Surgical Nail Intervention Techniques Comparison

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5th Oct 2017 Health Reference this

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Introduction

Critical appraisal is a methodical progression through which the strengths and weaknesses of a research study can be acknowledged. This progression enables the reader to gauge the study’s worth and whether its conclusions are dependable. The most significant element of critical appraisal is attentive appraisal of the study design; however, other steps, such as evaluation of the statistical methods used, interpretation of the findings and possible conflicts of interest are also important. Finally, reflection of the importance of the research to one’s own patients will help clinicians recognise the most relevant, high-quality studies available to monitor their own clinical practice

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In nail surgery, the hallux is typically involved; however surgery may also include the lesser toes (DeLauro 2004). Nail surgery may be accessed for an assortment of pathologies; onychocryptosis, an ingrowing nail being the most common; the patient can develop a tender and draining lesion, along with the formation of granulation tissue at the side of the pierced skin (Heidelbaugh 2009); onychogryphosis or onychomycosis. Any of these indicators can cause a great deal of distress, and they often have an influence on everyday activities experienced by the patient (Yang 2008).

Surgical nail interventions intend to eradicate the troublesome portion of the nail (in combination with matrix obliteration), thus, relieving symptoms and hopefully averting regrowth of the bothersome nail.

Surgical nail interventions are most likely to be of use when the ingrowing toenail is at a more severe stage of development (stage II and stage III).

There are variations of different surgical nail interventions. Virtually every surgical nail intervention aims to remove the bothersome part of the nail and destroy the underlying matrix so that there is a slight risk of recurrence. The techniques used nowadays are mostly modifications of the techniques originally described by Winograd, Zadik, and Ross (Ross 1969; Winograd 1929; Zadik 1950). The terminology in the classification of the surgical nail interventions is based on the description of the technique, instead of the names of the inventor of the technique.

Table 1 shows technique and combinations of techniques which are used as surgical nail interventions.

 

Description of Technique

Known as

1

Radical excision of the nail fold

‘Vandenbos’ procedure

2

Rotational flap technique of the nail fold

Unnamed

3

Wedge excision, wedge segmental excision, or wedge resection

  • combined with application of a caustic liquid, like phenol or sodium hydroxide

‘Winograd’ procedure

4

Total nail avulsion (TNA)

  • combined with total (chemical or surgical) excision of the matrix

‘Zadik’ procedure

5

Partial nail avulsion (PNA)

  • combined with surgical (partial) matricectomy
  • combined with chemical (partial) matricectomy with phenol or sodium hydroxide
  • combined with physical matricectomy electrofulguration

‘Ross’ procedure

Table 1: Surgical Nail Intervention Techniques

Study

Method

Intervention

Outcome

Participants

Anderson 1990

Randomised Control Trial

A: Zadik (n17)

B: Phenol and Zadik (n14)

  1. Symptomatic recurrence
  2. Total recurrence after 12 months
  3. Postoperative infection after 1 month
  4. Participant satisfaction

Total 31

(A/B 17:14 Ratio)

Arista 2006

Randomised Control Trial

A: Partial lateral matricectomy and phenol cauterization n(17)

B: Partial lateral matricectomy only (n16)

  1. Postoperative pain
  2. Time to heal

Total 33

(M/F Ratio 17:16).

Bos 2006

Randomised Control Trial

A: Partial nail avulsion (PNA) with excision of the matrix (n38)

B: PNA with excision of the matrix and application of antibiotics (n22)

C: PNA with application of phenol (n37)

D: PNA with application of phenol and application of antibiotics (n26)

  1. Recurrence after 12 months
  2. Infection after 1 week
  3. Regrowth/spike formation

Total 123, (M/F Ratio 72:45)

Flores 2006

Randomised Control Trial

A: surgical partial matricectomy (n17)

B: partial matricectomy with electrofulguration (n21)

  1. Postoperative pain intensity
  2. Postoperative oedema, secretion, and bleeding
  3. Healing time

Total 33

(A/B 17:21 Ratio)

Gem 1990

Randomised Control Trial

A: Chemical ablation with a 3-minute application of 80% phenol (n109)

B: Chemical ablation with a 2-minute application of 10% sodium hydroxide (n110)

  1. Recurrence
  2. Time to become pain free
  3. Healing time

Total 219

(A/B 109:110 ratio)

Issa 1988

Randomised Control Trial

A: phenol (n45)

B: winograd (n42)

C: phenol and Winograd (n53)

  1. Recurrence
  2. Pain duration first week
  3. Pain intensity (linear pain analogue scale)

Total 140

(A/B/C 45:42:53 Ratio)

Shaath 2005

Randomised Control Trial

A: Total nail ablation (n52)

B: Partial nail avulsion with chemical ablation by sodium hydroxide (n53)

  1. Recurrence
  2. Postoperative pain
  3. Number of dressings
  4. Return to normal shoe wear
  5. Return to normal activity and work

Total 105 (M/F Ratio 53:30)

22 were lost to follow up.

