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Nail Surgery

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Title: Nail Surgery Author: Robert Hermann Last modified by: Natalie Matson Created Date: 5/3/1997 12:01:56 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Nail Surgery


1
Onychocryptosis An Update
Angelo Salerno Podiatric Surgeon B App Sc, Grad
Dip, M Pod, FACPS
2
Overview
  • Etiology of IGTN other nail pathology
  • Review of PA procedure phenol
  • Surgical considerations
  • Various procedures available
  • Complications of nail surgery to consider

3
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)

4
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

5
Onychogryphosis
  • Observational diagnosis
  • Hard but often brittle

6
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

7
Onychauxis
  • Etiology
  • Diabetes
  • Psoriasis
  • PVD
  • Subungual exostosis
  • Hereditary
  • Acromegaly
  • Infection
  • Genetic Dariers Disease
  • Chronic disorder Pityriasis Rubra Pilaris

8
Incurvated Ingrown Toenail
  • Bony exostosis
  • Congenital

9
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?

10
Why is the nail painful
Injurious cutting
Incurvation
ungelabia
11
  • 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

12
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

13
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)
14
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

15
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)

16
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)

17
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)

18
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)

19
Phenol Safety
  • PHENOL EZ SWABS
  • Single use
  • 1 cotton swab ampoule containing 0.175-0.2 ml
    liquified Phenol 89

20
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?
21
Surgical considerations
  • Diabetes
  • Paediatrics
  • PVD
  • Long term corticosteroid use
  • Dabgatran/Warfarin/Aspirin use
  • Current infection

22
What is this? What would you do?
23
Osteochondroma
Tuft
versus
Shaft
Subungal Exostosis
24
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

25
Subungal Exostosis or Osteochondroma ?
Bone versus cartilage
26
Saucerisation
27
  • 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

28
Winograd Procedure
  • When ?
  • Ungelabia or when excessive tissue needs to be
    removed
  • Revisional surgery after failed previous
    procedure
  • True WEDGE resection

29
  • Inverted L or hockey stick incision

30
What are we seeing?
31
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
32
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

33
Total Matrixectomy (Zadik)
  • Indications
  • Onychogryphotic nail
  • Onychomycotic nail
  • Severely incurvated or
  • pincer type nail


34
Total Matrixectomy 1 week post Operative
12 Months Post Operative


35
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
36
Terminal Syme Removal nail terminal phalanx
  • Most often lesser toes
  • Long toe
  • Onychogryphotic nail mallet toe
  • Onychoclavus /- long deformed toe

37
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

38
Inclusion Cyst
39
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

40
Epidermal inclusion cyst
7 months post excisional matrixectomy
Curettage
Paronychia Pain
41
Failed previous nail procedures
Excisional matrixectomy
42
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)

43
The Vandenbos Procedure
44
Plastic Remodelling of nail lip
  • Removal of excessive soft tissue

45
Periungual fibroma
  • Multiple smooth, firm nodules formed at the PNF
  • Often gt10 mm in length
  • May create a longitudinal groove in nail

46
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
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