W008 Hands-On: Nail Surgery Molly Hinshaw, MD Associate Professor of Dermatology, Director Nail Clinic UWSMPH

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1 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY W008 Hands-On: Nail Surgery Molly Hinshaw, MD Associate Professor of Dermatology, Director Nail Clinic UWSMPH DISCLOSURES I do not have any relevant relationships with industry.

2 PHOTOGRAPHY & VIDEOTAPING ARE STRICTLY PROHIBITED IN ALL EDUCATIONAL SESSIONS CELL PHONES MUST BE PLACED ON VIBRATE OR TURNED OFF Session directors will be closely monitoring such occurrences. FOTOGRAFIA E FILMANDO SÃO ESTRITAMENTE PROIBIDOS EM TODAS AS SESSÕES EDUCACIONAIS TELEFONES CELULARES DEVEM SER COLOCADOS EM VIBRAR OU DESLIGADOS Violações desta política resultará na remoção de sessão e possível revogação do registo da reunião. Diretores de sessão irão acompanhar de perto tais ocorrências.

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4 Concern for Pain and Complications as Barriers

5 Nail Unit Anatomy

6 Introduction to Nail Surgery Pre-Op: Pt education Intra-Op: Anesthesia Intra-Op: Asepsis Intra-Op: Avulsions

7 Insert postop care handout here

8 Pre-Op: Pt Education Reassure them that you will control their pain Pain minimization strategies Offer appointment for first dressing change Discuss activity restrictions

9 Appearance of digit after surgery Pre-op day of surgery Intra-op Immediate Post-op 7 Weeks Post-Op

10 Intra-Operative: Useful Surgical Tray

11 Intraop: Useful Surgical Tray

12 Nail Templates Help Keep the Specimen Flat for Processing & Interpretation

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14 Intraoperative: Anesthesia

15 Anesthesia Anesthetic Onset Duration without Epinepherine Lidocaine <1 min min Vasodilating Bupivacaine 2-5 min min Longer duration Ropivacaine 1-15 min min Vasoconstricting, less cardiotoxic than bupivicaine Digital blocks (proximal vs distal) Some evidence that the subcutaneous variation of palmar block (3mL into subq not tendon sheath) has less post-op pain than transthecal, less theoretical risk tendon inflammation, infection, trigger finger Jellinek NJ, Velez NF. Nail Surgery: Best Way to Obtain Effective Anesthesia. Derm Clinics 2015;33:

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17 Comparison Proximal Block During Laceration Repair: Single sq Volar vs Two Lateral Randomized, prospective, 50 pts>18y/o (78% male) in ED with finger laceration any digit, n=63, 1 investigator, used lido 2% w/epi mg/mL Single sq volar: 3mL inject vertically through distal joint line of volar MCP Dual Dorsal: 1.5mL on each side, enter dorsally, inject half, push needle thru & inject rest volar Outcomes: 1. pain during anesthesia, 2. pain during suturing 3. onset time of total anesthesia, 4. need for additional aesthesia Visual analog scale (VAS) used for pain score Conclusions: No statistical difference in any of 4 measures. Single injection volar nerve block technique is suitable for digital anesthesia in emergency departments Okur, OM. Two injection digital block vs single subcutaneous palmar injection block for finger lacerations. Eur J Trauma Emerg Surg 2016; DOI /s

18 Comparison of Proximal Blocks: Single sq Volar vs Two Lateral Randomized, prospective 86 pts>18y/o in ED with finger injury (laceration (n=63), dislocation, crush, fracture, infection, other), multiple surgeons, lidocaine 1% without epi Also did not limit to digits 2, 3, 4 Single volar (n=41) performed via sq (not transthecal) route, 2-3mL Double dorsal (n=27)=1ml each side of proximal phalanx just distal to MCP 1 outcome=pain score during injection; 2 =pain of injury 5 min after anesthesia, success of anesthesia defined as ability to proceed without additional anesthesia, complications Conclusion: No statistical difference in single volar and double dorsal proximal block injection pain or anesthesia effectiveness Martin SP. Double-dorsal vs. single-volar digital subcutaneous anesthetic injection for finger injuries in the emergency department: A randomized controlled trial. Emerg Med Austral 2016;28:193-8.

19 Block Onset Anesthetic Quantity Uses Proximal sq digital block Up to 10 min 1-2% Lidocaine without epi or ropivacaine 2-3mL Any digit Distal digital block aka wing block Few minutes 1-2% lidocaine with or without epi or use ropivacaine 0.5-1mL each side Many inc. for epi or volumetric hemostasis; use quantity if working on PNF Matrical Few minutes Same as distal digital Same as distal digital Midline lesions that do not need avulsion

20 Intraoperative: Asepsis

21 Surgery: Minimizing Infection Risk Surgical scrub Sterile drape, consider applying glove to patient s hand Daily dressing changes, gentle soap and water Limit activity, trauma

22 Antisepsis: Surgical Scrub Pre-operative scrub with alcohol alone or with + chlorhex or iodophore alone OR chlorhexidine OR iodophor Rutala WA, Weber DJ. Disinfection, sterilization, & antisepsis: An overview. Amer J Infect Control 2016;44:1-6e

23 Intra-Operative Antisepsis in Ortho. (Foot/Ankle) Surgery Summary:70% isopropyl alcohol soft scrub then 4% chlorhexidine soft Prospective, randomized controlled, single institution (U Rochester) study looked at significance of sequence, use of soft sponges in 95 consec. pts Soft sponges to apply each; 1 superficial infection in each group (combined rate 2.1%) both pts had +cx after operative site prep Their results using soft sponges similar rates of positive cultures compared to other studies using bristled brushes (6.5%-35%) Statistically significant reduction in + cultures 7% vs 25%, p<0.02 Confirmed with logistic regression analysis IDing order of solutions as an independent factor Note: All given preop dose 1 st gen cephalosporin;scrub duration not listed Hunter JG, et al. Randomized prospective trial of the order of preoperative preparation solutions for patients undergoing foot and ankle orthopedic surgery. Foot & Ankle Intl. 2016;37:

24 General Principles of Nail Surgery Direct visualization of the pathology is important Tourniquet? if yes, consider glove (1/2 size smaller than their usual) or Penrose or T ring

25 General Principals of Nail Surgery: Hemostasis Do not stop anticoagulants Generally do not need chemical nor cautery Use pressure Use volumetric anesthesia OK to use aluminum chloride Cautery carries significant risk of scar

26 Approach to Nail Surgery Pre-Op: Pt education (critically important) Intra-Op: Asepsis (alcohol then chlorhexidine) Intra-Op: Anesthesia (consider ropivacaine) Intra-Op: Avulsions (partial if able, replace plate when possible)

27 General Principles of Nail Surgery Partial avulsions Do not force avulsion Replace plate Abimelec P, Dumontier C. Basic and Advanced Nail Surgery. In: Nails Dx, Rx, and Surgery Scher RS & DanielsCR Eds. Elsevier 2007.

28 Collins S, Cordova K, Jellinek NJ. JAAD 2008; 59(4)

29 Proximal Partial Avulsion

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31 Inspect Nail Plate and Consider Submitting the Portion over the Lesion

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33 Summary Pt education before surgery is critical Longer acting anesthesia useful Must visualize probable origin of pathology Choice of bx technique=tailored to origin of process and type of process being sampled Use partial avulsions, submit plate if has dx value, replace plate

34 Thank you! Torrey Pines State Park Molly Hinshaw, MD Assoc. Prof. Dermatology & Dermatopathology UWHealth Madison, WI