Br. J. Surg. Vol. 62 (1975) 409-412

The surgical management of ingrowing toenail W . R . M U R R A Y A N D B. S. B E D I * SUMMARY

A retrospective review has been carried out on 200 randomly selected patients with ingrowing toenail in order to assess the surgical management and its results. There was a predominance of males between the ages of I 1 and 30 with an ingrowing toenail. Despite the high recurrence rate following simple avulsion of the toenail, its place irl the initial management of the condition is justifred. As regards more definitive surgery, total proximal nail bed ablation was jound to give the best results. Sepsis at the time of operation neither increased the recurrence rate nor caused severe postoperative sepsis. A surgical management policy for the treatment of ingrowing toenail is outlined and discussed.

AN ingrowing toenail complicated by pain and sepsis is a common condition often treated by chiropodists, general practitioners and casualty surgeons before being referred for a definitive treatment. The surgical treatment of this condition and the decision as to which form of treatment should be instituted are commonly left to relatively inexperienced junior surgical staff, who would welcome a clear-cut management policy. Unfortunately, this does not appear to exist for ingrowing toenails. Lloyd-Davies and Brill (1963) showed that conservative outpatient management gave good results. However, their policy requires a careful and timeconsuming follow-up by both the medical and nursing staff, combined with a high degree of patient cooperation. The aims of the present study were therefore first to review the management and success of treatment of patients with a diagnosis of ingrowing toenail seen at the Western Infirmary, Glasgow, and secondly to construct a workable management policy, which could be applied to all such cases in the future. Patients The case records of 200 patients with ingrowing toenails between 1966 and 1970 were randomly selected and reviewed retrospectively. Patients with a diagnosis of onychogryphosis were excluded from the survey. The surgical procedures used and reviewed in this survey were as follows: I . Simple avulsion of the toenail. 2. Wedge resection of the medial or lateral aspects of the proximal nail bed as described by Winograd (1 929). 3. Wedge resection of both medial and lateral aspects of the proximal nail bed by the technique of Winograd (1929).

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4. Total proximal nail bed ablation as described by Zadik (1950).

Results Epidemiology The survey showed that the condition of ingrowing toenail affects males (68.5 per cent) more commonly than females (31.5 per cent). Males in the second and third decades of life accounted for 56 per cent of the patients in this series, the male predominance continuing into the fourth decade after which the incidence of ingrowing toenail is similar for both sexes (Fig. 1). Of the 200 patients in this study, 143 patients had only one hallux affected, and in 138 patients the condition involved both lateral and medial nail folds concurrently. In the remaining 62 cases where only one nail fold was affected at presentation it was more commonly the lateral fold than the medial fold (Table I ) . Table I : DETAILS OF PATIENTS WITH INGROWING TOENAILS Patients Site of disease

No.

%

Single hallux Both halluces Both nail folds Lateral fold only Medial fold only

143 57

71.5 28.5 69.0 21.5 9.5

138 43 19

Table I[: RESULTS OF SIMPLE AVULSION OF THE TOENAIL AT THE SAME SITE Patients Recurrence rate No. of avulsions No. % (%) at the same site 1 95 65.5 64 2 35 24.1 86 3 15 10.4 80

Simple avulsion One hundred and forty-five patients (72.5 per cent) had been submitted to a t least one simple avulsion of the toenail, 70 per cent of these procedures being performed under a local anaesthetic and 30 per cent under a general anaesthetic. Table 11 shows that 65.5 per cent of the patients who had avulsion of the toenail had only one avulsion, 24.1 per cent had two avulsions a t the same site and 10.4 per cent had more than two avulsions at the same site. The recurrence rates of ingrowing toenails requiring further surgery in this group were 64 per cent following the first avulsion, 86 per cent following the second avulsion and 80 per cent after more than two avulsions. * Department of Surgery, Western Infirmary, Glasgow.

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W. R. Murray and B. S. Bedi Nail bed ablation One hundred and fifty-eight patients (79 per cent) in this series sooner or later had some form of nail bed ablation, 65 per cent of these having had a previous simple avulsion. Ninety-seven per cent of the nail bed ablation procedures were performed under a general anaesthetic and 3 per cent under a local anaesthetic. Table iil shows that the commonest operation used was total proximal nail bed ablation (60 per Table 111: RESULTS OF NAIL BED ABLATION PROCEDURES Nail Further Patients regrowth operation*

---

Surgical procedure

No.