Table 2: Surgical Nail Interventions Study Critique Tool

In most nail surgery, the use of epinephrine with lidocaine is not recommended due to the probable risk of tissue necrosis resulting from prolonged vasoconstriction and extended wound healing due to tissue hypoxia. (Dauber et al 1994, Salasche 2005). The use of epinephrine is especially hazardous to patients with diabetes mellitus, elderly patients and in vascular insufficiency, or vasculitis and it should be avoided if possible.

Study

Reason for Exclusion

Aksahal 2001

Not a randomised control trial

Bostanci 2007

Participants were quasi-randomised (based on their attendance at the surgery unit)

Córdoba-Fernandez 2008

The follow-up period was shorter than 1 month.

Foley 1994

There was no obvious distinction between onychocryptosis and onychogryphosis

Herold 2001

Participants were quasi-randomised (based on their address).

Table 3: Characteristics of excluded studies.

Nail Surgery Pathway

Figure Proposed Nail Surgery Pathway

Conclusion

In the studies comparing a surgical nail intervention to a surgical nail intervention with application of phenol, the addition of phenol is probably more effective in preventing recurrence and regrowth. Because there is only one study in which surgical nail interventions in both study arms were equal and where the addition of phenol leads to better results, more studies have to be done to confirm these outcomes. A more invasive surgical intervention with application of phenol is likely to reduce the risk of recurrence more effectively than a less invasive surgical intervention with the application of phenol.

Postoperative interventions do not decrease the risk of postoperative infection or postoperative pain, or give a shorter healing time. This means that there is no evidence to give antibiotics to prevent postoperative infections.

References

Aksahal AB, Atahan C, Öztas P, Oruk, (2001) Minimizing postoperative drainage with 20% ferric chloride after chemical matricectomy with phenol. Dermatologic Surgery; 27:158–160.

Anderson JH, Greig JD, Ireland AJ, Anderson JR, (1990) Randomized, prospective study of nail bed ablation for recurrent ingrowing toenails. Journal of the Royal College of Surgeons of Edinburgh; 35:240–2. [Online] http://www.acps.edu.au/cms_files/ACPS%20Research%20Publications/Phenolisation%20nail%20matrix%20ablation.%20Historical%20profile%20and%20litreature%20review..pdf [Accessed 13/02/2015]

Arista GF, Merino JE, (2006) Onychocryptosis: study comparing postoperative period after partial lateral matricectomy vs partial lateral matricectomy with phenolisation Dermatología Revista Mexicana; 50(3):87–93.

Bos AMC, van Tilburg MWA, van Sorge AA, Klinkenbijl JHG, (2006) Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. British Journal of Surgery; 94:292–6.

Bostanci S, Kocyigit P, Gürgey E, (2007). Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatologic Surgery, 33:680–5.

Córdoba-Fernandez A, Rayo-Rosado R, Juarez-Jiménez JM, (2008) Platelet gel for the surgical treatment of onychocryptosis. Journal of the American Podiatric Medical Association; 98(4):296–301.

Dawber RP, Baran R, Berker D, (1994) Science of the nail: gross anatomy. Diseases of the Nails and their Management. Oxford, England: Blackwell Science; 1-34.

DeLauro T., (2004). Onychocryptosis. Clinics in Podiatric Medicine and Surgery 21: 617–630. [Online] http://www.hkcfp.org.hk/index.php/en/clinical-resource/452-past-issues/-september-2005/821-original-article-1 [Accessed 17/01/2015]

Flores AV, Merino JE, (2006) Partial matricectomy vs partial matricectomy with electrofulguration as a treatment for onychocryptosis Dermatología Revista Mexicana; 50(2):54–9.

