Ingrowing toenail surgery (wedge excision / nail avulsion / matrix phenolisation)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• regrowth of the nail edge or a nail spicule (recurrence)
• infection
• wound oozing for several weeks and slow healing
• chemical burn of the nail fold from phenol
• narrower nail after partial removal
• upturned pulp or nail deformity after repeated avulsions
• inclusion cyst
• permanent loss of the whole nail after total matrix excision

Pre-operative details for this operation

1. Toe and sideRight great toeLeft great toeOther toe (state)medial / lateral / both nail folds, mark the side
2. StageI: pain, swelling, rednessII: infection with dischargeIII: granulation tissue over the nail fold
3. Previous treatmentnumber of previous avulsions or matrix procedures, dates
4. Diabetes, peripheral vascular disease, neuropathypulses felt, blood sugar, closer follow-up if present
5. Bleeding tendency / anticoagulantsdrug and when stopped, if any
6. Patient told about nail regrowth time and narrow nailYes

Anaesthesia and position

1. AnaesthesiaDigital block (traditional two-injection)Digital H-blockSpinal / general (with other surgery)drug without adrenaline, volume
2. PositionSupine, foot at the end of the table
3. Toe tourniquetRubber drainGlove fingerCommercial toe tourniquettime applied and time removed

Operative findings

1. Nail fold involvedLateralMedialBoth
2. Granulation tissue and pusamount, pus present or not
3. Nail spiculesize and position
4. Nail plateNormalCurved (incurvated)Thickened

Procedure (steps)

1. Toe cleaned and drapedantiseptic used
2. Operation performedPartial nail avulsionPartial nail avulsion with phenol matricectomyTotal nail avulsionWinograd partial nail and matrix excisionZadik (Fowler) total matrix excisionWedge resection of nail foldTerminal Syme amputation
3. Nail edge separated from the nail bedelevator or scissors held flat, how much of the nail width (e.g. lateral one-fourth)
4. Nail cut lengthwise to the proximal end under the eponychiumNail splitterStraight scissorsNo. 11 blade
5. Nail strip removedtwisted towards the remaining nail, checked complete, including the root
6. Granulation tissue and debris removedCuretted / scrapedElliptical excision of nail fold
7. Matrix ablationPhenolSodium hydroxide 10%Sharp excision of matrix (Winograd / Zadik)Not donefor phenol: strength, number of applications and seconds each, total time, skin protected, neutralised with alcohol or irrigated
8. Eponychial flap or nail fold suturedNot suturedSutured (material, size)

Closure, drains and dressing

1. Dressingantibiotic ointment (no neomycin) or gel, non-adherent gauze, light toe dressing
2. Tourniquet removedtime, toe colour and capillary refill after release

Specimens and implants

1. Nail and tissueDiscardedSent for HPE (e.g. suspicious lesion, recurrent case)Sent for fungal culture
2. Pus for cultureSentNot sent

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Elevate the footfor 24 to 48 hours
2. First dressing changeday 2 or 3, warn that the phenolised area looks charred
3. Warm soaksafter the first dressing, 10 minutes several times a day, till healed
4. Footwearopen or wide toe box shoe, no tight socks or shoes for about a week
5. Antibioticsnot needed routinely, only for spreading infection (drug, dose, days)
6. Analgesiadrug, dose, frequency
7. Nail care advicecut the nail straight across, not curved at the corners
8. Expected courseoozing may last 2 to 6 weeks, nail takes 4 to 6 months to regrow after total avulsion
9. Reviewwound check in 48 to 72 hours, earlier for diabetes or poor circulation, suture removal at 10 to 15 days if sutured

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery