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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? • • • • • 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