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A New and Simple Suture Technique After Ingrown Toenail Surgery

Uygur, Esat MD

doi: 10.1097/BTO.0000000000000051
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Ingrown toenails are frequently encountered in clinical orthopedic practice. It mostly occurs in young people; therefore, it may cause a huge workforce or school-day loss. Numerous surgical techniques have been described as the treatment of ingrown toenail, and the Winograd technique is a reliable procedure since first described at 1929. This paper presents a new and simple suture technique after the Winograd procedure for ingrown toenail. With this technique, I claim low rates of recurrence, and better and satisfactory cosmetic results. In this technical report; excision of the partial nail bed and lateral nail fold, including the inflammatory granulation tissue, is described. Through this procedure, maintaining skin fold under the nail is detailed aiming to reduce recurrence rates.

Orthopaedics and Traumatology Department, Göztepe Research and Training Hospital, İstanbul Medeniyet University, İstanbul, Kadiköy, Turkey

The author declares that there is nothing to disclose.

Address correspondence and reprint requests to Esat Uygur, MD, Doktor Erkin Cad. Göztepe Eğitim ve Araştirma Hastanesi, 34732 Kadiköy-İstanbul, Turkey. E-mail: esatuygur@gmail.com.

Ingrown toenails are frequently encountered in clinical orthopedic practice. It mostly occurs in young people; therefore, it may cause a huge workforce or school-day loss.

Numerous surgical techniques have been described as a treatment of ingrown toenail; however, Winograd technique is a reliable procedure since first described at 1929.1

This paper presents a new and simple suture technique after Winograd procedure for ingrown toenail. This technique prospects lower rates of recurrence and better and satisfactory cosmetic results.

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SURGICAL TECHNIQUE

Surgical interventions are suggested to be performed under local proximal digital block anesthesia procedure. An elastic tourniquet is placed around the toe to obtain an exsanguinated toe and clear surgical view.

The Winograd procedure is performed first. A vertical incision is made along the border of the nail. On the ingrown side, 3 to 5 mm of the lateral side of the nail is cut longitudinally by a blade and then a wedge-shaped soft tissue including the whole infected granulation is removed along with the nail. The incision is lengthened 2 to 3 mm proximally. After nail matrix is excised, the cortex over the distal phalanx is removed by a curette.

After the procedure, closure of the wound is performed as detailed below:

  • The 2/0 polypropylene (Prolene) needle is firstly sticked into the dorsum of the nail corpus, leaning toward the wound (Fig. 1).
  • The needle exits at the lateral border of the nail fold (Fig. 1).
  • The needle is resticked from the wound into the nail leaning superiorly after surrounding the skin fold (Fig. 2). The most important part of the suture technique is surrounding the skin fold with suture. This maneuver maintains the skin fold to settle down under the nail corpus.
  • The suture ends are tied up, at the dorsum of the nail corpus (Fig. 3).
  • Wound closure (Fig. 4).
FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

FIGURE 4

FIGURE 4

Compression bandage is applied on the toe. Nonsteroidal anti-inflammatory drugs, elevation, and antibiotics are given after surgery for 3 days. Suture is removed after two weeks.

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DISCUSSION

Ingrown toenail, or onychocryptosis, is a common problem worldwide. Patients suffering from ingrown toenails are usually at their second or third decade of life. It means that complaints of the patients including painful toes, purulent drainage, and painful walking cause a vast workforce or school-day loss. Therefore, surgical treatment must be early recovering and must have low recurrence rates.2

There is no consensus on the best operative technique for the treatment of ingrown toenails. The recurrence rates for surgical approaches range between 1.7% and 27%. Besides none of these techniques achieve good cosmetic results.3 Chemical matricectomy with phenol is an alternative, with a recurrence rate of only 5%. However, postoperative infections were more frequently observed, and some alcohol burns were reported.4

Operative techniques include partial nail avulsion or complete nail excision with or without partial matricectomy. However, the high recurrence rate has been an unsolved problem.3

The Winograd technique is a classical surgical procedure for ingrown toenails.1 It consists of partial nail plate excision and subjacent growth-center destruction. In this technical report, both of the partial nail bed and inflamed lateral skin fold excision procedures are performed. After this procedure a different suture technique is performed, which leans the skin fold under the nail. In this way reducing recurrence rates is aimed.

To let the drainage of the exudates, closing the wound at the middle by a sole stitch is recommended.

In summary, this suture technique is simple, safe, and effective. It has very short learning curve. Therefore, it is also effective in untalented hands. The most important advantage of this technique is low recurrence rates due to remaining of the lateral fold lower than the side of the nail. Moreover, it has satisfactory cosmetic and comfortable results as removing the suture located on the nail corpus is less painful than the one located at the lateral nail fold. If the stitch knot is left at the lateral nail fold it gets into healing scar, which makes it more difficult and painful to remove.

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REFERENCES

1. Richardson EGCanale ST, Beaty JH. Disorders of nails and skin. Campbell s Operative Orthopaedics. 2008:Vol. 4, 11th ed.Philadelphia:Elsevier;4765.
2. Imai A, Takayama K, Satoh T, et al.. Ingrown nails and pachyonychia of the great toes impair lower limb functions: improvement of limb dysfunction by medical foot care. Int J Dermatol. 2011;50:215–220.
3. Aydin N, Kocaoglu B, Esemenli T. Partial removal of nail matrix in the treatment of ingrowing toe nail. Acta Orthop Traumatol Turc. 2008;42:174–177.
4. Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. 2005;2:CD001541.
Keywords:

ingrown toenail; Winograd procedure; suture technique

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