Partial Matricectomy with a CO2 Laser for Ingrown Toenail after Nail Matrix Staining

BACKGROUND: Ingrown toenail is a common nail disease that causes pain, discomfort, and difficulty in walking. It is treated with either conservative therapy or surgery. OBJECTIVE: To present a new surgical approach to ingrown toenail. MATERIALS AND METHODS: For 19 ingrown toenail borders of 14 toes in 14 patients (1 male and 13 females), the nail matrix was stained with methylene blue and then partial matricectomy was performed with a CO2 laser. RESULTS: There was no recurrence at 18 nail borders after a mean follow-up period of 13.4 months, whereas a spike grew at one border but caused no walking pain. No serious complications occurred. Cosmetic improvement was also satisfactory. CONCLUSIONS: Partial nail matricectomy with a CO2 laser after staining the nail matrix with methylene blue allows visual confirmation of the completeness of cauterization.     

Inherited Accessory Nail of the Fifth Toe Cured by Surgical Matricectomy

BACKGROUND: The inherited accessory nail of the fifth toe is a common condition in the Chinese population. OBJECTIVE: The objective was to demonstrate three lesions in two cases of inherited accessory nail of the fifth toe successfully treated with surgical matricectomy. METHODS: Under local anesthesia and use of tourniquet, the proximal nail fold was incised and the matrix of the accessory nail was exposed and then excised by scalpel surgery. The skin defect left after removal of the lesion was repaired with a rotation flap. RESULTS: Histopathologic examination of the surgical specimens revealed that the matrices of the accessory nails were completely extirpated. No recurrence was found 2 years after operation. CONCLUSION: The inherited accessory nail of the fifth toe was cured by surgical matricectomy.     

A new surgical technique for the correction of pincer nail deformity

BACKGROUND: Pincer nail is a rare deformity characterized by transverse overcurvature of the nail that increases distally. Many conservative and surgical treatment modalities have been recommended, but there is not a worldwide accepted technique for long lasting treatment of this deformity yet. PURPOSE: A new surgical technique for the treatment of pincer nail deformity is described. MATERIAL AND METHOD: In this procedure, after the osteophyte located on the dorsal surface of the distal phalanx is removed to provide a flat surface for the nail bed, the distal part of the nail bed is enlarged in a transverse direction by using a modified 5-flap z-plasty technique. Over 2 years, this technique has been performed on 15 toes in 8 patients. RESULTS: In all patients, the deformity was eliminated successfully with no recurrence in 2 years of follow up. The growing nail turned back into its natural form and all clinical signs and symptoms of the pincer nail deformity were relieved. CONCLUSIONS: Widening and flattening the nail bed provide a longlasting effective treatment of the pincer nail deformity with an excellent esthetic result. Pain and episodes of infection is relieved perfectly with this new technique.     

Avulsion and Partial Matricectomy with the Carbon Dioxide Laser for Pincer Nail Deformity

BACKGROUND: Pincer nail deformity is a common nail disorder that sometimes necessitates surgical intervention. A multitude of therapeutic modalities has been implemented to treat this condition. OBJECTIVE: To describe the use of the carbon dioxide laser in the successful treatment of pincer nail deformity. METHODS: This is a case report and literature review. RESULTS: A 63-year-old man was evaluated and treated with the carbon dioxide laser for a persistent pincer nail deformity. The patient tolerated the procedure well and had an acceptable surgical outcome. CONCLUSION: Pincer nail deformity may be successfully treated with the carbon dioxide laser, especially when a partial matricectomy is performed.     

Elastic intramedullary nail for treatment of extremity fractures in children

Objective： To assess the clinical therapeutic effects of elastic intramedullary nail on extremity fractures in children.
Methods： From June 2005 to March 2008, 40 children with extremity fractures were treated by elastic intramedullary nail, in whom femoral shaft fractures occurred in 26 cases, tibiofibular fractures in 8 cases, radial capitular fractures in 4 cases, ulnoradial fractures in 2 cases. All patients were treated by closed reduction and elastic intramedullary nail fixation. Results： All the fractures gained satisfactory reduction and healing. The average duration needed for fracturehealing was 1-2 months. Postoperative follow-up confirmed a sound functional recovery.
Conclusions： The elastic intramedullary nail is a minimally invasive and effective surgical approach for treatment of extremity fractures in children. It allows early functional exercises after operation and secures a satisfactory bone union and functional recovery.     

