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Results of the Mogensen's Lateral Wedge Resection Technique in The Eklem Hastalıkları ve Cerrahisi Joint Dis Rel Surg Joint Diseases and Related Surgery Original Article / Çalışma - Araştırma 2007;18(3):116-120 Results of the Mogensen’s lateral wedge resection technique in the treatment of ingrown toenail Ayak tırnak batmasının tedavisinde Mogensen’in lateral kama rezeksiyon tekniğinin sonuçları Ercan Çetinus, M.D.,1 Murat Uzel, M.D.,1 Erkal Bilgiç, M.D.,1 Sezai Şaşmaz, M.D.,2 Özer Arıcan, M.D.,2 Ahmet Karaoğuz, M.D.1 Departments of 1Orthopedics and Traumatology, and 2Dermatology, Medicine Faculty of Kahramanmaraş Sütçü İmam University Objectives: There are many options for the treatment Amaç: Ayak tırnak batmalarında basit konservatif yak- of ingrown toenail, ranging from simple conservative laşımlardan, kapsamlı cerrahi girişimlere kadar birçok approaches to extensive surgical procedures, but stage tedavi seçeneği olmakla birlikte, evre 3 tırnak batmaları 3 ingrown toenails are best treated surgically. The aim en iyi cerrahi olarak tedavi edilmektedir. Bu çalışmada, of this study was to evaluate the results of lateral wedge ayak başparmağında tırnak batması olan bir grup hasta- resection described by Mogensen in patients with ingrown da, Mogensen tarafından tarif edilen lateral kama rezek- toenail of the great toe. siyon tekniğinin sonuçları değerlendirildi. Patients and methods: The study included 21 con- Hastalar ve yöntemler: Ayak başparmağında evre 3 secutive patients (11 females, 10 males; mean age 23±10 tırnak batması nedeniyle 21 ardışık hasta (11 kadın, 10 years; range 12 to 45 years) who were treated with the erkek; ort. yaş 23±10; dağılım 12-45) Mogensen’in late- Mogensen’s lateral wedge resection technique for stage 3 ral kama rezeksiyon tekniği ile tedavi edildi. Hastalara ingrown toenails. A total of 37 ingrown nail edges were 37 ayak parmağında cerrahi girişim uygulandı ve tır- treated and all were located at the lateral aspect of the nak batmalarının hepsi başparmağın lateral yüzündeydi. toe. Infection was present in five patients and granulation Lezyon yerinde beş hastada enfeksiyon, tüm hastalarda tissue was present in all the patients. Eight patients under- granülasyon dokusu vardı. Sekiz hasta daha önce başka went one or more unsuccessful surgical nail procedures at merkezlerde bir veya daha fazla cerrah girişim geçir- another center. Recurrences and satisfaction level of the mişti. Ortalama 34 aylık takip dönemi (dağılım 14-58 patients were evaluated during a mean follow-up period ay) sonunda tedavide nüks oranı ve hasta memnuniyeti of 34 months (range 14 to 58 months). değerlendirildi. Results: No significant complications occurred. In 35 Bulgular: İşlemle ilgili önemli komplikasyon görülmedi. procedures (94.6%), no recurrences were recorded and 19 Takip dönemi sırasında 35 girişimde (94.6%) nüks olgu- patients (90.5%) were satisfied with the treatment, with suna rastlanmadı. On dokuz hasta (%90.5), yakınmaların relief of their symptoms. Two lesions (5.4%) recurred in geçtiğini ve tedaviden memnun kaldığını belirtti. İki has- two patients (9.5%). tadaki (%9.5) iki lezyonda (%5.4) nüks görüldü. Conclusion: Lateral wedge resection technique is a Sonuç: Lateral kama rezeksiyon tekniği, evre 3 tırnak successful surgical treatment of stage 3 ingrown toenails, batmalarının tedavisinde düşük nüks oranları ve yüksek with a relatively low recurrence rate and high levels of hasta memnuniyeti nedeniyle tercih edilebilir başarılı bir patient satisfaction. yöntemdir. Key words: Hallux/surgery; nails, ingrown/surgery; recurrence. Anahtar sözcükler: Halluks/cerrahi; tırnak batması/cerrahi; nüks. • Received: April 13, 2005 Accepted: February 20, 2006 • Correspondence: Ercan Cetinus, MD. Kahramanmaraş Sütçü İmam Üniversitesi Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, 46050 Kahramanmaraş, Turkey. Tel: +90 344 - 221 23 37 / 364-226 Fax: +90 344 - 221 23 71 e-mail: [email protected] Results of the Mogensen’s lateral wedge resection technique in the treatment of ingrown toenail 117 Ingrown toenail, or onychocryptosis, is a common was applied to each side of the toe for adequate disorder. It usually affects the big toe, but may also anesthesia. A sterile rubber band was placed as a affect the lesser toes.[1] It can be a source of great digital tourniquet around the base of the toe for a discomfort since the nerve supply of the nail bed dry operative field. After five to ten minutes, lat- is so rich and the pain is severe. Ingrown toenail eral fourth of the nail plate was cut from the distal appears to have the highest incidence among the (free) end to the most proximal end of the nail root young (aged 30 or less) with a male predomi- using straight scissors. A linear incision was made nance.[2] Many possible causes of ingrown toenail parallel to the lateral nail fold, extending from 1 have been proposed, including excessive external cm proximal to the lunula to the hyponychium. pressure, trauma, poor foot hygiene, ill-fitting This incision was carried out till to the bone. A footwear, hyperhidrosis, obesity, and improper second incision was started 2 to 3 mm lateral to the nail-trimming techniques.