Single wedge resection Double wedge resection Total proximal nail bed ablation

56 8 94

No:

”/,

No.

”/,

15 4 25

27

14 4 15

25

35 5 60

50 27

50

16

cent), with 35 per cent undergoing Winograd single wedge resection and 5 per cent having a Winograd double wedge resection. The recurrence rate or nail regrowth rate at the site of ablation was similar for total proximal nail bed ablation and single Winograd wedge resection at 27 per cent, but higher for Winograd double wedge resection at 50 per cent. When the patients who did not require a further surgical procedure are excluded, the symptomatic recurrence rate was found to be 16 per cent for total proximal nail bed ablation compared with 25 per cent for Winograd single wedge resection and 50 per cent for Winograd double wedge resection. Of the 33 patients with symptomatic recurrence requiring further surgery, 88 per cent were submitted to a total proximal nail bed ablation, with a recurrence rate of 34.5 per cent (Table I V ) . Ninety per cent of these recurrences were submitted to further total proximal nail bed ablation following which there were no recurrences.

* Symptomatic recurrence rate. Table IV: TREATMENT OF SYMPTOM4TIC RECURRENCE FOLLOWING NAIL BED ABLATION PROCEDURES Initial Droced ure SWR (56 patients) No.

%

DWR (8 patients)

No.

%,

TPNA (94 patients) No. X

Further ODeration 14 25 4 50 15 required Second procedure 3 9 1 3 29 Recurrence 0 0 Third procedure 0 0 9 Recurrence 0 0 0 SWR, Single wedge resection. DWR, Double wedge resection. TPNA, Total proximal nail bed ablation.

Sepsis Forty-five per cent of patients admitted for treatment of their ingrowing toenails had sepsis of the nail folds recorded at admission. Of the I58 patients submitted to nail bed ablation procedures, 28 per cent had sepsis present at the time of surgery. The sepsis had no effect on the rate of recurrence of ingrowing toenail.

16

88 34.5

Discussion The epidemiological findings in Table Z and Fig. 1 show that the sample studied was similar to previously reported groups of patients suffering from ingrowing toenails (Fowler, 1958; Lloyd-Davies and Brill, 1963; Townsend and Scott, 1966). The predominance of

200 Cases Male

Femalr

2nd

3rd

4t h

5th

61h

Age (decades)

Fig. 1. Age and sex distribution of the patients with an ingrowing toenail.

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7t h

8th

Ingrowing toenail males between the ages of I 1 and 30 (56 per cent of patients) must be regarded as an important factor in planning a management policy. A painful ingrowing toenail which is inefficiently treated and requires numerous visits to hospital could well have a significant detrimental effect on education, career prospects and recreational activities in this group. In this survey the recurrence rate of symptomatic ingrowing toenail following one avulsion was 64 per cent. However, cure is not the only aim of simple nail avulsion (Lloyd-Davies and Brill, 1963; Scott, 1968; Lepidus, 1972). The rapid relief of symptoms and the eradication of infection achieved by avulsion are important factors to be considered when contemplating the use of this treatment. For these reasons we feel that simple avulsion of the toenail has a definite place as a primary surgical procedure. Avulsion can easily be carried out on an outpatient basis under a local anaesthetic, unless infection has spread proximal to the interphalangeal joint, when a general anaesthetic should be used. The importance of explaining to the patient simple conservative care of the new nail as it grows has been stressed elsewhere, and a follow-up clinic visit at 6 months to assess the success of the treatment is advised (Lloyd-Davies and Brill, 1963). If the condition has recurred and is causing symptoms, then more definitive surgery is called for. Our results show that the recurrence rate after a second avulsion at the same site was 80 per cent and is so high that further avulsion alone has little to offer. Some form of nail bed ablation should therefore be advised. A second avulsion is only indicated to eradicate a persistent and severe infection and to relieve symptoms prior to a more definitive procedure in the next few weeks. It is very difficult to justify more than two simple avulsions at the same site. In this survey the commonest and most successful nail bed ablation procedure employed was total proximal nail bed ablation (Zadik, 1950), with a symptomatic recurrence rate of 16 per cent. This relatively high rate of recurrence is probably due in part to the lack of technical expertise of the junior surgical staff. Winograd single wedge resection gave a higher symptomatic recurrence rate of 25 per cent, but may nevertheless be justifiable when performed properly in patients whose symptoms and signs have always been localized to one nail fold and who are loath to forfeit the whole of the nail. The results of Winograd double wedge resection suggest that this procedure should be abandoned in favour of total proximal nail bed ablation, although a large number of cases would be needed to confirm this impression. Ninety-seven per cent of the nail bed ablations were performed under a general anaesthetic. This is a remarkably high figure when one considers that the anaesthesia for these procedures need be no greater than for a simple avulsion of a toenail, which is commonly performed under local anaesthesia. The use of local anaesthesia, sepsis permitting, allows satisfactory nail bed ablations to be carried out at an 30*

