Tırnak Batmalarının Tedavisinde Kama Şeklinde Çıkarımla Birlikte Yeni Bir Sütür Tekniğinin Sonuçları

Amac: Tirnak batmalarinda tirnak yataginin daraltilmasi ve yumusak dokudaki sisliklerin giderilmesi bircok cerrahi mudahalenin ortak noktasidir. Ancak bu cerrahi tekniklerin hicbiri tek basina cerrahi tedavide yeterli olmamaktadir. Bu calismada amac kama seklinde etraf yumusak dokuda eksizyon yapilarak tirnak yataginin daraltilmasi ve kalan yumusak dokularin ise yeni gelistirilen bir sutur teknigi ile yeniden tirnak yatagi olusturulmasini saglamaktir. Gerec ve Yontem: Calismamiza sinif 2-3 tirnak batmasi olan 52 hasta dahil edildi. Bu olgularin 12’sinde her iki ayakta ve 11’inde ise ayni ayakta tirnagin her iki tarafindatirnak batmasi mevcuttu. Toplam 64 ayaktaki 75 lezyon cerrahi olarak tedavi edildi. Nuks ve kozmetik memnuniyet acisinda sonuclar degerlendirildi. Bulgular: Hicbir hastada nuks gorulmedi ve tum hastalar kozmetik sonuclardan memnundu Sonuc: Yeni gelistirilen bu cerrahi teknigin tirnak batmasi tedavisinde cok etkili, mukemmel kozmetik sonuclar doguran alternatif bir yontem oldugunu dusunmekteyiz.


INTRODUCTION
Ingrown toenails are widely encountered among patients presenting to orthopedic, family medicine and dermatology outpatient clinics. Teenagers and young adults are mostly affected. The most common symptom is pain and difficulty in walking, which adversely affects patient quality of life. The pathology of an ingrown nail begins with the penetration of the lateral nail fold by the edge of the nail plate. This causes inflammatory responses, infections and granulated tissue formation (1). The primary cause of these conditions may be the nail plate itself or the bulky soft tissues of the lateral fold (2,3). The most common predisposing factors for ingrown toenails are poorly fitting shoes, improperly trimmed toenails, excessive sweating and nail infections (4,5).
Treatments of ingrown toenails differ according to the stage of the lesion, previous interventions, and recurrence of the lesion. Mild to moderate lesions with minimal erythema and no purulent drainage (Grade I-II) can be treated using conservative methods. Moderate to severe lesions (Grade II-III) and recurrent lesions with substantial granulomatous tissue and purulent drainage usually require surgical intervention (6,7). Surgical techniques in these cases are mainly based on either narrowing of the nail plate or the debulking of soft tissues. Although there are numerous reported surgical methods for treating an ingrown toenail, none of these procedures is sufficient alone to treat all types of such lesions. However, these techniques can result in delayed wound healing, a poor cosmetic result, and recurrence of ingrowth (8,9). Hence the surgical approach changes according to the type of pathology in these cases (2).
The aim of this study was to present the results of a new surgical wedge resection procedure for the treatment of an ingrown toenail and to compare other wedge resection techniques.