Foley GB, Allen J, (1994) Wound healing after toenail avulsion. A comparison of Kaltostat and Melolin as postoperative dressings. The Foot; 4:88–91.

Gem MA, Sykes PA, (1990) Ingrowing toenails: studies of segmental chemical ablation (study 1). British Journal of Clinical Practice; 44:562–3.

Heidelbaugh, J., J., Lee, H., (2009). Management of the Ingrown Toenail. American Family Physician. 79(4): 303-308

Herold N, Houshian S, Riegels-Nielsen P, (2001) A prospective comparison of wedge matrix resection with nail matrix phenolization for the treatment of ingrown toenail. The Journal of Foot & Ankle Surgery; 40(6):390–5.

Issa MM, Tanner WA, (1988) Approach to ingrowing toenails: the wedge resection/segmental phenolization combination treatment. British Journal of Surgery; 75:181–3.

New College Durham (2014) POD 505 Podiatric Surgery: Surgical Diary; Pre-Op Assessment

Northumbria Healthcare Trust (2010) Surgical nail intervention Pathway of Care

Ross WR., (1969) Treatment of the ingrown toenail and a new anaesthetic method. Surgical Clinics of North America; 49(6):1499–1504.

Salasche SJ, (2005) Surgery. In: Scher RK, Daniel CR, eds. Nails: Therapy, Diagnosis, Surgery. Philadelphia, Pa: WB Saunders; 326-49. [Online] http://emedicine.medscape.com/article/1126725-treatment [Accessed 07/02/2015]

Shaath N, Shea J, Whiteman I, Zarugh A, (2005). A prospective randomized comparison of the Zadik procedure and chemical ablation in the treatment of ingrown toenails. Foot & Ankle International; 26(5):401–5.

Siegle RJ, Swanson NA, (1982) Nail surgery: a review. J Dermatol Surg Oncol. Aug 8(8):659-66.

Winograd AM. (1929) A modification in the technic of operation for ingrown toenail. Journal of the American Medical Association; 92(3):229–230. [Online] http://jama.jamanetwork.com/article.aspx?articleid=276625 [Accessed 11/01/2015]

Zadik FR, (1950) Obliteration of the nail bed of the great toe without shortening the terminal phalanx. The Journal of Bone and Joint Surgery; 32(1):66–7.

Introduction

Critical appraisal is a methodical progression through which the strengths and weaknesses of a research study can be acknowledged. This progression enables the reader to gauge the study’s worth and whether its conclusions are dependable. The most significant element of critical appraisal is attentive appraisal of the study design; however, other steps, such as evaluation of the statistical methods used, interpretation of the findings and possible conflicts of interest are also important. Finally, reflection of the importance of the research to one’s own patients will help clinicians recognise the most relevant, high-quality studies available to monitor their own clinical practice

In nail surgery, the hallux is typically involved; however surgery may also include the lesser toes (DeLauro 2004). Nail surgery may be accessed for an assortment of pathologies; onychocryptosis, an ingrowing nail being the most common; the patient can develop a tender and draining lesion, along with the formation of granulation tissue at the side of the pierced skin (Heidelbaugh 2009); onychogryphosis or onychomycosis. Any of these indicators can cause a great deal of distress, and they often have an influence on everyday activities experienced by the patient (Yang 2008).

Surgical nail interventions intend to eradicate the troublesome portion of the nail (in combination with matrix obliteration), thus, relieving symptoms and hopefully averting regrowth of the bothersome nail.

Surgical nail interventions are most likely to be of use when the ingrowing toenail is at a more severe stage of development (stage II and stage III).

There are variations of different surgical nail interventions. Virtually every surgical nail intervention aims to remove the bothersome part of the nail and destroy the underlying matrix so that there is a slight risk of recurrence. The techniques used nowadays are mostly modifications of the techniques originally described by Winograd, Zadik, and Ross (Ross 1969; Winograd 1929; Zadik 1950). The terminology in the classification of the surgical nail interventions is based on the description of the technique, instead of the names of the inventor of the technique.

Table 1 shows technique and combinations of techniques which are used as surgical nail interventions.