[3] The ingrown nail plate inner edge of the lateral nail fold and was curved penetrates into the skin in the nail fold, creating obliquely at a 45-degree angle to the initial incision an entry for bacteria, which results in inflamma- to reach the lateral most margin of the germinal tion, infection, and hypertrophic granulation tissue matrix. This corner of the germinal matrix was formation.[4] exposed and removed. The periosteum on the matrix was removed, fat and subcutaneous tissues The aim of this study was to evaluate the results in the proximal corner were exposed to ensure of lateral wedge resection described by Mogensen[5] removal of the germinal matrix. Once the wedge in patients with ingrown toenail of the great toe. of the nail plate, matrix, and hypertrophic nail fold PATIENTS AND METHODS were removed, digital tourniquet was released and Between February 1999 and November 2002, 21 bleeding control was made. The incision was closed consecutive patients (11 females, 10 males; mean with 3-0 nylon mattress sutures and the wound age 23±10 years; range 12 to 45 years) with stage 3 was covered by an antibacterial ointment dressing ingrown toenail were treated with the Mogensen’s followed by a sterile compression wrap (Fig. 1). A lateral wedge resection technique. All ingrown total of 37 ingrown nail edges were treated with nails were located at the lateral aspect of the this technique. toe. Infection was present in five patients and Analgesics and cefuroxime axetil were pre- granulation tissue was present in all the patients. scribed for the postoperative period. The first dress- There was a history of fitted (tight) footwear in all ing was removed in the outpatient clinic after 24 the patients. Before presenting to our institution, hours. The wound was cleaned with normal saline eight patients underwent one or more (range 1-3, and antibacterial ointment was applied. Patients mean 1.5) unsuccessful surgical nail procedures were trained to change the dressing daily using (total avulsion of the nail) for onychocryptosis at the same technique. The sutures were removed two another center. All the patients were referred to the orthopedics clinic by the outpatient clinic of dermatology and were all treated by the first three authors. Patients having active infection at the site of ingrown toenail were treated with oral and topi- cal antibiotics for one week for complete regression of infection. Before treatment, informed written consent was obtained from the patient or parents. Surgical technique The patient was placed in the supine position, with the knees flexed and foot flat on the table. The toe was prepped with povidone-iodine solution. Using a 10-ml syringe and a 30-gauge needle, a standard digital block was performed with 4 ml physiologi- Fig. 1. Wedge resection of the nail, nail bed, and nail fold to cal saline (0.9% NaCl) mixed with 4 ml bupiva- include the nail matrix. The original illustration of Mogensen[5] caine 0.5%. About 3 ml of local anesthetic mixture was utilized for the production of this drawing. 118 Eklem Hastalıkları ve Cerrahisi - Joint Dis Rel Surg (a) (a) Fig. 2. (a) Preoperative and (b) 14-month follow-up views of the ingrowing toenail in the right foot. weeks postoperatively. Patient visits were sched- granulation tissue, and lateral nail-fold hypertro- uled weekly within the first month, and at 3 and phy. While conservative management is advocated 6 months. After 12 months, we evaluated recur- for stage 1 and stage 2 lesions, stage 3 ingrown rences and satisfaction of the patients by means of toenails are treated surgically. telephone interviews. The follow-up period ranged Stage 3 ingrown toenails can develop from a from 14 to 58 months (mean 34±14 months). laterally pointing spicule of nail beneath the nail RESULTS fold. Excision of the lateral nail plate combined with lateral matricectomy is believed to provide There were no significant complications during a the best option for eradication. In the treatment mean healing period of three weeks. In 35 proce- of stage 3 toenails, the associated granulation tis- dures (94.6%) no recurrences were recorded and 19 sue and lateral wall hypertrophy should also be patients (90.5%) were satisfied with the treatment removed. Among procedures commonly used are with regard to cosmetic aspects (Fig. 2, 3). These debridement of the lateral nail groove or trimming patients also reported improvement in their symp- of the lateral edge of the nail plate, incision and toms. Two lesions (5.4%) recurred in two patients drainage of abscesses of the lateral nail fold, nail (9.5%). They reported dissatisfaction. plate removal (partial or complete), wedge excision DISCUSSION of the lateral nail fold, partial nail matricectomy, complete matricectomy, and radical excision (Syme A three-stage classification has been proposed [8,9] [6,7] procedure).
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