RU2720847C1 - Method for surgical treatment of ingrown nail - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to surgery. T-shaped wound is formed. That is ensured by excising a lateral periungual roller with a skin distal to the nail and an anterior skin elevation in front of the nail. Continuous suture, distally, sutures of nail are sutured, intradermal side edge is pierced and wound back edge is pierced. Skin is pierced opposite to the first suture, a lateral edge, nail ligaments are sutured intradermally intracutaneously and a lateral edge of the wound is pierced. Proximal and distal ends of the wound are sutured with an interrupted suture. Skin and skin edges are adjoined with a nail bed under a ledge of a nail plate and ligatures seams.EFFECT: method enables reducing the length of postoperative treatment, reducing the number of recurrent ingrown nails, providing the cosmetic effect of the operation.1 cl, 11 dwg, 1 ex

Description

The invention relates to surgery, namely, to methods for surgical treatment of ingrown toenails.

Two cuts excise the affected okolonogtevaya roller and excess skin at the end of the phalanx, a skin elevation in front of the nail plate. A T-shaped wound is formed. The first continuous suture from the level of the proximal okolonogtevogo suture stitch the ligaments of the nail on the proximal half of the length of the nail bed, intradermally the edge of the wound on the distal half of the length of the nail bed and pierce the skin of the posterior edge of the wound. A second continuous suture, opposite the beginning of the previous suture, pierces the skin into the wound lumen, the wound is sutured intradermally to the proximal half of the length of the nail bed, the ligament of the nail to the distal half of the length of the nail bed and the skin of the side edge of the wound. Impose one suture on the proximal and distal ends of the wound. Compare the edges of the skin and skin with the nail bed under the edge of the nail and ligate the stitches (11 il.).

The invention relates to medicine, namely to surgery. The invention is indicated for surgical treatment of an ingrown nail and with its relapse.

The ingrown nail of the first toe is a common disease with anatomical and inflammatory changes in the periungual nail. The disease is characterized by the introduction (ingrowth) of the edge of the nail into the lateral periungual roller, in which a chronic wound develops over time. Inflammation joins with serous, subsequently, and serous-purulent discharge. Hypergranulations and pain are formed in the distal phalanx of the finger.

We prefer surgery without resection of the lateral side of the nail plate. At the end of the operation, we compare the edges of the skin and the skin with the nail bed under a small protrusion of the nail plate.

After excision of the affected okolonogtevogo overhanging over the nail plate, a skin elevation in front of the nail plate, which rests on the distal end of the nail, is clearly defined on the longitudinal section of the wound. We called it "anterior skin elevation." During surgery without resection of the lateral side of the nail plate, we additionally excise the anterior skin elevation in view of its subsequent displacement to the newly formed okolonogtevogo roller, which is one of the causes of relapse of the ingrown nail. When excising the periungual roller, excess skin is removed distal to the free edge of the nail. And excision of the anterior skin elevation gives the wound a T-shape, which allows you to freely mobilize, anatomically compare, and atraumatically suture the edges of the skin and the skin with the nail bed under the edge of the nail plate.

The application of holes on the edge of the nail with the subsequent tightening of the applied ligatures can lead to eruption of the nail plate, its delamination. Vertical needle punctures with an injury to the edge of the nail bed, as well as with a strong impact on the nail, can form a subungual hematoma, which contributes to the deformation of the nail. Often, in the interval between the interrupted sutures placed on the nail, it is possible to slip the edge of the skin and place it above the nail plate. This can cause wound healing by secondary intention, its rough scarring and relapse of the ingrown nail.

Given these factors, we consider the optimal method of surgical treatment of ingrown nail without resection of the edge of the nail plate, including the following steps:

1) excision of the lateral okolonogtevogo roller and excess skin at the end of the distal phalanx;

2) excision of the anterior skin elevation;

3) suturing the wound without involving the nail plate;

4) the correct matching and fixing of the edges of the skin and skin to the nail bed.

A known method for the surgical treatment of ingrown nails is the operation of W. Schmiden (2), which consists in longitudinal edge resection of the nail plate from the ingrown side, departing from the edge of the affected okolonogtevogo 3-5 mm. The incision is continued by dissection of eponychium to 5 mm and deepened to the periosteum. The resected edge of the nail plate is twisted with a clamp and removed. Next, the wound edges are connected by an arcuate incision along the periungual roller. The resulting wedge-shaped flap is removed in a single block. The edges of the resulting wound are not sutured, but are brought together with a tight bandage.

