THE
SURGICAL
J. D.
From
TREATMENT
GREIG,
J.
Hairmyres
H.
OF
ANDERSON,
Hospital,
A.
East
Kilbride
INGROWING
J. IRELAND,
and
J.
the Royal
R.
TOENAILS
ANDERSON
Infirmary,
Glasgow
Two prospective
studies
of ingrowing
toenail
management
were conducted.
In the first, 163 patients
(204
ingrowing
nail edges)
who had not had previous
surgery
were randomised
and treated
by total nail avulsion,
nail edge excision,
or nail edge excision
with phenolisation
of the germinal
matrix;
recurrence
rates one year
postoperatively
were 73%, 73% and 9% respectively.
In the second
study, 63 ingrowing
nail edges
nail edge excision
and phenolisation.
nail one year after operation.
The results
of ingrowing
toenail
variable.
The review
by Sykes
studies
quoted
recurrence
rates
86%. Most
independent
tions studied
There
which
was a 5%
treatment
are extremely
in 1986 of 32 published
which
ranged
from 0% to
of the
management
of recurrent
We have assessed
three
forms
in patients
who had not previously
reviewed
the
effectiveness
germinal
matrix
after a previous
of
phenolisation
operation.
PATIENTS
for
AND
edge
digital
We
included
all
patients
conservative
to Hairmyres
Hospital
and
between
August
1986 and July
or onychogryphotic
toenails
Patients
treatments
were
randomised
: group
1) total
of the ingrowing
nail edge ; group
and germinal
matrix
phenolisation.
J. D. Greig,
University
Laurieston
J. H. Anderson,
FRCS,
Registrar
A. J. Ireland,
FRCS,
Registrar
J. R. Anderson,
FRCS,
Consultant
University
Department
ofSurgery,
Glasgow
G3l 2ER,
Scotland.
Correspondence
should
be sent
Royal
to Mr
© 1991 British Editorial
Society
ofBone
0301-620X/91/1051
$2.00
JBoneJointSurg[Br]
1991; 73-B:l3l-3.
VOL.
73-B,
No.
I, JANUARY
1991
Joint
of
0.5%
0.5 cm of the
nail
trainees.
whole
nail
was
toenails
who
in
were
then
was
Alexandra
Surgery
Parade,
compressed
and
by
were introthe matrix.
by cutting
a tourniquet
performed
as for
.
the
venous
ooze. Paraffinjelly
was
the nail to protect
it. Liquified
removed
gutter
applied
phenol
dried
to
to the skin
(80%) was
Study 2
Consecutive
patients
who presented
with
a recurrent
ingrowing
toenail
excision
of Edinburgh,
toe was
Marcaine.
applied
in drops
from
a pipette
onto
the nail bed and
along
the gutter.
It was left for four minutes
and then
removed
with swabs.
Any remaining
phenol
was neutralised with methylated
spirit.
Glasgow
Royal
1987. Recurrent
were
excluded.
edge
2. The
control
around
checked
by a
pre-operatively
from
granulation
tissue
was
were carried
out by
removed
and
J. R. Anderson.
and
10 ml
At least
recurred
surgical
treated
Infirmary,
to
were taken
and excess
operations
forceps
it from
group
3) nail
FRCS,
Registrar
Department
of Surgery,
Royal
Infirmary
Place,
Edinburgh
EH3 9YW,
Scotland.
5
.
and
to receive
one
of three
avulsion
; group
2) excision
nail
with
of the
distal circulation
was
The toe was anaesthetised
down its longitudinal
axis.
Group 3) Nailedge
excision
andphenolisation
was applied
and nail edge excision
was
failed,
referred
Infirmary
ingrowing
The
underwent
of dystrophy
avulsion
with a pair of artery
forceps.
Group
2) Nail edge excision
artery
duced deep to the nail edge, separating
which
ingrowing
had
block
operations
incidence
treatment
and also
METHODS
with
treatment
techniques.
postoperatively.
Bacteriological
swabs
discharging
nail beds
curetted.
