Dr17
INNOVATIVE CARE Toenail Surgery for Diabetic Patients Ann Middleton and Frank Webb Chiropody Department, Hope Hospital, Salford.
may go undetected. Subsequently, soft tissue infection and ultimately osteomyelitis of the distal phalanx may occur. Peripheral Neuropathy. Absence of the early-warning signals of pain or discomfort may allow an initially minor problem to progress to a serious stage before being detected.
Introduction In people with diabetes, toenail surgery is generally employed as the last resort to deal with acute nail-related problems which have failed to respond to a variety of conservative approaches. By this late stage the viability of the toe is often compromised. The purpose of this article is to describe the work carried out in this field in the authors’ department, and to put forward a case for an early, definitive, surgical approach to nail-related problems before potentially serious complications occur. Our chiropody department is situated within the main hospital out-patient department and, although physically separate, is fully integrated into the diabetes unit. It is the key location for the multi-disciplinary management of diabetes foot problems.
Indications for Toenail Surgery Acute, infected, ingrowing nail. Recurrent paronychia. Recurring pain or chronic discomfort due to an abnormal nail shape. Thick deformed nail. Sinus or ulcer of the nail bed or sulcus.
NORMAL
ABRUPTLY CURVED
Figure 2: Acute infected ingrowing nail.
Predisposin Factors to Nail-Relate Problems
%
Pressure. Prolonged pressure on the nail caused by wearing tight hosiery, or a shoe with a shallow and/or narrow toe box leads to trauma of the nail sulcus or bed and is most likely to occur where the nail i s an abnormal shape. Direct Single Trauma to the toenail area. A toe with an abnormally shaped nail is most vulnerable. Inappropriate Nail Care. Attempts to cut down the side of a nail to relieve the discomfort caused by an abnormally shaped nail frequently leads to an ingrowing nail. Similarly, tearing nails and cutting nails too short often has the same outcome. Peripheral Vascular Disease. Where abnormal nail shapes and peripheral vascular disease co-exist, relatively minor pressure from the nail edge can lead to the development of a sinus in the nail sulcus which
EXCESSIVE CURVATU RE
To effect permanent removal of abnormally shaped nail shoulders. To effect permanent removal of the total nail. To provide relief from recurring pain or chronic discomfort. To allow free drainage of infection. To allow healing of a subungual ulcer or sinus. To reduce the risk of further episodes of infection, ulceration or sinus formation.
Advantages of Early Definitive Surgical Intervention Before Complications Occur Improved outcome is likely when surgery is performed whilst the patient is still relatively young and fit, with an optimum circulatory status. Reduces or eliminates the need for further chiropody treatment. Logic suggests it reduces the incidence of toe morbidity and amputation rate in the long term.
Considerations Before Proceeding with Surgery
INVOLUTED
Figure 1 : Abnormal nail shapes.
680
Aims of Surgery
Figure 3: Diagrammatic representation of an ingrowing nail resulting from cutting d&n the side of the nail, causing a spike to be left in the sulcus, which then grows forward unseen and penetrates the substance of the toe.
Infection. Any degree of infection is treated with appropriate antibiotic therapy before, during and after the procedure. Diabetes Control. This should be optimum at the time of the procedure. Raised blood-sugar levels predispose to infection and reduced healing rates. Specialist advice may be required. Prophylactic Antibiotic Cover. This may be considered appropriate if blood-sugar control is not optimum. Circulatory Status. A thorough assess-
INNOVATIVE CARE ment is carried out. This will include foot pulses, capillary refill time, skin colour, temperature and thickness. If these are inconclusive, an X-ray of the foot to show any vascular calcification, Doppler studies and occasionally angiography may be required. Referral to the vascular surgeon may be necessary. Mode of Anaesthetic. A local anaesthetic may be contra-indicated if the circulation is poor or there has been a previous adverse reaction. In these circumstances if the procedure is essential due to an acute problem, a general or epidural anaesthetic may be required. Use of a Tourniquet. If the circulation i s borderline and a local anaesthetic is decided upon, the procedure will be commenced without a tourniquet. This can be applied during the procedure if bleeding i s found to be profuse. When the circulation i s inadequate, the injection of a quantity of local anaesthetic into a toe can act as a tourniquet, having a constricting effect on the small blood vessels. The injection is halted if the toe becomes cyanotic. Drug Interactions. The patient's current medication is checked for potential adverse interaction with the local anaesthetic agent to be used. Medical History and Medication. This is checked for any contra-indications to surgery.
