Nail Surgery

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Onychocryptosis An Update
Angelo Salerno Podiatric Surgeon B App Sc, Grad
Dip, M Pod, FACPS
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Overview

• Etiology of IGTN other nail pathology
• Review of PA procedure phenol
• Surgical considerations
• Various procedures available
• Complications of nail surgery to consider

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Etiology of IGTN (onychocryptosis)

• 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. Zerboni et al. The Lancet (1998)
2. Darwish et al. The Foot (2008)
3. Ogawa Hyakusoku. Plastic reconstructive
   Surgery (2006)
4. Chaniotakis et al. J Am Aca Dermatology (2007)

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Onychogryphosis

• 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

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Onychogryphosis

• Observational diagnosis
• Hard but often brittle

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Onychauxis

• 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

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Onychauxis

• Etiology
• Diabetes
• Psoriasis
• PVD
• Subungual exostosis
• Hereditary
• Acromegaly
• Infection
• Genetic Dariers Disease
• Chronic disorder Pityriasis Rubra Pilaris

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Incurvated Ingrown Toenail

• Bony exostosis
• Congenital

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Questions to ask Yourself

• Why is the nail painful?
• Where is the nail painful?
• What (if any) other structures are involved?
• When is the nail painful?

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Why is the nail painful
Injurious cutting
Incurvation
ungelabia
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• 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

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Types of nail surgery

• Nail excision avulsion (drainage)
• Chemical matrixectomy
• Phenol procedure
• Partial excisional matrixectomy
• Winograd, Steindler, Frost
• Total excisional matrixectomy
• Zadik
• Subungual ostectomy
• Soft Tissue
• Symes amputation
• Vandenbos
• Plastic remodelling

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Excisional Matrixectomy Versus Chemical
Ablation

• 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)
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Nail Excision Avulsion

• 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

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Chemical procedures

• 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)

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Duration of application

• 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. Boberg et al. JAPMA (2002)
2. Kocyigit et al. Dermatologic surgery (2005)

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Alcohol Flush

• 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. Hunter et al. Ann Emerg Med (1992)
2. Goslin . The Foot (1992)
3. Espensen et al. JAPMA (2002)

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Phenol Safety

• 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. Losa Iglesias et al. Derm surg (2008)
2. Lin et al. Burns (2006)
3. EPA (2002)
4. Sugden et al. Burns (2001)
5. Gilles et al. JAPMA (1986)

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Phenol Safety

• PHENOL EZ SWABS
• Single use
• 1 cotton swab ampoule containing 0.175-0.2 ml
  liquified Phenol 89

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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?
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Surgical considerations

• Diabetes
• Paediatrics
• PVD
• Long term corticosteroid use
• Dabgatran/Warfarin/Aspirin use
• Current infection

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What is this? What would you do?
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Osteochondroma
Tuft
versus
Shaft
Subungal Exostosis
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What other structures are involved?
Subungual Exostosis
Subungual Osteochondroma

• Usually patients 40 years
• Suspect in involuted nails
• Suspect in patient with pain on distal dorsal
  aspect of nail
• May be associated with history of trauma

• Usually teenagers/young adults
• Nail plate may appear normal
• Suspect in patient with rapid onset
• /- trauma

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Subungal Exostosis or Osteochondroma ?
Bone versus cartilage
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Saucerisation
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• 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

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Winograd Procedure

• When ?
• Ungelabia or when excessive tissue needs to be
  removed
• Revisional surgery after failed previous
  procedure
• True WEDGE resection

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• Inverted L or hockey stick incision

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What are we seeing?
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What do we do?
Nail X thickened Nail X incurvated Centrally
peaked We can choose Partial procedures Total
procedures Chemical versus sharp Have we
forgotten to consider something else ?
Total nail is involved here
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Total Excisional Matrixectomy

• Does this finding change our treatment plan?
• YES
• Exostosis needs removing
• Total nail may need removing
• Total Excisional Matrixectomy
• Terminal phalangeal Ostectomy

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Total Matrixectomy (Zadik)

• Indications
• Onychogryphotic nail
• Onychomycotic nail
• Severely incurvated or
• pincer type nail

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Total Matrixectomy1 week post Operative
12 Months Post Operative


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Steindler Matrixectomy

• 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
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Terminal Syme Removal nail terminal phalanx

• Most often lesser toes
• Long toe
• Onychogryphotic nail mallet toe
• Onychoclavus /- long deformed toe

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Pain following nail procedures

• 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

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Inclusion Cyst
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Ongoing Pain 12 months later

• 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

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Epidermal inclusion cyst
7 months post excisional matrixectomy
Curettage
Paronychia Pain
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Failed previous nail procedures
Excisional matrixectomy
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The Vandenbos Theory (1)

• 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)

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The Vandenbos Procedure
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Plastic Remodelling of nail lip

• Removal of excessive soft tissue

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Periungual fibroma

• Multiple smooth, firm nodules formed at the PNF
• Often gt10 mm in length
• May create a longitudinal groove in nail

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Conclusion

• 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