More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures

Despite several studies showing a higher incidence of peri-implant femoral fractures with the Gamma nail than with a sliding screw plate (SSP), the Gamma nail has remained the standard implant for trochanteric fractures in many hospitals. We recorded 921 trochanteric fractures in the city of Oslo during 2 years and compared the reoperation frequency in patients treated with the Gamma nail (n 379) and SSP (n 542). The distribution of age and gender in the two treatment groups was the same. 65 patients were reoperated on, several of them more than once. The only significant difference between the two surgical methods in complications leading to a reoperation was the frequency of femoral shaft fractures. 17 of the patients treated with the Gamma nail had a new femoral fracture postoperatively, compared to 3 of those with a SSP. The relative risk of another femoral fracture after surgery was 12 (95% CI: 2.7-52) if the surgical device was a Gamma nail compared to a SSP.The Gamma nail therefore can not be recommended as the standard implant for trochanteric fractures.     

More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures

Despite several studies showing a higher incidence of peri-implant femoral fractures with the Gamma nail than with a sliding screw plate (SSP), the Gamma nail has remained the standard implant for trochanteric fractures in many hospitals.

We recorded 921 trochanteric fractures in the city of Oslo during 2 years and compared the reoperation frequency in patients treated with the Gamma nail (n 379) and SSP (n 542). The distribution of age and gender in the two treatment groups was the same. 65 patients were reoperated on, several of them more than once. The only significant difference between the two surgical methods in complications leading to a reoperation was the frequency of femoral shaft fractures. 17 of the patients treated with the Gamma nail had a new femoral fracture postoperatively, compared to 3 of those with a SSP. The relative risk of another femoral fracture after surgery was 12 (95% CI: 2.7-52) if the surgical device was a Gamma nail compared to a SSP.The Gamma nail therefore can not be recommended as the standard implant for trochanteric fractures.     

More postoperative femoral fractures with the Gamma nail than the sliding screw plate in the treatment of trochanteric fractures

Despite several studies showing a higher incidence of peri-implant femoral fractures with the Gamma nail than with a sliding screw plate (SSP), the Gamma nail has remained the standard implant for trochanteric fractures in many hospitals. We recorded 921 trochanteric fractures in the city of Oslo during 2 years and compared the reoperation frequency in patients treated with the Gamma nail (n 379) and SSP (n 542). The distribution of age and gender in the two treatment groups was the same. 65 patients were reoperated on, several of them more than once. The only significant difference between the two surgical methods in complications leading to a reoperation was the frequency of femoral shaft fractures. 17 of the patients treated with the Gamma nail had a new femoral fracture postoperatively, compared to 3 of those with a SSP. The relative risk of another femoral fracture after surgery was 12 (95 % CI: 2.7-52) if the surgical device was a Gamma nail compared to a SSP. The Gamma nail therefore can not be recommended as the standard implant for trochanteric fractures.     

A New Surgical Therapeutic Approach to Pincer Nail Deformity

BACKGROUND: Pincer nail deformity (PND) is an important health problem that causes discomfort in daily life. Until now, some surgical and conservative treatment modalities were applied with success. However, there is still no consensus on the common and accepted form of treatment. OBJECTIVE: To present a new surgical therapeutic approach to PND. METHODS: Ten patients, four with bilateral and six with unilateral PND, were treated with a new surgical technique which is a combination of chemical matricectomy with phenol and nail bed repair. RESULTS: No recurrence was observed in any of the patients after 12-16 months follow-up. No serious complication was encountered. The cosmetic improvement was also marked and satisfactory. CONCLUSION: This new surgical approach was found to be effective and is presented as an alternative treatment modality for PND.     

微创甲母质刮除术治疗嵌甲性甲沟炎206例术后疗效调查

目的：采用减少创伤,清除仅与疾病有关的肉芽、甲板、甲母质(nail matrix,或甲基质onychostroma)等病变组织术式治疗嵌甲性甲沟炎,并随访评估疗效。 方法：2010年-2013年6月,门诊手术治疗206例嵌甲性甲沟炎患者。术中剪除病变侧甲板3-4mm,并刮除与之相关的甲母质,刮出炎性肉芽,术后换药。 结果 术后随访6月-2年,复发13例,术后3月复发人数最多,复发率6.3%,优良率：93.6% 结论：微创甲母质刮出术,创伤小,手术简单,疗效满意,建议推广。     

Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur

OBJECTIVES: To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures. DESIGN: A prospective, randomised controlled clinical trial with observer blinding. SETTING: A regional teaching hospital in the United Kingdom. PATIENTS: All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death. INTERVENTION: The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richard's-type sliding hip screw and plate (197 patients). MAIN OUTCOME MEASUREMENTS: The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year. RESULTS: The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59-3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6-9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year. CONCLUSIONS: The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.     