MATERIAL AND METHOD
Patients with an ingrown toenail that were seen as outpatients at University Hospital Departments of Orthopedics, Plastic and ReconstructiveSurgery and Dermatology were enrolled in the study. The study protocol was reviewed and approved by the ethics board of University and written informed consent was obtained from all patients. The surgical procedures were conducted by VU and MT. Lesions were evaluated according to the Heifetz staging system: grade I, swelling and erythema is present; grade II, additional wound drainage and infection is present; grade III, chronic inflammation, and granulation tissue formation is evident (10). Patients were classified according to this staging system. From March 2011 to February 2013, this study started with 61 patients, but the patients with nail fungal infections (n:5), diabetes mellitus (n:3), circulating problems (n:1) in the same extremity and patients who refused surgery were excluded from this study.Then, the study included 52 patientswith grade 2-3 ingrown toenails were operated on at our hospital Surgical technique and patient management Prophylactic intravenous cefazolin was infused 30 minutes prior to surgery. Local anesthesia was performed with a digital nerve block (1% lidocaine). Surgical latex gloves were cut and used as a digital tourniquet. A longitudinal incision was made to the nail plate beginning 5 mm proximally to the eponychium and 3-4 mm far from the edge of the nail plate. A number 15 blade was used, and the incision was extended down to the bone. The proximal part of the incision was continued 5 mm proximally with a 45-degree inclined line. The proximal and distal ends of the incision were connected by an elliptic incision that included a small amount of normal tissue from the lateral fold. The latter incision was curved obliquely at a 45degree angle to the initial incision to reach the most lateral margin of the germinal matrix ( Fig.  1). After the wedge excision, the lateral horn where the germinal matrix is most likely to remain was cauterized using a monopolar tip at a 40-V setting. The wound was closed with 3/0 cutting polypropylene suture materials. The proximal part was closed with one vertical mattress or a plain suture. The middle of the remaining lateral fold was attached to the nail plate by a new suture technique: the first bite was made at the surface of the nail plate. The needle was passed through the nail plate and emerged from the wound and subsequently from the corresponding lateral fold. (Fig. 2a, 2b) The tip of the needle was then reversed and passed through the skin to emerge just near the edge of the wound. (Fig.  2c) This enabled us to recreate the normal anatomical curve of the lateral fold. Finally, the last suture bite was made at the middle of the distance between the first suture bite and the edge of the nail plate. (Figure 2d) The sutures were then tied on the surface of the nail plate. The distal corner of the wound was closed with one normal suture. (Fig. 2e) The tourniquet was removed, and fusidic acid was applied topically. The dressing remained in place for 24 to 48 hours. Cefaclor Monohydrate (1500mg/day) was given orally for antibiotic prophylaxis over a 10-day postoperative period. Etodolac (800mg/day) was used for postoperative pain control. The sutures were removed at the end of the second week. The patients were initially followedup at one, three and six months after surgery and then at one subsequent visit.

RESULTS
The authors included 75 lesions from 64 big toes from 52 patients (40 male and 12 female) in our current study. Of these, 25 had grade 2 and 50 had grade 3 ingrown nails, and 12 cases involved bilateral toes, and 11 toes had bilateral lesions. Sixteen of the patients had previously undergone surgery for ingrown nails. Forty-five of these lesions with active drainage and infection were treated orally for 10 days with 2000 mg/day cefaclor monohydrate prior to surgery.The median age of the patients was 31 years (range, 20-48). Patients were followed up for 10 months (range, 6-24 months).At each follow-up visit, the subjects were examined for recurrence, infection. No recurrence or infection was detected in any subject, and none of the patients required additional surgery during the follow-up period. The patients were interviewed to express their postoperative term satisfaction. They asked to evaluate their satisfaction as "Excellent, acceptable, poor". Their answers were rated, and 50 patients were assessed the postoperative results as "excellent". However, 2 patients were assessed as "acceptable." All of the patients reported that pain was substantially reduced after surgery, and foot-related quality of life was increased. The majority of patients involved in the study were satisfied with the cosmetic results of our surgical treatment. Additionally the natural view of the nail and the lateral fold tissue (bulky) were evaluated by an independent dermatologist according to the postoperative pictures. Moreover, the dermatologist was asked to assess the results as "Excellent, acceptable, poor". The dermatologist reported the evaluation of the results 48 as excellent and 4 as acceptable.

