TFP Thread

[air bud]

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I think you meet the wrong patient it’s going to get you. I just happened to have mine early in my career that I learned my lesson on. I too thought a simple avulsion can’t cause much harm, and as uncle @Feli mentioned I think even the injection did harm as he got a wound by that.

Was this patient neuropathic? Did you even need to numb them up? Doing a simple avulsion on neuropathy it's fine to just rip that baby off, no local needed.

 

[air bud]

Maybe could have looking back but didn’t even consider at the time that even an injection could do that much damage. If I can’t feel pulses I really think from now on it’s slant back/abx/betadine until I have studies.

That’s what the few articles on this essentially recommend full vascular workup too. So I would say that’s standard of care.

I don’t have enough vascular docs in my area to just send them every pad patient so I’m trying to filter them before I hit the “vascular” button like the lizard meme.

View attachment 408852.

Feeling pulses is overrated. You would never do any ingrowns then....i maintain use your brain. This is an ingrown nail. How can you kill a tow with the physical act of removing a nail. First of all, if ever a concern it's a total not a partial. Can generally do a total much less a traumatically than a partial. Anyway....takes time and experience. Obviously this approach works until it doesn't.

 

[DYK343]

I got my doppler off ebay, was about $700

Remember, toenails are just skin appendages, so simple avulsions (no matrixectomy) are going to be safe. Or at least it's a risk/benefits estimation. I've done avulsions liberally in pad pts and have been lucky...so far

I've made this comparison before: to say that a toenail procedure caused an amputation is like saying the assassination of Francis Ferdinand caused WWI. Yes it catalyzed things, but all the stuff happening in the decades prior led up to it and it was bound to happen no matter what.

I have about 10 vasculopaths that return about every 6-9 months for their partial nail avulsion
No way in hell im doing a matrixectomy.

I have an inherited Vasculopath patient now with a hallux amp and 3/4 of the dorsal foot soft tissue absent due to nec fasc from a matrixectomy another DPM did. STSG this coming friday after a month of kerecis/vac/debridements/and a revasc.

 

[DYK343]

Can generally do a total much less a traumatically than a partial. Anyway....takes time and experience.

Wait... Total is less traumatic than a partial?
What is this technique?

 

[Adam Smasher]

I have about 10 vasculopaths that return about every 6-9 months for their partial nail avulsion
No way in hell im doing a matrixectomy.

I have an inherited Vasculopath patient now with a hallux amp and 3/4 of the dorsal foot soft tissue absent due to nec fasc from a matrixectomy another DPM did. STSG this coming friday after a month of kerecis/vac/debridements/and a revasc.

I think I posted about this before, but I once did a matrixectomy on an 80 year old lady who probably had pad. She developed a patch of skin necrosis at the nail fold that never really healed. I lost her to follow up but heard about her a few months later from another podiatrist with whom I had a cordial relationship. Toe was gangrene. Not completely, but enough to probably require amputation. I didn't get blamed, but I dodged a bullet.

 

[Feli]

I think I posted about this before, but I once did a matrixectomy on an 80 year old lady who probably had pad. She developed a patch of skin necrosis at the nail fold that never really healed. I lost her to follow up but heard about her a few months later from another podiatrist with whom I had a cordial relationship. Toe was gangrene. Not completely, but enough to probably require amputation. I didn't get blamed, but I dodged a bullet.

Yeah.... and this would be the rare circumstance where the toe amp even heals. (most often gets chased more and more proximal)

Just say no on these, guys.