 

Description of Technique

Known as

1

Radical excision of the nail fold

‘Vandenbos’ procedure

2

Rotational flap technique of the nail fold

Unnamed

3

Wedge excision, wedge segmental excision, or wedge resection

  • combined with application of a caustic liquid, like phenol or sodium hydroxide

‘Winograd’ procedure

4

Total nail avulsion (TNA)

  • combined with total (chemical or surgical) excision of the matrix

‘Zadik’ procedure

5

Partial nail avulsion (PNA)

  • combined with surgical (partial) matricectomy
  • combined with chemical (partial) matricectomy with phenol or sodium hydroxide
  • combined with physical matricectomy electrofulguration

‘Ross’ procedure

Table 1: Surgical Nail Intervention Techniques

Study

Method

Intervention

Outcome

Participants

Anderson 1990

Randomised Control Trial

A: Zadik (n17)

B: Phenol and Zadik (n14)

  1. Symptomatic recurrence
  2. Total recurrence after 12 months
  3. Postoperative infection after 1 month
  4. Participant satisfaction

Total 31

(A/B 17:14 Ratio)

Arista 2006

Randomised Control Trial

A: Partial lateral matricectomy and phenol cauterization n(17)

B: Partial lateral matricectomy only (n16)

  1. Postoperative pain
  2. Time to heal

Total 33

(M/F Ratio 17:16).

Bos 2006

Randomised Control Trial

A: Partial nail avulsion (PNA) with excision of the matrix (n38)

B: PNA with excision of the matrix and application of antibiotics (n22)

C: PNA with application of phenol (n37)

D: PNA with application of phenol and application of antibiotics (n26)

  1. Recurrence after 12 months
  2. Infection after 1 week
  3. Regrowth/spike formation

Total 123, (M/F Ratio 72:45)

Flores 2006

Randomised Control Trial

A: surgical partial matricectomy (n17)

B: partial matricectomy with electrofulguration (n21)

  1. Postoperative pain intensity
  2. Postoperative oedema, secretion, and bleeding
  3. Healing time

Total 33

(A/B 17:21 Ratio)

Gem 1990

Randomised Control Trial

A: Chemical ablation with a 3-minute application of 80% phenol (n109)

B: Chemical ablation with a 2-minute application of 10% sodium hydroxide (n110)

  1. Recurrence
  2. Time to become pain free
  3. Healing time

Total 219

(A/B 109:110 ratio)

Issa 1988

Randomised Control Trial

A: phenol (n45)

B: winograd (n42)

C: phenol and Winograd (n53)

  1. Recurrence
  2. Pain duration first week
  3. Pain intensity (linear pain analogue scale)

Total 140

(A/B/C 45:42:53 Ratio)

Shaath 2005

Randomised Control Trial

A: Total nail ablation (n52)

B: Partial nail avulsion with chemical ablation by sodium hydroxide (n53)

  1. Recurrence
  2. Postoperative pain
  3. Number of dressings
  4. Return to normal shoe wear
  5. Return to normal activity and work

Total 105 (M/F Ratio 53:30)

22 were lost to follow up.

Table 2: Surgical Nail Interventions Study Critique Tool

In most nail surgery, the use of epinephrine with lidocaine is not recommended due to the probable risk of tissue necrosis resulting from prolonged vasoconstriction and extended wound healing due to tissue hypoxia. (Dauber et al 1994, Salasche 2005). The use of epinephrine is especially hazardous to patients with diabetes mellitus, elderly patients and in vascular insufficiency, or vasculitis and it should be avoided if possible.

Study

Reason for Exclusion

Aksahal 2001

Not a randomised control trial

Bostanci 2007

Participants were quasi-randomised (based on their attendance at the surgery unit)

Córdoba-Fernandez 2008

The follow-up period was shorter than 1 month.

Foley 1994

There was no obvious distinction between onychocryptosis and onychogryphosis

Herold 2001

Participants were quasi-randomised (based on their address).

Table 3: Characteristics of excluded studies.

Nail Surgery Pathway

Figure Proposed Nail Surgery Pathway

Conclusion

In the studies comparing a surgical nail intervention to a surgical nail intervention with application of phenol, the addition of phenol is probably more effective in preventing recurrence and regrowth. Because there is only one study in which surgical nail interventions in both study arms were equal and where the addition of phenol leads to better results, more studies have to be done to confirm these outcomes. A more invasive surgical intervention with application of phenol is likely to reduce the risk of recurrence more effectively than a less invasive surgical intervention with the application of phenol.

Postoperative interventions do not decrease the risk of postoperative infection or postoperative pain, or give a shorter healing time. This means that there is no evidence to give antibiotics to prevent postoperative infections.

