Management of Permanent Toenail Removal in Diabetic Patients
For a diabetic patient undergoing permanent toenail removal, comprehensive wound care, infection prevention, and proper offloading are essential to prevent complications and ensure optimal healing.
Pre-Procedure Considerations
- Assess peripheral circulation before the procedure by checking dorsalis pedis and posterior tibial pulses 1
- Evaluate for peripheral neuropathy using 10-g monofilament test at plantar surface sites 1
- Use ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol) as the surgical preparation solution, as it is most effective for eliminating bacteria from the forefoot prior to surgery 2
Procedure Technique
- Perform careful debridement of the nail and surrounding hyperkeratotic tissue 1
- Chemical or laser ablation is recommended for permanent nail removal to prevent future problems 1
- If primary closure is chosen, ensure clean margins and absence of infection 3
- Avoid footbaths during the healing process as they induce skin maceration 1
Post-Procedure Wound Care
- Inspect the wound frequently and debride as needed 1
- Select appropriate dressings to control exudation and maintain a moist environment 1
- Consider prophylactic antibiotics if there are signs of infection, targeting S. aureus and streptococci 1
- For deeper infections, evaluate for surgical intervention and initiate broader spectrum antibiotics 1
Offloading and Footwear Management
- Instruct the patient not to walk barefoot, in socks only, or in thin-soled slippers 1
- The approved diabetic shoes (Apex X521M) are appropriate for the patient, as therapeutic footwear helps prevent foot ulcers 1
- For non-plantar wounds like toenail removal sites, consider temporary footwear modifications or toe spacers to reduce pressure on the affected area 1
- Ensure the new diabetic shoes properly accommodate the shape of the feet and fit well 1
Patient Education
- Educate the patient on daily foot inspection, especially the surgical site 1
- Instruct on proper foot hygiene: daily washing with careful drying between toes 1
- Teach the patient to recognize and report signs of infection (fever, wound changes, worsening hyperglycemia) 1
- Emphasize the importance of consistently wearing the prescribed diabetic footwear 1
Follow-up Care
- Schedule follow-up visits based on the patient's risk level (IWGDF risk classification) 1
- For a 68-year-old diabetic patient with history requiring toenail removal, follow-up every 1-3 months is recommended (likely IWGDF risk 3) 1
- Monitor for proper wound healing and signs of complications 1
- Include the patient in an integrated foot-care program with ongoing professional foot treatment 1
Special Considerations
- If the wound is not healing within 6 weeks despite optimal management, consider vascular assessment 1
- For patients with peripheral arterial disease (PAD), revascularization may be necessary to promote healing 4
- Consider digital flexor tenotomy if the patient has hammertoes with pre-ulcerative lesions 1
By following these guidelines, you can minimize complications and promote optimal healing after permanent toenail removal in this diabetic patient while ensuring proper use of the new diabetic footwear.