Atlas of Primary Care Procedures, 1st Edition

Nail Procedures

30

Ingrown Nail Surgery

Ingrown nails, or onychocryptosis, is a common problem encountered in primary care practice. Individuals with ingrown nails often present in the second or third decades of life with pain, drainage, and difficulty walking. Many causes have been associated with the development of ingrown nails (Table 30-1). All of these causes alter the normal fit of the nail plate in the lateral groove, resulting in a foreign body reaction that produces edema, infection, and granulation tissue. Many ingrown nails exhibit a laterally pointing spicule of nail that digs into the lateral tissue.

TABLE 30-1. CAUSES OF INGROWN NAILS

 

Improperly trimmed nails or torn distal nails

Hyperhidrosis

Excessive external pressure from improperly fitting footwear or poor stance and gait

Trauma to the nail unit

Subungual neoplasms or skeletal abnormalities

Diabetes mellitus

Obesity

Nail changes of the elderly, including onychogryphosis and onychomycosis

 

Three stages have been described for the progression of ingrown nails. In stage I, the lateral nail fold exhibits erythema, mild edema, and pain when pressure is applied. In stage II, individuals experience increased symptoms, drainage, and infection. Stage III is characterized by magnified symptoms, the presence of granulation tissue in the lateral nail fold, and lateral wall hypertrophy.

Many management options have been proposed for ingrown nails. Soaks, topical or systemic antibiotics, and cotton wick insertion in the lateral nail groove have all been used for grade I disease. Surgical intervention is advocated for grade II and more often for grade III disease. Historically, simple nail avulsion or wedge resection of the distal corner of the nail has been performed. Because ingrown nails represent an abnormal lateral nail groove, removal of more than the lateral one fourth of the nail is unnecessary. High recurrence rates are associated with these simple nail excision procedures.

Matricectomy of the lateral nail matrix is required to permanently ablate lateral nail-forming tissue and to create a new lateral nail fold. Many physicians prefer to perform chemical matricectomy with sodium hydroxide or more commonly

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with phenol. Phenol produces adequate nail bed ablation, but it is associated with a pungent odor, lateral nail fold damage, excessive wound discharge, and infection. Electrosurgical ablation of the nail bed is a highly successful alternative that produces less discharge. Special matricectomy electrodes with one coated side can be used to avoid injury to the overlying normal tissue of the proximal nail fold (i.e., cuticle) while ablating the nail bed. Laser matricectomy is another option, but it is less attractive because of the high capital and upkeep costs for most primary care practices.

The granulation tissue produced by the foreign body reaction can produce lateral wall hypertrophy. Because this tissue is abnormal, many physicians advocate removal at the time of nail surgery. Removal of lateral wall hypertrophy can be accomplished with scalpel excision or with electrosurgical excision or ablation. Tissue removal can produce a scooped-out defect in the lateral tissue at the time of surgery. This defect fills in over several weeks as the remaining normal lateral tissue grows to the newly formed lateral nail edge.

INDICATIONS

  • Ingrown nail, grade II or grade III

RELATIVE CONTRAINDICATIONS

  • Diabetes mellitus
  • Peripheral vascular disease, especially if digital ischemia exists
  • Coagulopathy or bleeding diathesis
  • Uncooperative patient

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PROCEDURE

Notice the lateral wall hypertrophy with pus-filled drainage.

 

(1) An ingrown nail.

After digital block, some physicians prefer to place a tourniquet to limit bleeding during the procedure. A rubber band can be placed around the digit (toe) and held with a hemostat.

 

(2) A tourniquet can be applied to limit bleeding during the procedure.

PITFALL: Avoid pulling the rubber band too tightly and damaging the tissues. Limit the amount of time that the tourniquet is placed. It is advisable to withdraw the tourniquet after 10 minutes of application to limit vascular injury from interrupted blood flow to the digit.

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Free the lateral nail plate from the overlying proximal nail fold (i.e., cuticle.) A Freer septum elevator can be used to lift the cuticle off the nail plate.

 

(3) Lift the cuticle off the nail plate using a Freer septum elevator.

Remove the lateral one fifth to one fourth of the nail. Cut the nail with nail splitters or bandage scissors, placing the thin blade beneath the distal (free) edge of the nail (Figure 4A). Cut the nail straight back beneath the proximal nail fold (Figure 4B). As the proximal edge of nail is cut, a “give” is felt by the operator. Grasp the lateral nail with straight hemostats, and lift the nail out using a twisting motion that pulls outward and laterally (Figure 4C). After the nail has been removed, examine the lateral sulcus beneath the proximal nail fold to ensure no pieces of nail remain within the corner (Figure 4D).

 

(4) Remove the lateral one fifth to one fourth of the nail.

