Download Nail surgery update

Onychocryptosis : An Update
Angelo Salerno
Podiatric Surgeon
B App Sc, Grad Dip, M Pod, FACPS
 Etiology of IGTN & other nail pathology
 Review of P&A procedure & phenol
 Surgical considerations
 Various procedures available
 Complications of nail surgery to consider
 Oral retinoids (isotretinoin, acitrtin)1
 Nail changes: the nails may become brittle, slow growing. & skin
becomes dry & fragile
 Resolves when treatment ceased
 Trauma
 Fungal nail infections
 Hereditary
 Hallux valgus & hallux interphalangeus2
 Foot type3
 Genetic factors4
 Geriatric
1.
2.
3.
4.
Zerboni et al. The Lancet (1998)
Darwish et al. The Foot (2008)
Ogawa & Hyakusoku. Plastic & reconstructive Surgery
(2006)
Chaniotakis et al. J Am Aca Dermatology (2007)
 “Claw nail” or “Rams Horn Nail”
 Disease causes curvature of the nail
 Disease causes thickening of the nail
 Etiology
 Injury: dropping heavy objects or hitting toe
 Intense pressure over long periods of time: footwear
 Fungal infection
 Diabetes
 Peripheral vascular disease
 Nutritional
 Other conditions such as psoriasis, epidermal dysplasia & ichthyosis
 Observational diagnosis
 Hard but often brittle
 “Hypertrophy of the nail”
 Thickening of the nail involving hypertrophy of the nail bed & matrix
 Common in elderly
 Discoloration of the nail plate
 White or yellowish
 Nail edges break off
 Difficult nail for patient to self manage
 Etiology
 Diabetes
 Psoriasis
 PVD
 Subungual exostosis
 Hereditary
 Acromegaly
 Infection
 Genetic: Darier’s Disease
 Chronic disorder : Pityriasis Rubra Pilaris
 Bony exostosis
 Congenital
 Why is the nail painful?
 Where is the nail painful?
 What (if any) other structures are involved?
 When is the nail painful?
Injurious
cutting
Incurvation
ungelabia
Chemical matrixectomy
on patients with diabetes?
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Giacalone reviewed 57 patients with diabetes who underwent phenol
matrixectomies.
The results of his study showed no complications and a 5% regrowth rate.
The decision of whether to perform the phenol matrixectomy should be based
solely on the amount of arterial perfusion to the toe.
Diabetes is not a direct risk factor for non-healing in patients undergoing
phenol matrixectomy.
It is the arterial disease that will determine healing
 Nail excision & avulsion (drainage)
 Chemical matrixectomy
 Phenol procedure
 Partial excisional matrixectomy
 Winograd, Steindler, Frost
 Total excisional matrixectomy
 Zadik
 Subungual ostectomy
 Soft Tissue
 Syme’s amputation
 Vandenbos
 Plastic remodelling
 Many studies have compared the two techniques1,2,3
 Results would indicate relatively similar outcomes (pain & regrowth rate) 3
 Must assess patients on an individual basis as to preference of procedure
1. Gerritsma-Bleeker et al. Archives of surg (2002)
2. Mehta. The Centre of Allied Health Evidence (2003)
Rounding & Hulm. Cochrane database of systemic review (2002)
 Useful procedure for (infection)gross paronychia
 +/- oral antibiotics
 Very few contraindications
 Technically easy to execute
 Essentially same as phenol procedure, without the use of phenol
 Indicated for wide nail plate
 Technically easy to perform
 Requires patient compliance
 Extended recovery period
 Relative contraindication
 Hyperungelabia
 Previous failed procedure
 Questionable healing concerns (diabetes, PVD)
 Etiologies not derived solely from nail plate abnormalities
(osteochondroma, periungal fibroma)
 No studies identified that have performed in vivo analysis for desirable
application
 In vitro histological study by Borberg1 found 89% phenol should be applied to
the germinal matrix for at least 1 minute
 Sodium hydroxide has not been assessed histologically, but clinical outcome
study recommends 1 minute2
1.
2.
Boberg et al. JAPMA (2002)
Kocyigit et al. Dermatologic surgery (2005)
 Alcohol used following phenol spills on skin1
 Confusion on what effect alcohol has post-phenolisation
 Efficacy of alcohol flush following phenolisation has been studied2
 Current literature would suggest this is not useful, and may be harmful3
1.