Surgical Procedures Performed
Figure 5 : Nail removed from the right great toe shown on Figure 4. Partial Nail Avulsion with Chemical Ablation of the Nail Matrix The most common and least traumatic procedure, it is normally the procedure of choice where the nail is: (i)involuted; (ii)abruptly curved; (iii)ingrowing. Total Nail Avulsion with Chemical Ablation of the Nail Matrix and Bed This is normally the procedure of choice where there is: (i)deformity of the whole nail; (ii) ulceration or sinus of the nail bed or sulcus. Total Nail Avulsion without Chemical Ablation of the Nail Matrix Only rarely is this performed. When the nail is allowed to regrow, it usually does so in a more deformed state than before, with a consequent recurrence of problems. It has an occasional use as a temporary measure where there is gross sepsis or excessive hyper-granulation tissue and swelling.
Operative Procedure Administration of a Local Anaesthetic Our usual agent of choice is 2 % lignocaine plain. The technique adopted is a digital nerve block. Application of a Tourniquet, unless Contra-indicated Undue pressure may damage the microcirculation. Only sufficient pressure is applied to prevent bleeding from obscuring the operating field or washing away the chemical.
Figure 4: Right foot. Severely involuted great toenail.
Figure 6: Medial section of nail removed to its base below the nail fold.
Avulsion If partial avulsion is performed, the required section of nail is removed to its base below the nail fold.
Figure 7: Toe showing new nail edge with removed nail section (inset). In total avulsion, the whole nail is removed to its base below the nail fold. The techniques involved are such that minimum damage is inflicted on the nail matrix and nail bed. Chemical Ablation with Liquefied Phenol BP The phenol is gently rubbed into the associated nail matrix, and where appropriate, the nail bed. in the authors' department this is normally applied in two stages, for a total period of three minutes. The time period may vary with individual circumstances. This strong caustic destroys the cells of the nail matrix,
681
INNOVATIVE CARE thereby preventing regrowth of the appropriate section of nail.
Irrigation with Industrial Methylated Spirit (IMS) Any excess phenol is blotted up and the area irrigated well with industrial methylated spirit.
Removal of Tourniquet A careful check is kept on the period of application. Clearly this should be as short as possible. If the procedure is prolonged for any reason, the tourniquet i s removed and then reapplied.
Post-Operative Dressing An appropriate dressing is applied, care being taken not to restrict the circulation. The total procedure is carried out in a clean room using full aseptic technique. It is performed on an out-patient basis, requiring the patient’s attendance in the chiropody department for approximately 1 hour.
