SLR - June 2013 - Quinn T. Charbonneau
Reference: Perez CI, Maul XA, Heusser MC, Zavala A. (2013). Operative Technique with Rapid Recovery for Ingrown Nails with Granulation Tissue Formation in Childhood. Dermatol Surg. 39: 393-397.Scientific Literature Review
Reviewed by: Quinn T. Charbonneau, DPM
Residency Program: Massachusetts General Hospital, Boston, MA
Podiatric Relevance: Common in the pediatric and adolescent patient populations, onychocryptosis is a condition which causes chronic pain and inconvenience. There are many pre-disposing factors that may contribute to onychocryptosis, including hallux valgus, hyperhidrosis, hereditary predisposition, repetitive trauma, improper nail cutting, poor hygiene and inappropriate footwear. Typically this condition will not resolve without professional care. Both conservative and surgical treatment options are available, but recurrence rates are often unpredictable and can range from 2 percent to 73 percent. Wedge resection of the affected nail plate and phenol cauterization of the matrix has demonstrated a low recurrence rate but a significant incidence of postoperative wound colonization and infection, as well as cosmetic concerns. The authors of this study review a nail splinting technique utilizing a flexible tube secured to the nail plate using suture (FTSS) as treatment for onychocryptosis.
Methods: A retrospective descriptive study involving seventy-one pediatric patients under the age of 18 (46 male and 25 female) with Mozena stage 3 onychocryptosis (i.e. with granuloma formation) was conducted between July 2001 and July 2009 to evaluate FTSS in terms of the efficacy, recovery time and complications of the procedure. Patients with paronychia were treated with antibiotics pre-operatively. FTSS was performed by cutting the protective tube of a number 19 butterfly needle on one side and inserting this along the cryptotic nail edge, 1-2 mm below the eponychium and beyond the proximal nail fold. The tube was subsequently secured using one or two 4-0 nylon or silk sutures to the nail plate and kept in place for eight to twelve weeks. The procedures were performed under either local or general anesthesia. Patients were followed post-operatively for an average of thirteen months. Telephone survey or medical record reviews were utilized to obtain outcome data.
Results: Sixty-two of the seventy-one patients had resolution of their onychocryptosis with the FTSS procedure. Nine patients had recurrence within three months, ultimately achieving resolution – six with repeated FTSS and three with matrixectomy. All patients returned to school within 48 hours. Fourteen patients had complications, which included infection, loss of nail or tube, or need for additional procedures.
Conclusion: The FTSS technique is an effective, minimally invasive procedure for the treatment of onychocryptosis that carries lower risk of infection and nail plate narrowing than traditional surgical wedge resection. This procedure has advantages of early return to activity and good cosmetic outcome, and if unsuccessful, does not preclude patients from undergoing matrixectomy if later required due to recurrence.