Treatment of ingrown toenails in the pediatric population

Surgical interventions for ingrown toenail

BACKGROUND

Paronychia is a prevalent clinical disease affecting the soft tissue surrounding the nails. Most cases of toenail paronychia are commonly associated with ingrown toenails. While conservative treatment is effective for mild cases of ingrown toenails, surgical intervention becomes necessary for moderate to severe cases, particularly when granulomas form.

OBJECTIVE

To provide a systematic understanding of these classic and modified procedures for surgeons to select the appropriate surgical interventions for patients suffering from moderate to severe ingrown toenails and discuss this technology's advantages and limitations for dermatologic surgery.

METHODS

A literature search was performed using PubMed/MEDLINE and Google Scholar databases. Studies discussing surgical intervention for ingrown toenails were included. Moreover, the surgical steps were meticulously depicted by detailed schematic diagrams.

RESULTS

These surgical techniques can be divided into three categories: matrix resection, debulking of periungual soft tissues, and the rotational flap technique. Each approach possesses distinct advantages and limitations.

CONCLUSION

For moderate to severe cases, surgical interventions may exhibit superior outcomes, faster recovery times, and lower recurrence rates. The surgeon must possess a comprehensive understanding and proficient skillset in various surgical techniques for ingrown toenails.

Complications in nail surgery and how to avoid them

Complications in nail surgery are not that frequent. Apart from complications that are common to every hand procedure, intense pain is the major issue with nail surgery. To prevent complications, good knowledge of anatomy and physiology is required to avoid misdiagnosis or inappropriate technique. However, some complications, such as postoperative nail dystrophy, are unavoidable, and must be known and discussed with the patient prior to the procedure in order to prevent disappointment that may lead to medico-legal cases. This paper will discuss the most frequent complications encountered.

A novel nerve block technique for nail surgery

In pediatric patients, nail unit anesthesia is frequently required for procedures including matrixectomy or nail avulsion. However, nail unit anesthesia is very painful and requires a significant amount of time to take complete effect, causing a great deal of distress for most pediatric patients. By targeting the palmar and dorsal digital nerves in the distal part of the fingers, our method enables fast, simple, and less painful anesthesia.

Management of ingrowing nail

For decades, there has been debate about the cause of ingrown nail: is the nail plate or the periungual tissue at fault? There is no consensus and management relies on case-by-case analysis followed by tailored treatment. Conservative treatment should be attempted in children when the cause is transient (e.g., poor clipping) or the patient refuses surgery. Surgical treatments rely on two main approaches: either narrowing the nail plate, or debulking the soft tissue. It is up to the surgeon to select the most appropriate approach in each case. All procedures discussed in this chapter have high cure rates as long as they are properly performed. As with all surgical procedures, they are operator-dependent. Chemical cautery is the easiest and most versatile technique that may help in almost all instances for lateral ingrowth. For distal ingrowth and very hypertrophic and exuberant lateral folds, debulking with primary or secondary healing is most effective.

Does Electrocauterization of the Matrix After the Wedge Resection of the Toe-Nail Affect Recurrence in Discrete Age Groups Differently? A Retrospective Analysis

The onychocryptosis, also known as ingrown toe-nails, is a painful, common disorder which is less common in children than in adults. The purpose of the present study was to focus on the effect of electrocautery matricectomy on recurrence rate and clinical outcomes in different age groups. We performed a retrospective assessment of 189 consecutive ingrown toe-nails surgeries. Electrocautery matricectomy was performed in 68 (49.2%) of 138 (73%) adults, 25 (49%) of 51 (27%) adolescents. Recurrence was observed in 11 (21.5%) adolescent patients, while recurrence was observed in 12 (8.6%) adult patients. Recurrence was observed in 9 (9.6%) of 93 patients in whom cautery was used, while 14 (14.5%) recurrences were observed in 96 patients who did not use cautery. When the adolescent patient group was evaluated separately, recurrence was observed in 2 (8%) of 25 patients in the cautery group, while recurrence was observed in 9 (34.6%) of 26 patients in the other group. EM addition to the wedge excision does not affect the results in adult patients, but it significantly reduces recurrence in adolescent patients. Especially in younger patients, it is recommended to complete the matricectomy with electrocoagulation.

