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 P&A 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
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)

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: Darier’s 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
Syme’s 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
Boberg et al. JAPMA (2002)
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
Hunter et al. Ann Emerg Med (1992)
Goslin . The Foot (1992)
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
Losa Iglesias et al. Derm surg (2008)
Lin et al. Burns (2006)
EPA (2002)
Sugden et al. Burns (2001)
Gilles et al. JAPMA (1986)

19. Phenol Safety PHENOL EZ SWABS Single use
1 cotton swab & ampoule containing 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
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

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
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.

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
Epidermal inclusion cyst

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 >10 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