RU2579429C2 - Method for surgical treatment of ingrown nail of first toe - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to surgery. Method includes excising affected periungual roller tapered cut to periosteum. Using a pointed with a scalpel, making an incision from corner formed by eponychium and periungual roller 20° at an angle. Incision on lateral surface is extend to middle of finger axis. Second incision is made 4-6 mm inwards from corner of nail plate at an angle of 50°. Edges of incisions connect horizontal cut, running parallel to edge of nail plate so that unit removes tissue became hypertrophied periungual roller with hypergranulations, pyogranuloma and scars, depth of incision reaches periosteum of nail phalanx. Along nail plate shears excised subcutaneous tissue and scar tissue to form a groove, then carefully dissected tissue in wounds of distal angle. Two seams are made on distal and proximal wound angles, when applying sutures on distal and proximal angles of a lateral skin flap at edge of nail plate, while eliminating excessive soft tissues, which prevents growth of nail plate.

EFFECT: method enables to avoid recurrent disease, accelerates wound healing, prevents postoperative complications.

1 cl, 1 dwg, 1 ex

Description

Method for surgical treatment of ingrown toenail of the first toe

The invention relates to medicine, namely to surgery. An ingrown nail (unguis incarnates, ingrown toenail or onychocryptosis) is a complex pathological complex that occurs due to a number of reasons and is accompanied by a combination of morphological and functional changes in the nails of the toes, their matrices and soft tissues. An ingrown nail is one of the most common reasons for visiting surgeons on an outpatient basis - from 0.5 to 10% of patients (Skobelkin OK Treatment of an ingrown nail using a carbon dioxide laser / Skobelkin OK, Herzen A.V.// Surgery. - 1987. - No. 10. - P. 93-94; Permyakov PE Comparative evaluation of some methods of surgical treatment of ingrown toenails: Diss. Medical Sciences: 14.00.27 / P.E. Permyakov. - Astrakhan: [B. I.], 1999. - 112 p.).

Without adequate surgery, it is impossible to cure this pathology. The main reason for the unsatisfactory outcomes of most operations is that the methodology for their implementation is based on ingrained misconceptions regarding the etiology and pathogenesis of ingrown nails, according to which the nail seems to grow into the tissue of the lateral periungual ridges. In fact, the nail plate grows only in length, but its width is genetically determined (Meleshevich, A.V. Surgical treatment of ingrown nails: a guide for doctors / A.V. Meleshevich, M.V. Meleshevich. - Grodno: GOUT, 1993) .

The greatest application in the practical work of surgeons was found by surgical methods of treatment. There are about 75 types and modifications of operations, but most of them do not solve the problem of ingrown nails, and are often complicated by its repeated ingrowth. The most common operations include the following.

1. Operation Dupuytrena (G. Dupuitren 1847) - one of the most frequent and technically most simple operations. A complete removal of the nail plate with excision of granulation tissues is performed. Wound healing occurs after 7-10 days, a new nail plate fully grows after 4-5 months.

2. Bartlett's operation (R.W. Bartlett 1937): the skin and subcutaneous tissue to the nail phalanx with subsequent suturing on the edges of the wound defect are excised with two semi-oval cuts along the lateral surface of the affected periungual ridge. In this case, the roller pulls away from the edge of the nail plate.

3. The operation of Emmert-Schmiden (Emmert K., 1850; Schmiden V., 1927): produce a marginal resection of a 4-5 mm nail plate with excision of the matrix of the removed part of the nail and a semi-oval incision to excise a wedge-shaped flap of soft tissues and granulations. The edges of the wound bring together a bandage.

4. Operation Meleshevich (Meleshevich AV, Meleshevich MV, 1993): Finger skin and surrounding tissues are treated with a solution of iodine and alcohol. Conducted anesthesia according to Lukashevich solution of 1%. Novocaine. A trapezoidal resection of the periungual roller is performed: with a scalpel, a skin incision is made from the angle of the nail plate at an angle of 45 °, an incision is made from the proximal end of the lateral periungual roller at an angle of 30 °. The ends of the dissection of tissues are connected by a horizontal incision running parallel to the edge of the nail plate. The periosteum is excised to the periosteum. Subcutaneous tissue and granulation are excised along the nail plate with scissors to form a groove. Two stitches are applied. A new periungual roller is formed with a U-shaped suture: an injection is made from the side of the plantar surface, a puncture is made in the wound along the edge of the nail phalanx, then it is injected 1-1.5 mm from the edge of the lateral skin flap with the thread coming out onto the skin, then 4-5 mm a reverse injection is performed 1-1.5 mm from the edge of the lateral skin flap into the wound and then a puncture is made back to the plantar surface. After tying the ligatures on a small gauze ball on the plantar surface, the lateral skin flap moves under the edge of the nail plate. A second suture is applied to the distal corner of the wound.

disadvantages

1. U-shaped suture very often leads to necrosis of the edge of the newly formed periungual roller, which supports the inflammatory process in the wound.

2. A gauze ball on the plantar surface interferes with walking.

3. The trapezoidal incision made according to this technique does not remove the excess soft tissue in the region of the distal edge of the lateral periungual ridge.

4. The wound heals in the proximal corner of the wound for a long time.

The technical result of the proposed method for the surgical treatment of ingrown toenails of the first toe is that the skin is cut with a scalpel 4-6 mm inward from the angle of the nail plate at an angle of 50 °, then an incision is made from the proximal end of the periungual roller at an angle of 20 °, the edges of the cuts are connected by a horizontal cut parallel to the edge of the nail plate, the periungual roller is excised to the periosteum, the tissue is carefully removed in the area of the distal angle of the wound, one nodal suture is applied to the distal angle the wound and the second nodal suture at the proximal angle of the wound, while the lateral skin flap moves under the edge of the nail plate, and eliminate excess soft tissue, which interferes with the free growth of the nail.