En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia

BACKGROUND: Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. OBJECTIVES: The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. METHODS: Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. RESULTS: Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). CONCLUSION: En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.     

Recurrent Ingrown Big Toenails Are Efficiently Treated by CO2 Laser

BACKGROUND: Surgery for onychocryptosis has a high rate of recurrence. OBJECTIVE: To evaluate CO2 laser partial matricectomy for recurrent onychocryptosis. METHODS: One hundred ninety-six consecutive patients (predominantly teenagers) previously unsuccessfully treated by surgery underwent CO2 laser for recurrent onychocryptosis. After a digital nerve block and a simple partial nail plate avulsion, the laser was used (5 W, defocused 2 mm beam in continuous mode) to vaporize the matrix, the lateral horn, and the lateral nail groove, including local granulation tissue if present. Follow-up was at least 12 months. RESULTS: Three hundred forty-four matricectomies were performed. Disease was mostly at stage II and III, with severe local infection in 24 cases (12.2%). All wounds healed in 21.9 +/- 3.2 days, with no postoperative local infection or prolonged exudative drainage. Onychocryptosis reoccurred in 5 of 344 treated margins (1.45%, average 15 months), all after primary bilateral matricectomy. Spicules in the lateral nail groove occurred in 14 of 344 treated margins (4%, average 5.9 months), mostly after primary bilateral matricectomy (7 cases) and in infected margins (8 cases). One patient developed a neuroma in the lateral nail groove. CONCLUSION: CO2 laser is effective for the treatment of recurrent onychocryptosis. Bilateral matricectomy and local infection seem to be the predisposing factors for recurrence and postoperative spicule growth.     

Protruded and nonprotruded subungual exostosis: Differences in surgical approach

Background:

In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis.

Materials and Methods:

Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a“fish-mouth” type of incision.

Results:

The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence.

Conclusions:

In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a “fish-mouth” type incision at the toe tip without an iatrogenic damage.     

Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).     

Surgical factors contributing to nonunion in femoral shaft fracture followingintramedullary nailing

Purpose: To explore the possible surgical factors related with nonunion in femoral shaft fracture following intramedullary nailing. Methods: We retrospectively analyzed totally 425 patients with femoral shaft fracture in level I urban trauma center, including 254 males and 171 females, with an average age of 37.6 (ranging from 21 to 56) years old. The inclusion criteria included: (1) traumatically closed fracture of femoral shaft, with preoperative films showing non-comminuted fracture, such as transverse fracture, oblique fracture or spiral fracture; (2) closed reduction and fixation with interlocking intramedullary nail at 3e7 days after trauma; (3) complete follow-up data available. The relationship between the following factors (fracture site, reduction degree, direction of nail insertion and nail size) and nonunion was studied. Results: The incidence of femoral nonunion was 2.8% in patients with closed simple fracture undergoing interlocking intrameduallary nailing, including 11 cases of hypertrophic nonunion. Nonunion was related significantly to distal fracture, unsatisfactory reduction and unreamed nail (p<0.05). There was no significant difference between antegrade nail and retrograde nail (p>0.05). Conclusions: Nonunion in femoral shaft facture following interlocking intramedullary nailing is related to fracture site, fracture reduction and nail diameter. The choice of reamed nails or unreamed nails depends on the fracture site and reduction degree.     