2.
3.
Hunter et al. Ann Emerg Med (1992)
Goslin . The Foot (1992)
Espensen et al. JAPMA (2002)
For podiatrists
 Phenol is rapidly absorbed from the lungs
 Inadequate evidence that phenol is carcinogenic, however considered a
moderate acute risk (CNS, skin, lungs)
 Phenol vapours have been found to be safe-ish for operators performing
matrix ablation1 & caution in pregnancy2
For patients
 Must consider phenol burns3,4
 Periostitis/osteomyelitis5
1.
2.
3.
4.
5.
Losa Iglesias et al. Derm surg (2008)
Lin et al. Burns (2006)
EPA (2002)
Sugden et al. Burns (2001)
Gilles et al. JAPMA (1986)
 PHENOL EZ SWABS
 Single use
 1 cotton swab & ampoule containing 0.175-0.2 ml
liquified Phenol 89%
What is going on here?
How do we treat this?
What would we prescribe ?
What would we tell the patient on
what would happen afterwards?
 Diabetes
 Paediatrics
 PVD
 Long term corticosteroid use
 Dabgatran/Warfarin/Aspirin use
 Current infection
What is this?
What would you do?
Osteochondroma
Tuft
versus
Subungal Exostosis
Shaft
Subungual Exostosis
Subungual Osteochondroma
• Usually patients 40+
years
• Usually
teenagers/young adults
• Suspect in involuted
nails
• Nail plate may appear
normal
• Suspect in patient with
pain on distal dorsal
aspect of nail
• Suspect in patient with
rapid onset
• May be associated with
history of trauma
• +/- trauma
Subungal Exostosis or Osteochondroma ?
Bone versus cartilage
• First need to resolve the infection
• Oral antibiotics: Drug of first choice?
• Partial nail avulsion
• Then need to perform a permanent procedure
• Hypertrophied Ungelabia so Wedge resection
When ?
• Ungelabia or when excessive tissue needs to be removed
• Revisional surgery after failed previous procedure
• True WEDGE resection
• Inverted L or hockey stick incision
Nail X thickened
Nail X incurvated
Total nail is involved here
Centrally peaked
We can choose :
Partial procedures
Total procedures
Chemical versus sharp
Have we forgotten to consider
something else ?
Does this finding change our
treatment plan?
YES
• Exostosis needs removing
• Total nail may need removing
Total Excisional
Matrixectomy
+
Terminal phalangeal Ostectomy
Indications:
• Onychogryphotic nail
• Onychomycotic nail
• Severely incurvated or
pincer type nail
• This involves a straight longitudinal incision across the nail
root with reflection of the skin and subcutaneous tissue to
expose the nail matrix
• Normal or reduced nail fold
Winograd
• Most often lesser toes
• Long toe
• Onychogryphotic nail + mallet toe
• Onychoclavus +/- long deformed toe
• 76 year old female
• All enclosed footwear ‘pain’
• Total matrixectomy by GP
but painful regrowth
• Second procedure but still
painful
• ‘Ouch’ palpation over medial
aspect of proximal nail fold
• On observation does not look
like much
•
•
•
•
Pain even at rest
Pain with and without footwear
X-ray : revealed bone changes suggestive of bone cyst
Terminal syme amputation : removal of the distal phalanx
7 months post excisional matrixectomy
Paronychia
Pain
 IGTN : “fault lies not with the nail but with an
excess of soft tissue
 “The term ‘Ingrown toenail’ is unfortunate in
that it incriminates the nail as the causative factor.”
 “Persons who develop this condition have an
unusually wide area of tissue medially and laterally
to the nail.”
 With weight bearing this tissue tends to bulge up &
around the nail & pressure necrosis occurs
(1). Vandenbos & Bpwers (1959)
Surgery
Surgery
• Removal of excessive soft tissue
• Multiple smooth, firm nodules formed at the PNF
• Often >10 mm in length
• May create a longitudinal groove in nail
 Primary aim if infection present
 Resolve the paronychia
 Excision, avulsion & drainage
 Penicillen is drug of first choice
 Once infection resolved can perform permanent
matrixectomy safely
 Advise that recurrence on regrowth of nail is likely
 Consider age, medical status & blood supply
 Rule out bone involvement
 Complication: consider epidermal inclusion cyst
 Failed procedures : excisional matrixectomy