The operation technique in our modification: the finger skin and surrounding tissues are treated with a solution of iodopiron and alcohol. Combination of conduction and infiltration anesthesia Sol. Lidocaini 2% - 2.0-4.0 ml on the affected side. On the main phalanx we impose a rubber tourniquet. With a pointed scalpel we make an incision from the angle formed by eponychia and the periungual roller at an angle of 20 °, extend the incision on the side surface to the middle of the axis of the finger. The second incision is made 4-6 mm inward from the angle of the nail plate at an angle of 50. The edges of the sections are connected by a horizontal incision parallel to the edge of the nail plate so that a hypertrophied periungual roller with hypergranulations, pyogranulomas and scars enters the block of removed tissues. The depth of the incision reaches the periosteum of the nail phalanx of the finger. Subcutaneous tissue and scar tissue are cut along the nail plate with scissors to form a groove, and the tissue is carefully dissected in the distal corner of the wound. Two sutures are applied to the distal and proximal corners of the wound (figure). When suturing the distal and proximal corners of the wound, the lateral skin flap moves under the edge of the nail plate. This eliminates the excess of soft tissues that interferes with the growth of the nail plate. Sutures are applied with an atraumatic needle with a 3/0 monofilament thread. The operation ends with the application of a dressing with an antiseptic (chlorhexidine, miramistin). On the day of surgery, we recommend rest, cold to the area of surgery, analgesics per os. The first dressing the next day: the dressing is thoroughly soaked with a weak solution of potassium permanganate, the wound is treated with 3% hydrogen peroxide, a dressing with an antiseptic is applied. Dressings are carried out daily. On day 3, we burn the wound along the edge of the nail plate with verrucacide solution. We remove the stitches for 6-7 days.

Disability is restored on the 7th-9th day.

With the simultaneous defeat of two periungual ridges on one finger, the operation is performed simultaneously from two sides. With simultaneous damage to the periungual ridges on different feet, the operation is performed first on the more affected finger. On the other hand, the operation is performed after 5-9 days.

As a result of the applied method, the following effect is achieved.

1. The edge of the newly formed okolonogtevogo roller is not exposed to necrosis due to the lack of pressure from the ligature thread.

2. After excision of the excess soft tissue in the region of the distal edge of the periungual nail, the forward-growing nail plate does not encounter an obstacle, which eliminates the recurrence of the disease.

3. Suturing the proximal corner of the wound contributes to faster healing of the wound.

4. The use of an atraumatic needle with a 3/0 monofilament thread prevents the onset of a “wicked” infection.

Clinical case:

Patient E. 54 years. Received November 6, 2013 with complaints of pain in the first toe of the left foot. The disease is 2 months old. On examination, there is edema and hyperemia of the lateral periungual roller with the growth of granulation tissue and purulent discharge. November 6, 2013, an operation was performed according to our method: the skin of the first finger and surrounding tissues were treated with a solution of iodopirone and alcohol. Combination of conduction and infiltration anesthesia Sol. Lidocaini 2% -3.0 on the affected side. A rubber band is applied to the main phalanx. A sharp-pointed scalpel made an incision from the angle formed by eponychia and the periungual roller at an angle of 20 °, the incision was extended to the side surface to the middle of the axis of the finger. The second incision was made 4 mm inwards from the angle of the nail plate at an angle of 50 °. The edges of the cuts are connected by a horizontal cut running parallel to the edge of the nail plate. A single block removed a hypertrophied periungual roller with hypergranulations and scars to the periosteum of the nail phalanx of the finger. After excision of the periungual roller, it was revealed that it covered the lateral edge of the nail plate by 5 mm, the angle of the nail plate on the affected side was cut obliquely. Subcutaneous tissue and scar tissue were cut along the nail plate with scissors to form grooves, and tissue was carefully dissected in the distal corner of the wound. Two sutures were laid with an atraumatic needle with a 3/0 monofilament thread on the distal and proximal corners of the wound with the lateral skin flap moving under the edge of the nail plate. Conducted daily dressings with a solution of chlorhexidine. 11/08/2013, cauterization of the wound along the edge of the nail plate with a solution of verrucacide was performed. The sutures were removed on November 12, 2013, there are no discharge in the area of the periungual roller. Discharged for labor from November 13, 2013. Re-examination of November 26, 2013. No complaints. The edge of the nail plate is free of soft tissues, there is no edema of the lateral periungual roller.

Claims (1)

A method for the surgical treatment of an ingrown nail of the first toe, including excising the affected okolonogtovy roller with a trapezoidal incision to the periosteum, characterized in that a pointed scalpel makes an incision from the angle formed by eponychia and okolonogtevogo roller, at an angle of 20 °, the incision is extended to the lateral surface to the middle of the axis , the second incision is made 4-6 mm inward from the angle of the nail plate at an angle of 50 °, the edges of the cuts are connected by a horizontal cut parallel to the edge of the nail plate in this way m, so that a hypertrophied okolonogtevy roller with hypergranulations, piogranulomas and scars enters the block of removed tissues, the depth of the cut reaches the periosteum of the nail phalanx of the finger, subcutaneous tissue and scar tissue are cut with scissors to form grooves, then the distal tissue is carefully dissected into the region two sutures are placed on the distal and proximal corners of the wound; when suturing on the distal and proximal corners, the lateral skin flap moves under the edge of of the nail plate, while eliminating the excess of soft tissues that interferes with the growth of the nail plate.

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