outpatient theatre session or on a day case basis, with minimal inconvenience to the patient and significant saving of the anaesthetist’s time. Fifty-five patients in our series were subjected to nail bed ablation without a previous avulsion of the toenail. It could be argued from our figures that approximately 20 of these patients would have regrown a normal nail if simple avulsion had been carried out as the initial surgical procedure. In cases of troublesome recurrence following any of the ablation procedures, a total proximal nail bed ablation was commonly performed (88 per cent of patients), with a recurrence rate of 34.5 per cent. Townsend and Scott (1966) have stated that repetition of total proximal nail bed ablation for recurrence often proves unsatisfactory and recommend the use of the Synies terminal amputation procedure as reported by ThomsonandTerwilliger( 1951), and found satisfactory by Rees (1964). Our results indicate that sepsis present at the time of a nail bed ablation procedure does not lead to an increased incidence of recurrence, as suggested by Townsend and Scott (1966). Moreover, the incidence of postoperative sepsis in our cases was surprisingly low and on no occasion was infection difficult to eradicate. The practice of performing a second avulsion on a recurrent septic ingrowing toenail 2-3 weeks before nail bed ablation, thereby rendering the nail bed clean, is, however, preferable to operating on a septic toe. This avulsion can be performed at the 6-month clinic visit or at a re-referral clinic visit and therefore does not unduly prolong the definitive surgery. The outline of our management policy for cases of ingrowing toenail referred to the surgical clinic is now as follows: 1 . Simple avulsion under local anaesthetic if there has been no previous surgical treatment. 2. Advice regarding conservative management of the new nail plus a 6-month clinic visit for assessment of the new nail growth. 3. Nail bed ablation under a local anaesthetic is advised for recurrent ingrowing toenails. 4. Septic recurrent ingrowing toenails are avulsed under local anaesthetic if possible and definitive surgery postponed for 2-3 weeks. The use of this policy as a broad outline should result in the majority of cases of ingrowing toenail referred to surgical clinics being treated with minimal delay and inconvenience to the patient. A greater awareness by the junior surgical staff of the problems involved in the treatment of this annoying condition may well lead to improved management in the future.

References

w. (1958) Excision of the germinal matrix: a unified treatment for embedded toe-nail and onychogryphosis. Br. J. Surg. 45, 382-387. LEPIDUS P. (1972) The ingrown toenail. B d l . Hosp. Joint Dis. 33, 181-192.

FOWLER A.

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W. R. Murray and B. S. Bedi and BRILL G. C. (1963) The aetiology and out-patient management of ingrowing toe-nails. Br. J . Surg. 50, 592-597. REES R. w. M. (1964) Radical surgery for embedded or deformed great toe-nails. Proc. R. Soc. Med. 57, 355-356. SCOTT P. R. (1968) Ingrown toenails. Med. J. Airsf. 1, 47-5 1. THOMPSON T. C. and TERWILLIGER C. (1951) The terminal Syme operation for ingrowing toe-nail. Surg. Clin. North Am. 31, 575-584. LLOYD-DAVIES R. W .

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c. and SCOTT R. R. (1966) Ingrowing toenail and onychogryphosis. J . Bone Joint Surg. (Br.) 48, 354-358. WINOGRAD A. M. (1929) A modification in the technique of operation for ingrown toe-nail. JAMA 92, 229-230. ZADIK F. R. (1950) Obliteration of the nailbed of the great toe without shortening the terminal phalanx. J. Bone Joint Surg. (Br.) 32, 66-67. TOWNSEND A.

The surgical management of ingrowing toenail.

A retrospective review has been carried out on 200 randomly selected patients with ingrowing toenail in order to assess the surgical management and it...
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