bull****. $100.

he wouldn't even prescribe an antibiotic. this toe is infected! very infected! he pushed and a huge blob of pus popped out. oh and it hurts even i can't wear shoes (not that it seems to matter to dr. xxx). i ask about another antibiotic to settle it down before next week and he said "nope, we'll get to it soon enough next week; shouldn't need it."

wtf? it's a 3 week old infection that survived a full course of treatment with one antibiotic. over in my end of the medical world that needs another antibiotic. a strong one.

i had a funny feeling about how it was that i had to call 5 pods before i found one with an opening this week. strangely, the receptionist said that this one had "openings pretty much whenever it works for you... luckily he's able to see quite a few new patients" and I ask "ok, is he new to the practice" pause "no, Dr. xxx has been here for several years."

/rant off/

perhaps i'm enough out of my element that i don't understand the priniples in the treatment of this condition and should just roll with it. i'm not looking for answers here, just venting. sometimes we all need remeinders that if you're going to charge $100 dollars for an office visit, you'd better spend more than 5 minutes in the room and do something to make the patient feel like you've earned (and i'm not level blame at dpm in general here - all physicians are guilty of this from time to time)

Dude, that sucks. I obviously dont have anything near the experience that pod had but I would be thinking the same as you. He should have at least given you antibiotics. I dont think you should ever leave an infection if you dont have to. Its too bad you cant get in to see another pod. I would drop this guy in a heart beat.

 

[psionic_blast]

so i saw the dpm and i have to say i was unfortunately not pleased with my experience. he came in the room, looked at my toe, and "said, yup, that's an infected ingrown toenail. we'll need to take that out. does sometime next week work for you?" brilliant. that cost $100. total bull****. $100.

he wouldn't even prescribe an antibiotic. this toe is infected! very infected! he pushed and a huge blob of pus popped out. oh and it hurts even i can't wear shoes (not that it seems to matter to dr. xxx). i ask about another antibiotic to settle it down before next week and he said "nope, we'll get to it soon enough next week; shouldn't need it."

wtf? it's a 3 week old infection that survived a full course of treatment with one antibiotic. over in my end of the medical world that needs another antibiotic. a strong one.

i had a funny feeling about how it was that i had to call 5 pods before i found one with an opening this week. strangely, the receptionist said that this one had "openings pretty much whenever it works for you... luckily he's able to see quite a few new patients" and I ask "ok, is he new to the practice" pause "no, Dr. xxx has been here for several years."

/rant off/

perhaps i'm enough out of my element that i don't understand the priniples in the treatment of this condition and should just roll with it. i'm not looking for answers here, just venting. sometimes we all need remeinders that if you're going to charge $100 dollars for an office visit, you'd better spend more than 5 minutes in the room and do something to make the patient feel like you've earned (and i'm not level blame at dpm in general here - all physicians are guilty of this from time to time)

I am sorry This should have been dealt with immediately, I am sorry. Every doctor that I am with take it out same day and don't think twice about it. Where do you live? best of luck

 

[dpmgrad]

so i saw the dpm and i have to say i was unfortunately not pleased with my experience. he came in the room, looked at my toe, and "said, yup, that's an infected ingrown toenail. we'll need to take that out. does sometime next week work for you?" brilliant. that cost $100. total bull****. $100.

he wouldn't even prescribe an antibiotic. this toe is infected! very infected! he pushed and a huge blob of pus popped out. oh and it hurts even i can't wear shoes (not that it seems to matter to dr. xxx). i ask about another antibiotic to settle it down before next week and he said "nope, we'll get to it soon enough next week; shouldn't need it."

wtf? it's a 3 week old infection that survived a full course of treatment with one antibiotic. over in my end of the medical world that needs another antibiotic. a strong one.

i had a funny feeling about how it was that i had to call 5 pods before i found one with an opening this week. strangely, the receptionist said that this one had "openings pretty much whenever it works for you... luckily he's able to see quite a few new patients" and I ask "ok, is he new to the practice" pause "no, Dr. xxx has been here for several years."

/rant off/

perhaps i'm enough out of my element that i don't understand the priniples in the treatment of this condition and should just roll with it. i'm not looking for answers here, just venting. sometimes we all need remeinders that if you're going to charge $100 dollars for an office visit, you'd better spend more than 5 minutes in the room and do something to make the patient feel like you've earned (and i'm not level blame at dpm in general here - all physicians are guilty of this from time to time)

I am sorry that you encounter one of those few bad apples in our Podiatric profession. Like any medical specialty, there are a few doctors do whatever it takes to increase their income. The purpose of this particular DPM in delaying your nail avulsion to the next visit is so that he can bill for an initial visit for today's visit and then bill for the permanent nail correction procedure on the next visit. In my practice, we would at least performed the partial nail avulsion (if not permanent correction) on the same initial visit. You would need to remove the offending nail, in order to allow for the infection to go down. We would put all individuals with paronychia (infected ingrown nail) on antibiotics. However, the need for oral antibiotics when performing partial nail avulsion or permanent correction for paronychia remains somewhat controversial in literature.

 

[stoic]

Since several ask, I'm in Kansas City.

Thanks for the support guys (and or gals). It's interesting to hear that these are generally removed on a same day basis in the dpm world. In my primary care experience we always treated them the same day, too. My visit today served absolutely no purpose in the overall treatment of my toe and the more I think about it, the more annoyed I get. Especially because it cost me $100 (I'll probably get some back from insurance, but who knows). I do feel like I'm being screwed and am planning on writing a letter to the office expressing my feelings. I'm scared to know what it would actually cost to have the guy do the procedure.

I have a family friend who's a podiatrist in my hometown a few hours away and was able to talk to him on the phone tonight. He agreed that this encounter was less than ideal, to say the least. I will not be returning to the podiatrist I saw this afternoon. Instead, I'm going to go over to student health and have them do a digital block (or if the NP they have working doesn't know how, I'll do it myself) and have them take the part of the nail that's currently ingrown and causing the inflammation/infection out (it's deep, but visible... I just can't get it on my own due discomfort) but leave the matrix intact as well as start a different antibiotic (leviquin, most likely - it covers most everything gram+ and -). Hopefully that will get this episode cleared up. Then, when I get a chance, I'll get back to my hometown and have our family friend do the matricectomy. And then I'll (hopefully) never have to deal with this again.

Anyway, thanks for the info and listening to me bitch and moan. Don't worry, this experience hasn't soured me on pods. I've run into sooo many MD's who are the same or worse that in the scheme of things it isn't that big of deal. But if you're in the KC area and need to see a DPM, pm me and I'll tell you who NOT to go to.

Dave