Matrix Cauterization With Silver Nitrate in the Treatment of Ingrown Toenails in Children: Pilot Study

BACKGROUND

Although partial onychectomy with chemical matricectomy has been described asthe treatment of choice, there is sparse evidence in the literature regarding the use of silvernitrate for matricectomy. Our aim is to describe the effectiveness of silver nitrate for matrixcauterization after partial onychectomy.

METHODS

A prospective observational study was performed on patients with ingrown toenailsstage 2-3 who underwent partial onychectomy with silver nitrate chemical matricectomy during 2018-2019 in our institution. All patients were evaluated in the outpatient clinic on the 7th and 30th post-operative day and a telephone evaluation was performed every 6 months afterthe surgical procedure to date.

RESULTS

One hundred and twenty-three patients, who underwent 231 partial onychectomies with silver nitrate chemical matricectomy were included, with a median follow-up of 21 months (interquartile range, 12-29). The procedure had an effectiveness of 95.3%, with only 11 recur-rences (4.7%) reported so far on follow-up. Postoperative infections were observed in 4 patients (1.7%). Adverse effects, such as pain and postoperative drainage, were irrelevant in mostpatients.

CONCLUSIONS

Silver nitrate matricectomy after partial onychectomy is an effective and safealternative for the treatment of ingrown toenail in children, with scarce postoperative morbidityand low recurrence rate.

Matrix Cauterization With Silver Nitrate in the Treatment of Ingrown Toenails in Children: Pilot Study

BACKGROUND

Although partial onychectomy with chemical matricectomy has been described as the treatment of choice, there is sparse evidence in the literature regarding the use of silver nitrate for matricectomy. Our aim is to describe the effectiveness of silver nitrate for matrix cauterization after partial onychectomy.

METHODS

A prospective observational study was performed on patients with ingrown toenails stage 2-3 who underwent partial onychectomy with silver nitrate chemical matricectomy during 2018-2019 in our institution. All patients were evaluated in the outpatient clinic on the 7th and 30th post-operative day and a telephone evaluation was performed every 6 months after the surgical procedure to date.

RESULTS

One hundred and twenty-three patients, who underwent 231 partial onychectomies with silver nitrate chemical matricectomy were included, with a median follow-up of 21 months (interquartile range, 12-29). The procedure had an effectiveness of 95.3%, with only 11 recurrences (4.7%) reported so far on follow-up. Postoperative infections were observed in 4 patients (1.7%). Adverse effects, such as pain and postoperative drainage, were irrelevant in most patients.

CONCLUSIONS

Silver nitrate matricectomy after partial onychectomy is an effective and safe alternative for the treatment of ingrown toenail in children, with scarce postoperative morbidity and low recurrence rate.

The effectiveness of matrix ablation with silver nitrate in the treatment of ingrown toenails. A single-center case-control study

BACKGROUND

Partial onychectomy with chemical matrixectomy is considered the gold standard treatment for stage II-III ingrown toenails (IT). However, there are scarce reports describing the use of silver nitrate in IT management in adolescents. Our aim is to analyze the effectiveness of matrix ablation with silver nitrate and compare it with partial onychectomy by electrocautery.

METHODS

A retrospective study of adolescent patients with stage II-III IT was performed. Those who underwent electrocautery matricectomy in a major outpatient surgical center (Group A) and those who were treated with silver nitrate at an outpatient clinic (Group B) were compared. Efficacy was determined by recurrence and postoperative infection rates.

RESULTS

Two hundred and nine patients were included (86 group A; 123 group B), with a total of 382 partial onychectomies (151 group A; 231 group B). Group B patients exhibited a lower recurrence rate (4.7%) when compared to group A (11.2%, p = .02), and had a lower postoperative infection rate (4.0% group A vs. 1.7% group B; p = .18), although not statistically significant.

CONCLUSION

Silver nitrate chemical matricectomy after partial onychectomy is an effective treatment for IT in adolescents, with few postoperative complications and low recurrence rate. Therefore, it should be considered as a possible alternative to electrocautery matricectomy.