References

Aksahal AB, Atahan C, Öztas P, Oruk, (2001) Minimizing postoperative drainage with 20% ferric chloride after chemical matricectomy with phenol. Dermatologic Surgery; 27:158–160.

Anderson JH, Greig JD, Ireland AJ, Anderson JR, (1990) Randomized, prospective study of nail bed ablation for recurrent ingrowing toenails. Journal of the Royal College of Surgeons of Edinburgh; 35:240–2. [Online] http://www.acps.edu.au/cms_files/ACPS%20Research%20Publications/Phenolisation%20nail%20matrix%20ablation.%20Historical%20profile%20and%20litreature%20review..pdf [Accessed 13/02/2015]

Arista GF, Merino JE, (2006) Onychocryptosis: study comparing postoperative period after partial lateral matricectomy vs partial lateral matricectomy with phenolisation Dermatología Revista Mexicana; 50(3):87–93.

Bos AMC, van Tilburg MWA, van Sorge AA, Klinkenbijl JHG, (2006) Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. British Journal of Surgery; 94:292–6.

Bostanci S, Kocyigit P, Gürgey E, (2007). Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatologic Surgery, 33:680–5.

Córdoba-Fernandez A, Rayo-Rosado R, Juarez-Jiménez JM, (2008) Platelet gel for the surgical treatment of onychocryptosis. Journal of the American Podiatric Medical Association; 98(4):296–301.

Dawber RP, Baran R, Berker D, (1994) Science of the nail: gross anatomy. Diseases of the Nails and their Management. Oxford, England: Blackwell Science; 1-34.

DeLauro T., (2004). Onychocryptosis. Clinics in Podiatric Medicine and Surgery 21: 617–630. [Online] http://www.hkcfp.org.hk/index.php/en/clinical-resource/452-past-issues/-september-2005/821-original-article-1 [Accessed 17/01/2015]

Flores AV, Merino JE, (2006) Partial matricectomy vs partial matricectomy with electrofulguration as a treatment for onychocryptosis Dermatología Revista Mexicana; 50(2):54–9.

Foley GB, Allen J, (1994) Wound healing after toenail avulsion. A comparison of Kaltostat and Melolin as postoperative dressings. The Foot; 4:88–91.

Gem MA, Sykes PA, (1990) Ingrowing toenails: studies of segmental chemical ablation (study 1). British Journal of Clinical Practice; 44:562–3.

Heidelbaugh, J., J., Lee, H., (2009). Management of the Ingrown Toenail. American Family Physician. 79(4): 303-308

Herold N, Houshian S, Riegels-Nielsen P, (2001) A prospective comparison of wedge matrix resection with nail matrix phenolization for the treatment of ingrown toenail. The Journal of Foot & Ankle Surgery; 40(6):390–5.

Issa MM, Tanner WA, (1988) Approach to ingrowing toenails: the wedge resection/segmental phenolization combination treatment. British Journal of Surgery; 75:181–3.

New College Durham (2014) POD 505 Podiatric Surgery: Surgical Diary; Pre-Op Assessment

Northumbria Healthcare Trust (2010) Surgical nail intervention Pathway of Care

Ross WR., (1969) Treatment of the ingrown toenail and a new anaesthetic method. Surgical Clinics of North America; 49(6):1499–1504.

Salasche SJ, (2005) Surgery. In: Scher RK, Daniel CR, eds. Nails: Therapy, Diagnosis, Surgery. Philadelphia, Pa: WB Saunders; 326-49. [Online] http://emedicine.medscape.com/article/1126725-treatment [Accessed 07/02/2015]

Shaath N, Shea J, Whiteman I, Zarugh A, (2005). A prospective randomized comparison of the Zadik procedure and chemical ablation in the treatment of ingrown toenails. Foot & Ankle International; 26(5):401–5.

Siegle RJ, Swanson NA, (1982) Nail surgery: a review. J Dermatol Surg Oncol. Aug 8(8):659-66.

Winograd AM. (1929) A modification in the technic of operation for ingrown toenail. Journal of the American Medical Association; 92(3):229–230. [Online] http://jama.jamanetwork.com/article.aspx?articleid=276625 [Accessed 11/01/2015]

Zadik FR, (1950) Obliteration of the nail bed of the great toe without shortening the terminal phalanx. The Journal of Bone and Joint Surgery; 32(1):66–7.

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