Surgical Treatment of Ingrown Toenail without Matricectomy

BACKGROUND Partial excision of the nail matrix (matricectomy) is generally considered necessary in the surgical treatment of ingrown toenail. Recurrences may occur, however, and poor cosmetic results are frequently observed.
OBJECTIVE The objective is to present a new surgical procedure for ingrown toenail with complete preservation of the nail matrix.
METHODS Twenty-three patients with ingrown toenail were included in this study. The surgical excision was performed 1 week after the completion of treatment of the initial infection. A large volume of soft tissue surrounding the nail plate was removed under local anesthesia. No matrix excision was performed.
RESULTS Short-term results were excellent. No recurrences or severe complications were observed during the minimum 12-months follow-up period. Cosmetic results were remarkable.
CONCLUSIONS Ingrown toenail results from the compression of the lateral nail folds on the nail plate. This study shows that ingrown toenail can be surgically treated without matricectomy. A large volume of soft tissue surrounding the nail plate should be removed to decompress the nail and reduce inflammation. Cosmetic results are excellent and superior to the classical Emmert plasty. Postoperative nail dystrophies and spicule formation are not observed. The main advantage of this surgical approach is the complete preservation of the anatomy and function of the nail to improve both therapeutic and cosmetic results.     

Silicone Gel Sheeting for the Management and Prevention of Onychocryptosis

BACKGROUND: Onychocryptosis, commonly referred to as ingrown nails, has many therapeutic alternatives for its management. Although mild cases can be treated conservatively, in severe cases, surgical treatment is preferred. Silicone gel sheeting is found to be effective in the treatment of hypertrophic scars and keloids. OBJECTIVE: To document the effectiveness of silicone gel sheeting in the management of patients with onychocryptosis and in the prevention of the recurrences by breaking the devil's circle, which usually took place after the surgical procedures used in the treatment of the onychocryptosis. METHODS: Fourteen patients were enrolled in the study. Entry criteria required the presence of slight (2 patients), moderate (2 patients), or severe (10 patients) onychocryptosis. The simple technique used in the study was the excision of the one-quarter part of the lesional side of the nail plate without excising the granulation tissue. After 24 hours, the silicone was placed on the granulation tissue and the exposed nail bed. Silicone gel sheet was bandaged loosely without applying any pressure. Patients entering the study were given detailed instructions in applying and using the gel for 12 hours during the daytime. The study lasted for 14 months and was composed of a treatment period of 4 months and a follow-up period of 10 months. The patients were evaluated every 2 weeks in the first month and then monthly. The change in thickness of granulation tissue was evaluated by comparing them with the baseline photographs and those taken at each visit. RESULTS: The management and prevention of onychocryptosis were achieved in 12 of 14 patients (85.71%). The silicone gel sheeting treatment was well tolerated except for an occasional transient exudation, which was resolved when the treatment was withdrawn. CONCLUSION: The results show that the new method that we used for the treatment of onychocryptosis is successful in reducing the thickness of the hypertrophic nail fold and prevents the recurrence of the condition during the regrowth of the nail plate by breaking the devil's circle. The advantage of this method is that it is not destructive to the nail matrix and the adjacent tissue.     

Surgical treatments for ingrowing toenails

Background: Ingrowing toenails are a common condition which, when recurrent and painful, are often treated surgically.Objectives: To evaluate the effectiveness of methods of the surgical treatment of ingrowing toenails.Search strategy: Electronic database searching (Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL) followed by investigation of reference lists of the papers identified from the initial search.Selection criteria: Any randomized (or quasi-randomized) controlled trial which compares one form of surgical removal of all or part of a toenail due to its impact on the soft tissues to another or others. Studies must have a minimum follow period of 6 months and aim to permanently remove the troublesome portion of the nail.Data collection and analysis: Data extraction was carried out independently by the two reviewers using a pre-derived data extraction form and entered into RevMan. Categorical outcomes were analysed as odds ratios with 95% confidence intervals.Main results:

• •Avulsion with phenol versus surgical excision
• •Phenolization combined with simple avulsion of a nail is more effective than the use ofmore invasive excisional surgical procedures to prevent symptomatic recurrence at 6months or more (OR 0.44 CI 95% 0.24–0.80)
• •Avulsion with phenol versus avulsion without phenol
• •The addition of phenol, when performing a total or partial nail avulsion dramatically reduces the rate of symptomatic recurrence (OR 0.07 95% CI 0.04–0.12). This is offset byasignificant increase in the rate of post-operative infection when phenol is used (OR5.69 95% CI 1.93–16.77)

Conclusions: The evidence suggests that simple nail avulsion combined with the use of phenol, compared to surgical excisional techniques without the use of phenol, is more effective at preventing symptomatic recurrence of ingrowing toenails. The addition of phenol when simple nail avulsion is performed dramatically decreases symptomatic recurrence, but at the cost of increased post-operative infection.