The following
Study!
whom
previous
and a 5%
one or other of three surgical
Group
1) Total avulsion
: the
excision
those
rate
ingrowing
of surgical
had surgery
nail
after
recurred
Operative
pre- and
of these
studies
were retrospective,
without
assessment
of the results,
and the populawere inadequately
defined.
There
have been
few reports
toenail.
had
recurrence
1
operation
by nail
were
edge
described
above.
In both studies,
days and subsequent
entered
excision
dressings
postoperative
the general
practitioner.
surgeon
two weeks
later
were
taken
if appropriate.
growth
antibiotic
Patients
hygiene.
of
over the same period
after
one previous
in this
and
were
study.
They
phenolisation
changed
care was
advised
after three
provided
by
Patients
were assessed
by the
when
bacteriological
cultures
Infection
was defined
as
a pathogenic
organism
from
treatment
was guided
by reported
were
were
as
on
wound
care,
the wound;
sensitivities.
footwear
and
131
J. D. GREIG,
I 32
The
independent
patients
were
reviewed
one
assessor
who did not know
J. H. ANDERSON,
A. J. IRELAND,
Table
groups
year later
by an
which
procedure
had been performed.
of ingrowth
of the
Recurrence
nail edge
presence
or absence
The statistical
and the Bonferroni
of symptoms
was noted.
methods
used were the
comparison
tests.
J. R. ANDERSON
was defined
as evidence
or spicu!e
formation;
the
I. Clinical
data of the three
in first study (163 patients)
chi-squared
(group)
Male
Female
Total
avulsion(1)
41
18
26.3
(12to69)
33
14
28.1
(13 to 77)
39
18
28.3
(12 to 70)
Nailedge
RESULTS
(2)
Nail edge
and
phenolisation
excision
1
There
were
168 patients
follow-up,
leaving
163
surgery
were
assessed.
ages
shown
in Table
II. In
developed
a postoperative
toenail
pre-operatively.
group
2, the one
infection
had
Patients
undergoing
patient
who
an infected
nail edge
results
were
nail
incidence
for the
not
edges
were
of recurrence
three groups
surgeon-dependent.
HI.
Total
avulsion(l)
Nailedge
excision
Infection
treated
was
(Table.
rates
after
three
22
0
0
18
38
1
2
15
26
7
12
(2)
N
%
N
81
59
73
46
(3)
toenails
(204
Time
%
Patient
satisfaction
(%)
to
mean
and range
57
46
4.4
(2to
11)
recurrence
41
73
36
64
49
5.4
(2 to 12)
67
6
9
6
9
84
4.2
(2 to 10)
(months)
(3)
between
1 and
3 (p
<
0.01)
and
in
groups
treatment,
(Table III).
Study 2
study,
edge excision
and total nail
27 of 59 (46%)
patients
in group
1 said that they were satisfied,
23 of
47 (49%)
in group
2 and 48 of 57 (84%)
in group
3
in this
female,
with an average
age of 22 years
They had 64 recurrent
ingrowing
toenail
treatments
included
: total nail avulsion
29 male
and
with germinal
avulsion
with
tion (2). At the time
(27%) were infected.
0.01).
their
procedures)
56
different:
patients
for ingrowing
Sym ptomatic
in
about
and
phenolisation
n = 57
Rec urrences
groups
1 and 2. However,
the results
were significantly
groups
Nailedge
Number of
ingrowing
nail edges
rates
between
two comparisons
42
13
excision
operations
recurrence
the other
were
Post-operative
(1)
Nailedge
73%,
III).
in
asked
Pre-operative
in
in group
3 were symptomatic
but not all recurrences
groups
1 and 2 produced
symptoms.
Using the Bonferroni
comparison
test, there
was no significant
difference
When
Total
avulsion
n = 59
(2)
Nailedge
excision
and
phenolisation
<
toe
Procedure
(group)
All recurrences
Recurrence
Procedure
(group)
2and3(p
and
postoperative
for ingrowing
of group
n =47
ingrowing
Table
There
II. Incidence
of preinfection
in 163 patients
treated
nails by number
and percentage
is
excision
the 1 63 patients.