PITFALL: Grasp as much of the lateral nail in the hemostats before attempting withdrawal. If just the end of the nail plate is grasped, the nail frequently breaks on removal.

PITFALL: Avoid damaging the nail bed when cutting the nail plate. If the scissors are used, the blade placed beneath the nail plate can traumatize the nail bed. Advance the scissors by cutting just with the tips of the scissors, and angle the tips of the scissors upward away from the nail bed.

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Matricectomy can be performed chemically or electrosurgically, as demonstrated here. Place the electrode over the lateral nail bed with the Teflon-coated portion upward (Figure 5A). Activate the electrode for 3 to 10 seconds, gently bouncing the electrode against the nail bed to produce ablation of the tissue. Make sure the lateral horn of the matrix is ablated by moving the electrode laterally beneath the proximal nail fold (Figure 5B). A properly treated nail bed appears white after thermal ablation.

 

(5) Perform a matricectomy.

PITFALL: Avoid prolonged activation of the electrode against the nail bed. Prolonged burning can damage the deep tissues (i.e., extensor tendon insertion beneath the nail bed) and cause excessive time (months) to healing.

PITFALL: If the lateral horn of the matrix is not destroyed, a new spicule of nail will grow into the new lateral nail fold, with recurrence of symptoms in the months after the procedure.

The hypertrophied lateral tissue can be cut away or ablated with the electrode and scraped away with gauze (Figure 6A). After the tissue is removed, normal tissue remains. A large, scooped-out defect (Figure 6B) will rapidly fill in over the next few weeks. Place antibiotic ointment in the wound, and tape a bulky gauze dressing over the site. Disposable surgical slippers can be worn by the patient on leaving the office.

 

(6) Remove the hypertrophied lateral tissue.

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CODING INFORMATION

Code 11750 is most commonly reported when partial avulsion and matricectomy are performed for permanent nail removal. Although simple avulsion without matricectomy is not advocated, some practitioners continue to perform the technique and should report 11730 or 11730 and 11732.

 

CPT® Code

Description

2002 Average 50th Percentile Fee

 

11730*

Avulsion of a single nail plate, partial or complete, simple

$120

11732

Avulsion of each additional nail plate

$75

11750

Excision of nail and nail matrix, partial or complete

$345

11765

Wedge excision of skin of nail fold

$189

 

CPT® is a trademark of the American Medical Association.

   

INSTRUMENT AND MATERIALS ORDERING

The Freer septum elevator, bandage scissors or nail splitters, and hemostats are available from surgical supply stores or instrument dealers. Disposable surgical slippers are available from surgical supply houses. Matricectomy electrodes and electrosurgical equipment are available from Ellman International, Hewlett, NY (phone: 800-835-5355; http://www.ellman.com). A suggested anesthesia tray that can be used for this procedure is listed in Appendix G.

BIBLIOGRAPHY

Appenheimer AT. Treatment of ingrown toenail. Patient Care 1987;21:119–125.

Brown JS. Minor surgery: a text and atlas. London: Chapman & Hall, 1997:224–235.

Ceilley RI, Collison DW. Matricectomy. J Dermatol Surg Oncol 1992;18:728–734.

Clark RE, Madani S, Bettencourt MS. Nail surgery. Dermatol Clin 1998;16:145–164.

Clark RE, Tope WD. Nail surgery. In: Wheeland RG, ed. Cutaneous surgery. Philadelphia: WB Saunders, 1994:375–402.

Daniel CR 3rd. Basic nail plate avulsion. J Dermatol Surg Oncol 1992;18:685–688.

Gillette RD. Practical management of ingrown toenails. Postgrad Med 1988;84:145–146, 151–153, 156–158.

Hettinger DF, Valinsky MS, Nuccio G, et al. Nail matrixectomies using radio wave technique. J Am Podiatr Med Assoc 1991;81:317–321.

Leahy AL, Timon CI, Craig A, et al. Ingrowing toenails: improving treatment. Surgery 1990;107:566–567.

Onumah N, Scher RK. Nail surgery. Emedicine September 18, 2002. Available at http://www.emedicine.com/derm/topic818.htm

Quill G, Myerson M. A guide to office treatment of ingrown toenails. Hosp Med 1994; 30: 51–54.

Zuber TJ, Pfenninger JL. Management of ingrown toenails. Am Fam Physician 1995;52: 181–188.

Zuber TJ. Ingrown toenail removal. Am Fam Physician 2002;65:2547–2550, 2551–2552, 2554, 2557–2558.

Zuber TJ. Office procedures. The AAFP collection of quick reference guides for family physicians. Kansas City: American Academy of Family Physicians, 1998:123–130.