DISCUSSION
The skill of the surgeon is a critical determinant of the outcome of all surgical procedures. The best treatment of ingrown toenails should be an effective, simple, inexpensive outpatient procedure with little postoperative discomfort and a rapid return to normal activities. Moreover, low complication and recurrence rates with acceptable cosmetic outcomes are of great importance (11,7). We believe that our technique covers most of these requirements. The anatomy of the nail matrix must be accurately determined, and all residue of the germinal matrix must be excised to prevent recurrence. In our novel surgical technique, the trapezoidal shape of the incision at the proximal side provided an excellent view of the germinal matrix and enabled us to remove it without any residue. Debulking of the lateral fold and our suture technique, which keeps the lateral fold under the nail plate, also contributed to the prevention of recurrence. Another aspect of our technique is that when the proximal part of the incision, which has a trapezoidal shape, is closed the lateral fold translates a little bit proximally. The distal corner of the lateral fold, which plays a significant role in the pathogenesis of an ingrown toenail, is thereby decompressed.
Plication of the skin with our suture technique contributed to the reconstruction of a normal anatomic convexity of the lateral fold that gave excellent cosmetic outcomes (Fig. 3). This technique is an easy surgical procedure and has several advantages, including no requirement for specific chemicals, or surgical tools and patients can resume work after the surgery. Various methods have been used to treat ingrown or pincer-like(curved) toenails, including taping (12), cotton wool packing, (13) gutter treatment (14) with a tube (15) and with or without formable acrylic (16) 32, 17). The common feature of these proceedings is a bloc resection of the lateral part of the nail plate, and its corresponding bed and matrix and conflicting results from these approaches have been reported in the literature. Huang JZ et al. (33) reported a study that they compared the Winograd technıque wıth the total nail plate avulsion tecnıque assocıated wıth wedge resectıon. They showed that there was not any sıgnıfıcıent dıfference between the two technıques from the aspect of recurrence. They stated that the Winograd technique was resulted with better cosmetic results. In our technique, the cosmetic results were satısfactory for both, the patient, and the surgeon. The sımultanous correctıon of the lateral naıl fold by wedge resectıon and the destructıon of the stem cells by cauterısatıon prevents recurrencıes. The naıl plate avulsıon technıque has an adverse effect over the life qualıty of the patıent and delays the beginning to the work. Thus, ıt ıs not a wıdely chosen technıque. The healing time is too short than then the techniques, so our technıque also shortens the return time back to daily life.  (36, 37), but a higher postoperative infection frequency is reported (38). In our current study series, no recurrences were detected during the follow-up period, and all patients were satisfied with the cosmetic results. We think that destructing the germinal matrix cells by monopolar cauterization or chemical matrix ectomy is associated with the absence of the recurrence. Good outcomes have also been reported for soft tissue debulking procedures (27, 28, 30, 34). Noel et al. reported a complete cure in 23 ingrown toenail patients treated with a vertical wedge shape resection procedure. The incision in that technique resembles the one we use in our new surgical method but includes only the soft tissue of the lateral fold without any part of the nail plate or matrix (30). In our technique, the excess tissue of lateral fold is removed. In the "Knot Technique" study of Ince B. et al.
(39), they use only the suspension force of suture. They resected only the tissue excess of the lateral fold without excising the in growing part of the germinal matrix at the lateral aspect of the nail. Then they suspend the lateral of the nail by suturing by monofilament polypropylene suture. The long-term recurrence is inevitable if there is a lack of germinal matrix resection at the lateral aspect of the ingrowth nail. Moreover, the monofilament sutures have a higher opening potential and tensile power reduction. In our study, the technique is depended on the restoration of the lateral nail tissue than the tensile strength of sutures. As a result, we achieve a flat surface for nail location. Rusmir et al. retrospectively reviewed the postoperative infection rate after toenail matrixectomy and found high rates of clean foot surgery. Routine antibiotic prophylaxis after surgery is, therefore, warranted (40). In our present study, no infection arose in any of our patient subjects during the postoperative period. The inadequate number of the patients and excluding the patients with comorbidities such as fungal infections, diabetes and peripheral vessel diseases due insufficient patient number are the limiting aspects of this study. Furthermore, the study includes only the healthy individuals. It is also a limiting factor the limiting factors of the study can be eliminated by increasing the number of the patients with and without comorbidities. In conclusion, our novel surgical procedure for an ingrown toenail is an alternative treatment approach that is very effective and produces excellent cosmetic results.