The
73% and 9% respectively
The
Table
I).
infection
and phenolisation
had more
wound
infections
postoperatively
in whom
only
two
had
preinfection)
than
did those
in the other
two
All infections
settled
rapidly
on appropriate
antibiotic
therapy.
A total of 204
(2)
in this study.
Five were lost to
patients
in whom
the results
of
The sex distribution
and mean
of the three groups
were similar
(Table
The incidence
of pre- and postoperative
excision
(seven
operative
groups.
Mean age
in years
(range)
Sex
Procedure
excision
Study
treatment
13
bed
Two weeks
infections.
postoperatively,
Three
were
but one required
nail
Two
of the
infected
operatively.
One
year
of the
later
THE
avulsion
nails
63 edges
JOURNAL
(range
edges.
alone
1 1 to 63).
Previous
(51); nail
matrix
germinal
phenolisation
(1 1);
matrix
phenolisa-
revision
operation
cured
four patients
with oral
to eradicate
had
been
were
17 edges
assessed
OF BONE
AND
had nail
antibiotics
the infection.
infected
pre(one
JOINT
patient
SURGERY
THE
was
lost
ingrowing
to follow-up).
nail edges;
recurred
three
to
all
four
There
were
SURGICAL
TREATMENT
OF INGROWING
three
and
recurrent
they
had
Murray
toenail
avulsion
postoperatively.
Two
(86%).
Radical
were
painful
months
patients
(three
edges)
developed
nail at the site of phenolisation,
painful
eight
dystrophy
of the
and
12 months
postoperatively.
Of the 42 patients,
37 were
satisfied
with
their
treatment.
The five patients
who developed
ingrowing
or
dystrophic
nails were dissatisfied.
Out of 63 nail edges,
57 (90%) were asymptomatic
one year after surgery.
Sykes’
1986
survey
and
and
found
that more than
half advocated
did not ablate
the nail
bed.
The
recurrence
(73%) for simple
avulsion
general
surgeons
procedures
which
high
incidence
of
in the present
study
(1975)
demonstrated
there
was
ablative
undergone
previous
from consideration
an even
edge
state
indicated.
The
reported
recurrence
rates
following
surgical
ablation
of the nail bed have varied
widely
: for Zadik’s
operation,
1% to 50% (Fowler
1958 ; Townsend
and Scott
1966 ; Andrew
and Wallace
1979); for segmental
excision
16% to 30%(Wal!ace,
Milne and Andrew
1979 ; Morkane,
Robertson
compared
and
and
Inglis
1984).
These
to the recurrence
rates after
phenolisation
(studies
shown
in the
present
1 and 2). Other
reports
low failure
rates
(3%
study
eight
six months
Robb
and
Hamer-Hodges
report
of 9%
and
5%
method
have also
(Cameron
1981;
Murray
1982;
Varma,
Kinninmonth
1983).
However,
in wider
practise
and
the
results
may be worse,
as was suggested
by a three-year
retrospective
audit of the treatment
of ingrowing
toenails
in a general
hospital
where
the
responsibility
for
treatment
of patients
was often
delegated
to inexperienced
junior
staff (Greig
1989).
Their
recurrence
rate
after total avulsion
and phenolisation
was 53%, although
only half the recurrences
were
symptomatic.
Issa and
Tanner
(1988)
showed
that combined
wedge
resection
and
segmental
ablation
alone.
The reasons
have
included
phenol
ablation
for
recurrence
: failure
to
remove
was
better
after
all
than
phenol
nail
phenol
2, symptomatic
and
12 months.
should
We
therefore
suggest
fragments,
particularly
in the angular
fold ; the use of insufficient
phenol,
or for too short
a time ; inadequate
control
venous
ooze ; inappropriate
postoperative
footwear.
meticulous
attention
is paid to technique
and good advice
is given
to the patient,
recurrences
can be minimised.
Postoperative
infection
did not predispose
to recurrence.
The management
of recurrent
ingrowing
toenails
has received
little
attention
though
it is so common.
VOL.