The effectiveness of nail excision versus Vandenbos procedure for the surgical management of ingrown toenails in children: A retrospective chart review

BACKGROUND

Ingrown toenail commonly occurs in patients who have experienced trauma or long-term compression to their toes. There exist two common methods of surgical management - wedge resection and Vandenbos procedure. We compared the recurrence rate of these two methods in pediatric patients.

METHODS

We conducted a retrospective study reviewing patients who presented to our institution with ingrown toenail between 2009 and 2015. Patients who received any surgical treatment outside of our institution or were over 18 years of age were excluded.

RESULTS

There were 523 patients seen at our institution with ingrown toenail. Of these patients, 482 had sufficient data available to be included in this study, with a total of 929 ingrown toenails. Out of these, 333 were managed conservatively while the remaining 596 required surgical intervention; 373 had wedge resection performed and the other 223 had Vandenbos procedure. Our analysis determined that 78 total complications arose in the wedge resection group (21%) while 32 total complications arose in the Vandenbos group (14%; p = 0.0949). Wedge resections had a significantly higher recurrence rate than Vandenbos procedures (41 (11%) vs 5 (2%), p = 0.0001).

CONCLUSION

Surgical complications are comparable between wedge resections and Vandenbos procedure. Vandenbos procedure offers a significantly lower recurrence rate than wedge resection.

LEVEL OF EVIDENCE

Level III.

A Minimally-Invasive, Simple, Rapid, and Effective Surgical Technique for the Treatment of Ingrown Toenails: A Reminder of the Original Winograd Procedure

(1) Background: Ingrown toenail is a common disorder of the toe that induces severe toe pain and limits daily activities. The Winograd method, the most widely used operative modality for ingrown toenails, has been modified over years to include wedge resection of the nail fold and complete ablation of the germinal matrix. We evaluated the outcomes of original Winograd procedure without wedge resection with electrocautery-aided matrixectomy. (2) Methods: We retrospectively analyzed the outcomes of patients who underwent surgery for ingrown toenails at a university hospital for two years from November 2015 to October 2017. Surgery was performed in 76 feet with a mean operation time of 9.34 min. (3) Results: The minimal interval from surgery to return to regular activities was 13.26 (range 7 to 22) days. Recurrence and postoperative wound infections were found in 3 (3.95%) and 2 (2.63%) patients, respectively. Evaluation of patient satisfaction at one-year follow-up showed that 40 (52.63%) patients were very satisfied, 33 (43.42%) were satisfied, 3 (3.95%) were dissatisfied, and none of them were very dissatisfied. The average follow-up duration was 14.66 (range 12 to 25) months. (4) Conclusions: Therefore, it is believed that this less-invasive and simple procedure could be easily performed by clinicians, with satisfactory patient outcomes.

Surgical site infection leading to gangrene and amputation after ambulatory surgical care of an ingrown toenail: a case report

Background

Currently, the management of ingrown toenail (onychocryptosis) ranges from conservative medical management to surgical treatment. Surgical management is typically performed as an outpatient procedure due to it numerous advantages such as the simplicity of the technique and the low incidence of postoperative complications. The most common postoperative complications are recurrences and surgical site infections, whereas gangrene complicating a surgical site infection has been scarcely reported. We are reporting a rare complication following ambulatory surgery untimely requiring amputation.

Case presentation

A twelve-year-old boy was referred to our orthopedic surgical department for a surgical site infection complicating an initial surgical management of a left ingrown big toenail leading to a dry gangrene of the affected toe. The gangrene toe was amputated under peripheral nerve block and the patient was discharged home the same day on antibiotics, analgesics and with sessions of rehabilitation and psychological support planned. The postoperative course was uneventful at 6 months of follow-up.

Conclusion

The authors report this case to draw clinicians’ attention, especially wound care specialists, orthopedists and podiatrists to this rare but potentially debilitating disease.

Ingrowing toenails in children and adolescents: is nail avulsion superior to nonoperative treatment?

INTRODUCTION

Ingrowing toenail (IGTN) or onychocryptosis is not uncommon in children and adolescents. However, there is a dearth of evidence in the literature on the management of IGTN in this age group. This study aimed to compare the results of nonoperative treatment for IGTN with that of operative treatment among children and adolescents.