Post-Operative Care Vigilant post-operative care is crucial to a successful uncomplicated outcome for people with diabetes. Equal attention is given to this phase as i s given to preoperative considerations and the procedure
682
itself. All patients receive verbal and written post-operative instructions. Choice of Dressing. Simple dressings which provide a warm moist environment in which healing can take place are normally used. Our own choice i s an antiseptic ointment such as Betadine or Cetavlex. Where the total nail has been removed, this is combined with an impregnated tulle such as Paratulle or Codliver Oil and Honey Tulle to prevent adherence of the dressing to the nail bed. In our experience these are safe and adequate. It is the frequency and vigilance in the way that the dressing procedure is carried out which influences the outcome. Cleansing prior to dressing is carried out using Normasol solution. Where maceration is evident hypertonic saline footbaths are substituted for Normasol. This acts as both an astringent and antiseptic. Dressing Regimen. The first dressing is carried out after 24 hours. Subsequent chiropody appointments are normally given twice weekly, progressing to weekly depending on progres. Daily dressings are advocated in most cases unless infection is present, when this may be increased to twice daily. Able patients or a suitable relative are recruited to carry out home dressings between appointments. Comprehensive instructions, advice and support are provided by the chiropody staff. Occasionally the district nurse may be needed to carry out home dressings in
DT17 partnership with the chiropody department. Footwear. Complete freedom from pressure is vital for post-operative healing. We advocate an open-toed sandal or an old shoe with the appropriate section cut away. Rest. The degree of rest required for healing to take place varies depending on individual circumstances. Good communication with the patient is required in order to reach a mutual decision as to what is appropriate. Monitoring. The patient is closely monitored for:
The Presence of Infection. Swabs are sent for culture and sensitivity if infection is suspected. Undue Swelling or Inflammation. This may indicate an adverse reaction to the phenol. Pain. Pain is not a normal feature postoperatively, although some discomfort may be experienced during the first 24 hours. Diabetes Control. There may be some temporary disturbance at the time of the procedure, but in the absence of complications this settles quickly. Rate of Healing. A review of the dressing regimen is required if healing is not progressing at a steady rate and other factors have been excluded. The patient’s compliance to post-operative instructions i s also monitored carefully.
DT17
INNOVATIVE CARE
683
INNOVATIVE CARE
Discussion The incidence of minor or major amputations, precipitated in the first instance by a nail problem, is unknown. What we do know is that definitive nail surgery affords instant and long-term relief from the pain and discomfort caused by an abnormal nail, and allows for free drainage from an infected nail sulcus or bed. Where a nail is causing pain or discom-
Pen Injectors-The
fort, then it is logical to assume that it is acting as an irritant to the underlying tissue, predisposing it to breakdown and the subsequent entry of bacteria. It is also known that peripheral vascular disease renders the tissues more vulnerable to breakdown. Consequently, when an abnormal nail shape and peripheral vascular disease coexist, the toe is at increased risk, with the probability of a poor prognosis should a problem occur. Although we have no formal study to
DTT7
support our views, we advocate that early definitive surgery for abnormally shaped nails has the potential to prevent serious toe morbidity. Acknowledgements Our thanks to Drs RJ Young and TL Dornan for their encouragement and support; Barbara Harrison, our chiropody assistant; Pat Atkinson for typing the script and the Medical Illustration Department of Salford General Hospitals Unit.
Way Forward?
Kenneth Paterson and David Sandler Royal Infirmary, Glasgow.
The first 60 years of insulin treatment saw major changes in the purity, pharmaceutical presentation and source of insulin itself, culminating in the variety of highly purified preparations in use today. No such changes were seen in commonly used insulin delivery devices and Leonard Thomson would easily recognise the standard glass insulin syringe and insulin vial used in the 1980s as little changed from the syringe and vial from which he received his first injection in 1922. The concept of a self-contained ‘pen‘ device acting as a combined insulin store, syringe and dose meter now seems so 684
simple that it is surprising that it was only described in 1981.1 The original paper described the ’pen’, which was based around a standard disposable plastic syringe, as a means to ‘simplify injection’ and ease the drudgery of injection therapy for insulintreated patients. The first commercially available ‘pen‘ (’Penject’, Hypoguard Ltd, Woodbridge, UK) was based on the prototype device but the original paper foresaw the use of pre-filled insulin cartridges as a way to streamline the device and make it more compact. With ’NovoPen’ (Novo Nordisk Ltd, Crawley, UK) the cartridge concept be-
came reality, the device being both attractive and reliable, but with it came another concept, for only human soluble insulin (Human Actrapid) was available in cartridges. Thus the use of the pen imposed a relatively new and untried (in general use) insulin regimen of multiple injections, based on the ‘physiological’ concept of basal-bolus insulin therapy. Over the past 5 years, the debate on the role of pens in diabetes treatment has been tied up with the debate on the benefits and risks of multiple-injection therapy. Now that a wide range of insulins is available in cartridge form for a
INNOVATIVE CARE Toenail Surgery for Diabetic Patients Ann Middleton and Frank Webb Chiropody Department, Hope Hospital, Salford.
may go undetected. Subsequently, soft tissue infection and ultimately osteomyelitis of the distal phalanx may occur. Peripheral Neuropathy. Absence of the early-warning signals of pain or discomfort may allow an initially minor problem to progress to a serious stage before being detected.