73-B,
No. 1, JANUARY
1991
of
If
pheno!isation
patients
had
,
after
the operation,
dystrophic
Follow-up
and
nails
developed
in this type of
be for at least one year.
that nail edge excision
with
in
after
study
phenolisa-
treatment
for ingrowing
treatment
has failed
and
has followed
a previous
the medical
and nursing
staff of Hairmyres
Royal
Infirmary
for their
co-operation
in
to Miss E. Anderson
for statistical
analysis.
form
have
been
received
or will be received
related
directly
or indirectly
to the subject
of
REFERENCES
Anderson
JH,
Greig
JD,
prospective
study
of
toenails.
J R Coil Surg
Andrew
T, Wallace
controlled
study.
Ireland
AJ,
Anderson
nail bed ablation
for
Edinb
l990:in
press.
WA.
Nail
Br MedJ
: an evaluation
Fowler
AW. Excision
of the germinal
matrix
embedded
toe-nail
and
onychogryphosis.
45:382-7.
Greig
JD.
[Br]
Issa
MM,
Tanner
WA.
Approach
resection/segmental
phenolization
Surg 1988; 75:181-3.
Results
of surgery
1989; 71-B :859.
Morkane
AJ,
ingrowing
71 :526-7.
Robertson
toenails
Bedi BS. The
surgical
1975; 62:409-12.
JE, Murray
WR.
ingrowing
toenails.
Sykes
PA. Ingrowing
toenails
Edinb 1986; 31 :300-4.
Townsend
Bone
Varma
AC,
Joint
Scott
PJ.
Surg [Br]
to
Ingrowing
1966; 48-B
of two
toenails.
ingrowing
combination
cauterise?
A
treatments.
Br
treatment
for
Surg
1957-58;
J Bone
Joint
toenails
: the
treatment.
management
in the
27:236-9.
for critical
toenail
:354-8.
of ingrowing
appraisal?
and
of
1984;
toenail.
management
of
J R Coil
Surg
onychogryphosis.
JS, Kinninmonth
AWG,
Hamer-Hodges
DW.
Surgical
excision
versus
phenol
wedge
cauterisation
for ingrowing
a controlled
study.
J R CoilSurg
Edinb
1983 ; 28:331-2.
Wallace
WA, Milne
DD, Andrew
T. Gutter
toenails. Br MedJ
1979; ii:168-171.
Surg
wedge
Br J
GS. Segmental
phenolization
controlled
study.
Br J Surg
Phenol
cauterization
Scott Med J 1982;
: time
or
: a unified
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RW,
Inglis
: a randomized
Robb
JR.
A randomised,
recurrent
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1979 ; i :1539.
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PF. Ingrowing
toenails
MedJ
1981 ; 283 :821-2.
Murray
WR,
BrJSurg
ablation
rate
disfiguring.
(Anderson
et a! 1990).
1 34% of the recurrences
or more
figures
should
be
nail edge excision
of the
to 25%)
recurrence
excision
and
how
many
for multiple
recurrences
In group
2 of our study
The authors
wish to thank
Hospital
and
Glasgow
supporting
this study and
No benefits
in any
from
a commercial
party
this article.
alone
contra-
a second
or failed
to exclude
them
1981 ; Robb
and Murray
that neither
should
be
excision
is
after
are often
operations
(Cameron
tion is a logical
and effective
toenails
in which
conservative
for those
in which
recurrence
surgical
procedure.
avulsion
nor nail edge
unless
phenolisation
higher
procedures
is similar
to that
reported
by him.
Nail
edge
excision
alone
has been
advocated
because
it can be performed
without
local
anaesthesia
and
was said
by Cameron
(1981)
to have a lower
recurrence
rate (39%).
However,
we found
it no better
than nail avulsion.
We recommend
simple
practised
that
1982 ; Varma
et a! 1983).
The importance
of adequate
primary
treatment
is emphasised
by the high failure
rate
(47%) reported
after total nail bed excision
and phenol-
happened
of orthopaedic
Bedi
133
Previous
studies
of nail
have
either
failed
to
isation
DISCUSSION
TOENAILS
treatment
for
J
wedge
toenail:
ingrowing