METHODS

All children and adolescents who were treated for IGTN at our institution between 2010 and 2014 were included for this retrospective study. Demographic data, treatment prescribed and outcome at six months after presentation were analysed.

RESULTS

Overall, 199 patients were recruited. There were 123 (61.8%) boys and 76 (38.2%) girls. Median age was 14 years. Among 199 toes, 162 (81.4%) were treated nonoperatively, with nail care advice, topical antibiotics and daily cleansing. Only 37 (18.6%) toes were treated operatively. In the operative group, 23 (62.2%) patients underwent wedge resections, while the remaining 14 (37.8%) had total nail avulsions; for all patients, germinal matrices were preserved. At the six-month follow-up, there were 5 (3.1%) cases of recurrence in the nonoperative group when compared to 3 (8.1%) recurrences in the operative group.

CONCLUSION

We recommend that IGTN in children and adolescents be treated in the first instance by nonoperative methods. Operative options can be considered for resistant cases or in case of recurrence of IGTN.

Clinical and Sociodemographic Characteristics of Ingrown Nails in Children

BACKGROUND

Ingrown nail is a condition frequently seen in children and adolescents, the pain from which can affect their daily living activities and school performances. The purpose of this study was to determine the clinical and sociodemographic characteristics of ingrown nails in children.

METHODS

The clinical and sociodemographic characteristics of patients aged 0 to 18 years presenting with ingrown nail were evaluated retrospectively from clinic records.

RESULTS

Sixty-two patients aged 3 to 18 years (mean age, 15 years; male to female ratio, 1.06) were enrolled. A total of 175 ingrown nails were evaluated (all of them were in the halluces, 54.3% of them were on the lateral margin). A positive family history of ingrown nail was present in 15.7%. High prevalences of incorrect nail cutting (72.1%), trauma (36.1%), poorly fitting shoes (29%), hyperhidrosis (12.9%), obesity (9.7%), and accompanying nail disorders (9.7%) were determined among the patients.

CONCLUSIONS

This study revealed the clinical and sociodemographic characteristics of ingrown nails in children. These data will be useful in preventing the occurrence of ingrown nail by revealing and then eliminating predisposing factors.

The Recurrence of Onychocryptosis when Treated with Phenolization: Does Phenol Application Time Play a Role? A Follow-Up Study on 622 Procedures

INTRODUCTION

Chemical matricectomy using phenol (CMP) is a recognized treatment option for onychocryptosis. However, the appropriate phenol application time to achieve nail matrix destruction is still unknown. Optimal ablation leads to low recurrence rates. The aim of this research was to assess the recurrence rate of onychocryptosis in a cohort of 622 consecutive patients treated with a 4-min CMP.

METHODS

We recruited all patients undergoing a 4-min CMP for onychocryptosis at the Istituto Podologico Italiano, Rome, Italy, in 2008-2017. Postoperative follow-up visits were set at 24 h, 7, 14, 21, and 28 days, 6 months, and 1 year after surgery. We used adjusted logistic regression to evaluate the potential risk factors for the disease recurrence including age, gender, toe shape, comorbidities, and disease localization.

RESULTS

The risk of recurrence in all patients treated with a 4-min CMP was 1.1% (n = 622, 95% CI = 0.5%-2.3%). In the subgroup of patients with cardiovascular disease (n = 39) the recurrence risk was 5.1% (95% CI = 0.61-7.3). Young age was also associated with increased odds of recurrence (p = 0.036).

CONCLUSION

In this observational study, 4 min with no interruptions seems to be the appropriate application time of phenol when using CMP for the treatment of onychocryptosis. A randomized controlled trial should be carried out to confirm our results.

Nonrandomized assessment of ingrown toenails treated with excision of skinfold rather than toenail (NAILTEST): An observational study of the Vandenbos procedure

BACKGROUND

The Vandenbos procedure for ingrown toenails consists of excising the surrounding skinfold and allowing the wound to heal by secondary intention. Previous studies have documented low rates of recurrence, but patient-reported outcomes remain uncertain.

METHODS

This study was a prospective, observational assessment of children and adolescents who underwent the Vandenbos procedure for one or more ingrown toenails. Standardized assessments of pain, functional status, and quality of life were completed before surgery and then one, two, and six months postoperatively.