Introduction In people with diabetes, toenail surgery is generally employed as the last resort to deal with acute nail-related problems which have failed to respond to a variety of conservative approaches. By this late stage the viability of the toe is often compromised. The purpose of this article is to describe the work carried out in this field in the authors’ department, and to put forward a case for an early, definitive, surgical approach to nail-related problems before potentially serious complications occur. Our chiropody department is situated within the main hospital out-patient department and, although physically separate, is fully integrated into the diabetes unit. It is the key location for the multi-disciplinary management of diabetes foot problems.
Indications for Toenail Surgery Acute, infected, ingrowing nail. Recurrent paronychia. Recurring pain or chronic discomfort due to an abnormal nail shape. Thick deformed nail. Sinus or ulcer of the nail bed or sulcus.
NORMAL
ABRUPTLY CURVED
Figure 2: Acute infected ingrowing nail.
Predisposin Factors to Nail-Relate Problems
%
Pressure. Prolonged pressure on the nail caused by wearing tight hosiery, or a shoe with a shallow and/or narrow toe box leads to trauma of the nail sulcus or bed and is most likely to occur where the nail i s an abnormal shape. Direct Single Trauma to the toenail area. A toe with an abnormally shaped nail is most vulnerable. Inappropriate Nail Care. Attempts to cut down the side of a nail to relieve the discomfort caused by an abnormally shaped nail frequently leads to an ingrowing nail. Similarly, tearing nails and cutting nails too short often has the same outcome. Peripheral Vascular Disease. Where abnormal nail shapes and peripheral vascular disease co-exist, relatively minor pressure from the nail edge can lead to the development of a sinus in the nail sulcus which
EXCESSIVE CURVATU RE
To effect permanent removal of abnormally shaped nail shoulders. To effect permanent removal of the total nail. To provide relief from recurring pain or chronic discomfort. To allow free drainage of infection. To allow healing of a subungual ulcer or sinus. To reduce the risk of further episodes of infection, ulceration or sinus formation.
Advantages of Early Definitive Surgical Intervention Before Complications Occur Improved outcome is likely when surgery is performed whilst the patient is still relatively young and fit, with an optimum circulatory status. Reduces or eliminates the need for further chiropody treatment. Logic suggests it reduces the incidence of toe morbidity and amputation rate in the long term.
Considerations Before Proceeding with Surgery
INVOLUTED
Figure 1 : Abnormal nail shapes.
680
Aims of Surgery
Figure 3: Diagrammatic representation of an ingrowing nail resulting from cutting d&n the side of the nail, causing a spike to be left in the sulcus, which then grows forward unseen and penetrates the substance of the toe.
Infection. Any degree of infection is treated with appropriate antibiotic therapy before, during and after the procedure. Diabetes Control. This should be optimum at the time of the procedure. Raised blood-sugar levels predispose to infection and reduced healing rates. Specialist advice may be required. Prophylactic Antibiotic Cover. This may be considered appropriate if blood-sugar control is not optimum. Circulatory Status. A thorough assess-
INNOVATIVE CARE ment is carried out. This will include foot pulses, capillary refill time, skin colour, temperature and thickness. If these are inconclusive, an X-ray of the foot to show any vascular calcification, Doppler studies and occasionally angiography may be required. Referral to the vascular surgeon may be necessary. Mode of Anaesthetic. A local anaesthetic may be contra-indicated if the circulation is poor or there has been a previous adverse reaction. In these circumstances if the procedure is essential due to an acute problem, a general or epidural anaesthetic may be required. Use of a Tourniquet. If the circulation i s borderline and a local anaesthetic is decided upon, the procedure will be commenced without a tourniquet. This can be applied during the procedure if bleeding i s found to be profuse. When the circulation i s inadequate, the injection of a quantity of local anaesthetic into a toe can act as a tourniquet, having a constricting effect on the small blood vessels. The injection is halted if the toe becomes cyanotic. Drug Interactions. The patient's current medication is checked for potential adverse interaction with the local anaesthetic agent to be used. Medical History and Medication. This is checked for any contra-indications to surgery.
