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

Overview Etiology of IGTN & other nail pathology Review of P&A procedure & phenol Surgical considerations Various procedures available Complications of nail surgery to consider

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 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)

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

Onychogryphosis Observational diagnosis Hard but often brittle

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

Onychauxis Etiology Diabetes Psoriasis PVD Subungual exostosis Hereditary Acromegaly Infection Genetic: Darier’s Disease Chronic disorder : Pityriasis Rubra Pilaris

Incurvated Ingrown Toenail Bony exostosis Congenital

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?

Why 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

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 Syme’s amputation Vandenbos Plastic remodelling

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)

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

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)

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

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

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 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 Safety 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?

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

What is this? What would you do?

Osteochondroma Tuft versus Shaft Subungal Exostosis

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

Subungal Exostosis or Osteochondroma ? Bone versus cartilage

Saucerisation

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

Winograd Procedure When ? Ungelabia or when excessive tissue needs to be removed Revisional surgery after failed previous procedure True WEDGE resection Indications : recurrent nail growth : hypertrophied ungualabia : sensitivity to phenol Contraindication : virgin IGTN with mild hypertrophy of ungualabia : presence of any sepsis More painful than P&A and narcotic(I.M./P.O.) pain relief may be needed Sutures are usually needed for 10 to 14 days

Inverted L or hockey stick incision

What are we seeing?

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

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

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

Total Matrixectomy 1 week post Operative 12 Months Post Operative

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

Terminal Syme = Removal nail + terminal phalanx Most often lesser toes Long toe Onychogryphotic nail + mallet toe Onychoclavus +/- long deformed toe Zadik’s - greater dissection. Wilson’s - shorter proximal incisions. Both usually require remodelling of distal tuft of distal phalanx in order to close the wound. This is due to tissue defect caused by excision of entire matrix. Often times a subungal exostosis is present and must be removed anyway.

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

Inclusion Cyst

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

Epidermal inclusion cyst 7 months post excisional matrixectomy Curettage Paronychia Pain Epidermal inclusion cyst

Failed previous nail procedures: [ Excisional matrixectomy ]

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)

The Vandenbos Procedure

Plastic Remodelling of nail lip Removal of excessive soft tissue

Periungual fibroma Multiple smooth, firm nodules formed at the PNF Often >10 mm in length May create a longitudinal groove in nail

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