RESULTS

Thirty-nine participants (with 59 ingrown toenails) completed at least one postoperative assessment and were included in the analysis. Age ranged from 4 to 20years (mean 13.5years). Recovery time was a median of 7days for return to school or work and 23days for being able to wear enclosed shoes. Seven participants (18%) experienced one or more minor complications within the first two months of surgery. There were no recurrences. Ninety-five percent of participants and 100% of parents would recommend the Vandenbos procedure.

CONCLUSIONS

We conclude that the Vandenbos procedure is associated with a low recurrence rate in children, adolescents, and young adults with ingrown toenails. Patient-reported recovery time, complication rate, functional outcomes, and satisfaction are excellent.

LEVEL OF EVIDENCE

3.

Periungual myiasis caused by wohlfahrtia magnifica mimicking an ingrown toenail

Myiasis is the infestation of organs and tissues of human being or other vertebrate animals with dipterous larvae. Myiasis is generally rare in humans, especially in children. We present the first case of periungual myiasis by Wohlfahrtia magnifica in a 5-year-old female. Wohlfahrtia magnifica is an obligatory parasite, which has been described as cause of ophthalmomyiasis, otomyiasis, oral myiasis, vulvar myiasis and wound myiasis. Treatment of myiasis and ingrown toenail is generally non-operative although both entities can be serious and/or non-responsive to conservative therapy.

Antifungal therapy for onychomycosis in children

Onychomycosis is a chronic infection of the nail unit, and its prevalence increases with age. Treatment options for children are similar to those for adults and include both oral and topical therapies. Oral agents, such as terbinafine, itraconazole, and fluconazole have been reported to have good efficacy and a low rate of side effects in children. Topical therapies, such as amorolfine and ciclopirox, can also be used as monotherapy or combined with oral agents to treat onychomycosis. Due to their thinner, faster-growing nails, children are more likely to respond to topical monotherapy than adults. There is currently insufficient data comparing emerging medical devices, such as laser therapy, with standard therapeutic options to recommend their use in children.

Partial matricectomy with curettage and electrocautery: a comparison of two surgical methods in the treatment of ingrown toenails

BACKGROUND

An ingrown toenail is a common, painful, and debilitating condition.

OBJECTIVE

This study aims to compare 2 surgical methods (partial matricectomy with curettage and electrocautery) in the treatment of ingrown toenails.

MATERIALS AND METHODS

A total of 92 ingrown nails of the big toe in 86 patients underwent partial matricectomy with curettage, whereas 57 ingrown nails of the big toe in 52 patients underwent partial matricectomy with electrocautery.

RESULTS

Recurrence was observed in 2 toenails in the partial matricectomy with curettage group, whereas no recurrence was observed in the partial matricectomy with electrocautery group (p > .05). The mean period of postoperative pain was 2.3 and 3.1 days in the curettage group and the electrocautery group, respectively (p < .05). There was a significant difference in the duration of scar tissue inflammation (p < .05).

CONCLUSION

Both surgical methods are safe treatment modalities with a high success rate. Partial matricectomy, which is achieved using curettage, seems to be superior to electrocautery in respect of reduced inflammation and duration of pain.

[Pediatric nail surgery]

BACKGROUND

Although interventions on the skin of children and adolescents often heal better than in adults, inappropriate interventions on nails can lead to avoidable trauma and irreparable damage to fingers and toes.

PROBLEMS

When are interventions on nails indicated in children? What age-related characteristics are important?

MATERIAL AND METHODS

With reference to the literature and experience from own clinical cases, the most commonly occurring constellations in children are discussed and approaches to protective treatment are demonstrated.

RESULTS

Ingrown toenails are one of the most common reasons for presentation due to nail problems in childhood. Conservative measures or protective interventions on the nail matrix avoid unnecessary trauma caused by currently obsolete techniques. Additional nail problems in children which could be treated operatively included nail pigmentation, exostosis and onychodystrophy.

CONCLUSION

A thorough evaluation of the indications and cautious implementation allows a targeted nail surgery or its avoidance even in childhood.

Nail-fold excision for the treatment of ingrown toenail in children

OBJECTIVE

To evaluate the effectiveness of the nail-fold excision procedure in children.