Surgical Procedures Performed
Figure 5 : Nail removed from the right great toe shown on Figure 4. Partial Nail Avulsion with Chemical Ablation of the Nail Matrix The most common and least traumatic procedure, it is normally the procedure of choice where the nail is: (i)involuted; (ii)abruptly curved; (iii)ingrowing. Total Nail Avulsion with Chemical Ablation of the Nail Matrix and Bed This is normally the procedure of choice where there is: (i)deformity of the whole nail; (ii) ulceration or sinus of the nail bed or sulcus. Total Nail Avulsion without Chemical Ablation of the Nail Matrix Only rarely is this performed. When the nail is allowed to regrow, it usually does so in a more deformed state than before, with a consequent recurrence of problems. It has an occasional use as a temporary measure where there is gross sepsis or excessive hyper-granulation tissue and swelling.
Operative Procedure Administration of a Local Anaesthetic Our usual agent of choice is 2 % lignocaine plain. The technique adopted is a digital nerve block. Application of a Tourniquet, unless Contra-indicated Undue pressure may damage the microcirculation. Only sufficient pressure is applied to prevent bleeding from obscuring the operating field or washing away the chemical.
Figure 4: Right foot. Severely involuted great toenail.
Figure 6: Medial section of nail removed to its base below the nail fold.
Avulsion If partial avulsion is performed, the required section of nail is removed to its base below the nail fold.
Figure 7: Toe showing new nail edge with removed nail section (inset). In total avulsion, the whole nail is removed to its base below the nail fold. The techniques involved are such that minimum damage is inflicted on the nail matrix and nail bed. Chemical Ablation with Liquefied Phenol BP The phenol is gently rubbed into the associated nail matrix, and where appropriate, the nail bed. in the authors' department this is normally applied in two stages, for a total period of three minutes. The time period may vary with individual circumstances. This strong caustic destroys the cells of the nail matrix,
681
INNOVATIVE CARE thereby preventing regrowth of the appropriate section of nail.
Irrigation with Industrial Methylated Spirit (IMS) Any excess phenol is blotted up and the area irrigated well with industrial methylated spirit.
Removal of Tourniquet A careful check is kept on the period of application. Clearly this should be as short as possible. If the procedure is prolonged for any reason, the tourniquet i s removed and then reapplied.
Post-Operative Dressing An appropriate dressing is applied, care being taken not to restrict the circulation. The total procedure is carried out in a clean room using full aseptic technique. It is performed on an out-patient basis, requiring the patient’s attendance in the chiropody department for approximately 1 hour.
