Reperfusion injury after Vandenbos procedure in the primary care office

Case

A 21-year-old man presented to the family medicine office with a 4-month history of recurrent infection in the right great toe (Figure 1A). He had been treated with multiple courses of cephalexin for “ingrown toenails.” He tolerated a previous Vandenbos procedure¹ to the same area on his left toe. He had no relevant past medical history, including no personal history of peripheral vascular disease, diabetes, immunocompromise, or allergies to anesthetics. He was taking no medications and had no allergies.

The patient elected for the Vandenbos procedure, which was performed in an academic family physician’s office. Informed consent was obtained. Periungual skin and soft tissue were excised from both sides of the right great toenail in a sterile fashion. A tourniquet was applied for approximately 15 minutes in total. The patient was given a written set of discharge instructions for pain management and wound care¹ (Figure 1B) and he returned for follow-up on postoperative day 4 (Figure 1C), when he presented with progressive swelling, redness, discoloration, and decreased sensation in his right toe. The patient denied fevers, chills, fatigue, or pain out of proportion to the lesion on his toe. A small amount of serosanguinous drainage was seen. There was substantial edema, blistering, and ecchymosis over the dorsal and plantar surfaces of the great toe, and well-demarcated erythema at the base of the toe where the tourniquet had been applied. However, active flexion and capillary refill remained normal. Given the changed appearance, a provisional diagnosis of postoperative infection was made. The patient was empirically treated with a 7-day course of clindamycin.

During the next week, the patient continued to have decreased sensation in the distal toe but denied severe pain, fever, or malaise. The affected area remained well demarcated and had not spread proximally. No purulent drainage was seen, active flexion at the interphalangeal joint remained intact, and the patient remained afebrile. No bony destructive lesion or substantial joint space narrowing were identified on an x-ray scan. However, given the evolving appearance of the lesion, there remained concern about necrosis secondary to infection. Thus, the antimicrobial regimen was switched to a 10-day course of 500 mg of oral cephalexin 4 times a day. Additionally, an infectious disease specialist and an orthopedic surgeon were consulted. Both agreed that the appearance was worrisome. Although culture and sensitivity analyses showed light growth of Staphylococcus aureus, his white blood cell count (5 × 10⁹/L) and C-reactive protein level (< 10 nmol/L) were both normal.

A family physician with expertise in the Vandenbos procedure was also consulted.¹ He proposed an alternative diagnosis of reperfusion injury—a paradoxical inflammatory response that occurs after rapid return of blood to ischemic tissue. This diagnosis was consistent with the presentation and quite plausible. The infectious disease specialist and orthopedic surgeon agreed. Antimicrobial therapy was thus discontinued. The patient was encouraged to continue strict adherence to the prescribed wound care regimen.

During the postoperative course, the violaceous discoloration resolved and areas of erythema became pink. Vesicles on the plantar aspect of the toe began to resolve. There was granulation tissue on the medial and lateral aspects of the nail at the sites of excision (Figures 1D to 1F). The patient remained systemically well.

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Figure 1.

Appearance and course of resolution of reperfusion injury to the right great toe before and after the Vandenbos procedure:A) Before the procedure, B) postoperative day 2, C) postoperative day 4, D) postoperative day 19, E) postoperative day 28, and F) postoperative day 37.