STUDY DESIGN

Prospectively collected data on patients less than 18 years of age who underwent a nail-fold excision for symptomatic ingrown toenail were analyzed. Patients were seen in 2 centers and data collected included demographics, site of ingrown toenail, complications (including recurrence), patient satisfaction, and duration of follow-up.

RESULTS

Overall, 67 procedures were performed on 50 patients between June 2009 and July 2011 at the 2 institutions. The mean age was 14 years (range, 9-18 years) and 30 were male patients. No recurrences were seen after a follow-up for a median of 14 months (range 6-28 months). Patients were very satisfied with the cosmetic outcomes. Six minor complications occurred, including 3 patients with bleeding requiring dressing change, 2 with excessive granulation tissue, and 1 with nail growth abnormality.

CONCLUSIONS

The nail-fold excision technique is highly effective in the pediatric population, with no recurrence, excellent cosmesis, and very high patient satisfaction.

Interventions for ingrowing toenails

BACKGROUND

Ingrowing toenails are a common problem in which part of the nail penetrates the skinfold alongside the nail, creating a painful area. Different non-surgical and surgical interventions for ingrowing toenails are available, but there is no consensus about a standard first-choice treatment.

OBJECTIVES

To evaluate the effects of non-surgical and surgical interventions in a medical setting for ingrowing toenails, with the aim of relieving symptoms and preventing regrowth of the nail edge or recurrence of the ingrowing toenail.

SEARCH METHODS

We updated our searches of the following databases to January 2010: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE, and EMBASE. We also updated our searches of CINAHL, WEB of SCIENCE, ongoing trials databases, and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of non-surgical and surgical interventions for ingrowing toenails, which are also known by the terms 'unguis incarnatus' and 'onychocryptosis', and those comparing postoperative treatment options. Studies must have had a follow-up period of at least one month.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed methodological quality, and extracted data from selected studies. We analysed outcomes as risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

This is an update of the Cochrane review 'Surgical treatments for ingrowing toenails'. In this update we included 24 studies, with a total of 2826 participants (of which 7 were also included in the previous review). Five studies were on non-surgical interventions, and 19 were on surgical interventions.The risk of bias of each included study was assessed; this is a measure of the methodological quality of several characteristics in these studies. It was found to be unclear for several items, due to incomplete reporting. Participants were not blinded to the treatment they received because of the nature of the interventions, e.g. surgery or wearing a brace on the toe. Outcome assessors were reported to be blinded in only 9 of the 24 studies.None of the included studies addressed our primary outcomes of 'relief of symptoms' or 'regrowth', but 16 did address 'recurrence'. Not all of the included studies addressed all of our secondary outcomes (healing time, postoperative complications - infection and haemorrhage, pain of operation/postoperative pain, participant satisfaction), and two studies did not address any of the secondary outcomes.Surgical interventions were better at preventing recurrence than non-surgical interventions with gutter treatment (or gutter removal), and they were probably better than non-surgical treatments with orthonyxia (brace treatment).In 4 of the 12 studies in which a surgical intervention with chemical ablation (e.g. phenol) was compared with a surgical intervention without chemical ablation, a significant reduction of recurrence was found. The surgical interventions on both sides in these comparisons were not equal, so it is not clear if the reduction was caused by the addition of the chemical ablation.In only one study, a comparison was made of a surgical intervention known as partial nail avulsion with matrix excision compared to the same surgical intervention with phenol. In this study of 117 participants, the surgical intervention with phenol was significantly more effective in preventing recurrence than the surgical intervention alone (14% compared to 41% respectively, RR 0.34, 95% CI 0.17 to 0.69).None of the postoperative interventions described, such as the use of antibiotics or manuka honey; povidone-iodine with paraffin; hydrogel with paraffin; or paraffin gauze, showed any significant difference when looking at infection rates, pain, or healing time.

AUTHORS' CONCLUSIONS

Surgical interventions are more effective than non-surgical interventions in preventing the recurrence of an ingrowing toenail.In the studies comparing a surgical intervention to a surgical intervention with the application of phenol, the addition of phenol is probably more effective in preventing recurrence and regrowth of the ingrowing toenail. Because there is only one study in which the surgical interventions in both study arms were equal, more studies have to be done to confirm these outcomes.Postoperative interventions do not decrease the risk of postoperative infection, postoperative pain, or healing time.