Post-Operative Care Vigilant post-operative care is crucial to a successful uncomplicated outcome for people with diabetes. Equal attention is given to this phase as i s given to preoperative considerations and the procedure
682
itself. All patients receive verbal and written post-operative instructions. Choice of Dressing. Simple dressings which provide a warm moist environment in which healing can take place are normally used. Our own choice i s an antiseptic ointment such as Betadine or Cetavlex. Where the total nail has been removed, this is combined with an impregnated tulle such as Paratulle or Codliver Oil and Honey Tulle to prevent adherence of the dressing to the nail bed. In our experience these are safe and adequate. It is the frequency and vigilance in the way that the dressing procedure is carried out which influences the outcome. Cleansing prior to dressing is carried out using Normasol solution. Where maceration is evident hypertonic saline footbaths are substituted for Normasol. This acts as both an astringent and antiseptic. Dressing Regimen. The first dressing is carried out after 24 hours. Subsequent chiropody appointments are normally given twice weekly, progressing to weekly depending on progres. Daily dressings are advocated in most cases unless infection is present, when this may be increased to twice daily. Able patients or a suitable relative are recruited to carry out home dressings between appointments. Comprehensive instructions, advice and support are provided by the chiropody staff. Occasionally the district nurse may be needed to carry out home dressings in
DT17 partnership with the chiropody department. Footwear. Complete freedom from pressure is vital for post-operative healing. We advocate an open-toed sandal or an old shoe with the appropriate section cut away. Rest. The degree of rest required for healing to take place varies depending on individual circumstances. Good communication with the patient is required in order to reach a mutual decision as to what is appropriate. Monitoring. The patient is closely monitored for:
The Presence of Infection. Swabs are sent for culture and sensitivity if infection is suspected. Undue Swelling or Inflammation. This may indicate an adverse reaction to the phenol. Pain. Pain is not a normal feature postoperatively, although some discomfort may be experienced during the first 24 hours. Diabetes Control. There may be some temporary disturbance at the time of the procedure, but in the absence of complications this settles quickly. Rate of Healing. A review of the dressing regimen is required if healing is not progressing at a steady rate and other factors have been excluded. The patient’s compliance to post-operative instructions i s also monitored carefully.
DT17
INNOVATIVE CARE
683
INNOVATIVE CARE
Discussion The incidence of minor or major amputations, precipitated in the first instance by a nail problem, is unknown. What we do know is that definitive nail surgery affords instant and long-term relief from the pain and discomfort caused by an abnormal nail, and allows for free drainage from an infected nail sulcus or bed. Where a nail is causing pain or discom-
Pen Injectors-The
fort, then it is logical to assume that it is acting as an irritant to the underlying tissue, predisposing it to breakdown and the subsequent entry of bacteria. It is also known that peripheral vascular disease renders the tissues more vulnerable to breakdown. Consequently, when an abnormal nail shape and peripheral vascular disease coexist, the toe is at increased risk, with the probability of a poor prognosis should a problem occur. Although we have no formal study to
DTT7
support our views, we advocate that early definitive surgery for abnormally shaped nails has the potential to prevent serious toe morbidity. Acknowledgements Our thanks to Drs RJ Young and TL Dornan for their encouragement and support; Barbara Harrison, our chiropody assistant; Pat Atkinson for typing the script and the Medical Illustration Department of Salford General Hospitals Unit.
Way Forward?
Kenneth Paterson and David Sandler Royal Infirmary, Glasgow.
The first 60 years of insulin treatment saw major changes in the purity, pharmaceutical presentation and source of insulin itself, culminating in the variety of highly purified preparations in use today. No such changes were seen in commonly used insulin delivery devices and Leonard Thomson would easily recognise the standard glass insulin syringe and insulin vial used in the 1980s as little changed from the syringe and vial from which he received his first injection in 1922. The concept of a self-contained ‘pen‘ device acting as a combined insulin store, syringe and dose meter now seems so 684
simple that it is surprising that it was only described in 1981.1 The original paper described the ’pen’, which was based around a standard disposable plastic syringe, as a means to ‘simplify injection’ and ease the drudgery of injection therapy for insulintreated patients. The first commercially available ‘pen‘ (’Penject’, Hypoguard Ltd, Woodbridge, UK) was based on the prototype device but the original paper foresaw the use of pre-filled insulin cartridges as a way to streamline the device and make it more compact. With ’NovoPen’ (Novo Nordisk Ltd, Crawley, UK) the cartridge concept be-
came reality, the device being both attractive and reliable, but with it came another concept, for only human soluble insulin (Human Actrapid) was available in cartridges. Thus the use of the pen imposed a relatively new and untried (in general use) insulin regimen of multiple injections, based on the ‘physiological’ concept of basal-bolus insulin therapy. Over the past 5 years, the debate on the role of pens in diabetes treatment has been tied up with the debate on the benefits and risks of multiple-injection therapy. Now that a wide range of insulins is available in cartridge form for a