Postoperative infection after excisional toenail matrixectomy: a retrospective clinical audit

BACKGROUND

Excisional toenail matrixectomies are performed on the area of the foot that has been reported to have the highest concentration of resident microorganisms. A retrospective infection audit was performed to identify whether this unique area of the foot was more susceptible to postoperative infection.

METHODS

A retrospective audit reviewing the postoperative infection rate over a 6-year period after excisional nail matrixectomy in 111 patients was undertaken.

RESULTS

The postoperative infection rate was found to be high (18.9%) relative to that of clean orthopedic foot and ankle surgery (0.5%-6.5%).

CONCLUSIONS

The unique concentration of resident microbes found in the nail folds could help explain the high rate of postoperative infections identified in this study. This may provide some argument to classify excisional nail matrixectomy as clean-contaminated surgery and, thus, warrant routine antibiotic prophylaxis. Further research is recommended to confirm the results of this study and to determine whether appropriately timed oral antibiotic prophylaxis will reduce the infection rate after nail surgery.

A quantitative method for measuring forces applied by nail braces

BACKGROUND

Nail bracing is a conservative method used for ingrown nails; however, lack of objective measurements limits its use for various nails.

METHODS

Double-string nail braces with extra metal springs were applied to 12 patients with 21 chronic, thick, and overcurved ingrown nails. Force was measured with a force gauge meter. Treatment was stopped once patients stood on their tiptoes and walked in shoes pain free without braces. A force gauge meter was also used on a model nail to show the forces applied by various nail braces and to compare their pulling forces.

RESULTS

After 6 to 10 months of treatment, all of the patients were pain free; 600 to 1,000 centi Newtons of force were applied to the nails. As the width of the nail increased, so did the force.

CONCLUSIONS

Braces exert more force on larger nails, which may shorten treatment durations. By measuring forces, it may be possible to standardize force and duration of treatment according to variables such as nail thickness, nail width, angle of ingrown nail, and duration of symptoms.

Results of partial matrixectomy for chronic ingrown toenail

BACKGROUND

Several treatment modalities which targeted partial matrixectomies, including chemical, laser matrixectomy, and partial nail avulsion, have been used in the dermatology, podiatry, and orthopaedic literature. We report our experience with surgical matrixectomy.

METHODS

We treated 224 patients with severe ingrowing toenails. Segmental wedge resection of involved margin was performed. Followup time was a minimum of 10 months.

RESULTS

Statistical analysis of recurrence and disease parameters such as stage of disease, infection, involved margin, previous surgery, followup time, and age showed no significant correlation (p>0.05). Twenty-two patients (9.8%) had a recurrence. Revision surgery was performed in 16 patients (7.1%).

CONCLUSION

We recommend the Winograd technique with a few modifications especially for severe Stage 2 and 3 cases. Both loupe magnification and observation of soft tissue in the postoperative period were important details.

Surgical treatment of ingrown toenails in children: what is best practice?

INTRODUCTION

Surgery for ingrowing toenails carries a significant re-operation rate. We reviewed our departmental figures to assess the optimal management of these patients.

PATIENTS AND METHODS

We performed a 10-year retrospective review of all patients undergoing surgery for ingrown toenails (IGTN) in order to determine the operations most commonly used and the re-operation rate of each of these procedures.

RESULTS

A total of 880 procedures were performed on 414 patients. The median age at operation was 8.5 years. About half (48%) of children underwent two or more procedures with wedge excision and phenol application being the most common initial and repeat procedure. Recurrent surgery was most likely following plain avulsion or wedge avulsion without phenol application. Excision of the nailbed with phenol application had the lowest recurrence rate at 18.4%.

CONCLUSIONS

We recommend wedge resection with phenol application as first-line treatment with simple avulsion reserved for severely infected toes. Total nail bed excisions should be reserved for patients with significant on-going morbidity associated with IGTN. Families must be made aware of the likely outcome of IGTN surgery and the choice of operation must be tailored to the individual.