During this operation, the non-sutured wound heals by secondary intention, which contributes to the risk of early purulent complications, frequent relapses of the disease and wound healing with poor cosmetic effect. Patient disability also lengthens.

A known method of surgical treatment of ingrown nail (1), which consists in the fact that the edge of the nail, the matrix and the affected periungual nail are excised. In this method, in the form of a wedge, the ingrown part of the nail plate with its root, matrix, nail groove and nail roll is removed with a single block, with the closure of the wound defect with two adaptive-screwing sutures with the formation of a new periungual roller. The method does not exclude relapse of the ingrown nail due to the likelihood of non-radical removal of the root of the nail plate and matrix, the formation of a rigid periungual roller, pressing on the nail plate.

An operation according to V. Schmiden with the help of a carbon dioxide laser in a modification of the Clinic named after V. Shmiden was adopted as a prototype for the surgical treatment of an ingrown nail. N.I. Pirogov (St. Petersburg) (3, 4), during which tissue is cut from the proximal interphalangeal joint to the middle of the fingertip vertically to the periosteum with the grip of 1 / 3-1 / 5 of the nail plate and the nail roll is tapered with a mandatory lateral grip growth zones (bed) of the nail. Cellulose, which enters the wound with pressure, is dissected, and connective tissue jumpers between the skin and periosteum are dissected to the required extent. Atraumatic sutures are applied with monofilament threads No. 3.

The method has several disadvantages that contribute to the recurrence of an ingrown nail and a cosmetic defect of the finger.

1. During the operation with atraumatic sutures with monofilament threads No. 3, it is not always possible to optimally match the edges of the skin and the nail bed “butt to butt” due to the lack of a sufficient width of the protrusion of the nail plate. Therefore, the development of granulations near the edge of the nail plate is not ruled out.

2. Wound healing by secondary intention lengthens the period of temporary disability, and also contributes to the relapse of the disease.

3. Frequent cosmetic defects in the form of asymmetry of the nail phalanx and nail (due to the predominance of the width of the soft tissues on one side of the phalanx and the right angle at the ends of the resected nail), a narrow nail plate and an extended scar.

The objective of our invention is to reduce the time of postoperative treatment, reduce the number of relapses of the ingrown nail, and ensure the cosmetic effect of the operation.

The task is provided by:

1) excision of the lateral periungual platen and excess skin at the end of the distal phalanx, anterior skin elevation in front of the nail;

2) creating a wound of the distal phalanx of a T-shape;

3) by applying a continuous combined atraumatic suture without suturing the nail plate;

4) the correct matching and fixing of the edges of the skin and skin to the nail bed under the edge of the nail.

To solve the problem, two longitudinal incisions parallel to the nail plate excise the affected okolonogte roller with an adjacent strip of skin and excess skin at the end of the phalanx. The proximal end of the wound ends on the lateral side of the finger, and the distal end is at the end of the phalanx, distal to the end of the nail with a bend down. Two cuts excise in the form of a wedge the front skin elevation in front of the nail plate. Both wounds connect and form a single T-shaped wound. Granulations and scar tissue underneath the edge of the nail are excised to form a protrusion of the nail plate. The proximal edge of the nail is aligned from the place of its damage (defect). To do this, from the site of damage (defect) along the groove of the nail, a narrow protruding strip of the proximal edge of the nail plate is excised along with the germination zone, the strip of the nail root and the matrix. The first continuous combined atraumatic suture is applied without suturing the nail plate. To do this, from the side, at the level of the proximal periungual nail, the nail ligaments are stitched to half the length of the nail bed. Intradermally suture the lateral edge of the wound to the distal half of the length of the nail bed and pierce the skin of the posterior edge of the wound. A second continuous combined atraumatic suture is applied. To do this, opposite the beginning of the previous suture, pierce the skin into the lumen of the wound and intradermally suture the edge of the same wound to half the length of the nail bed. Next, the nail ligaments are sutured to the distal half of the length of the nail bed and, after a puncture under the free edge of the nail, the skin of the lateral wound is pierced downward at the site of its bend. Impose one suture on the proximal and distal ends of the wound. Ligatures are sipped, the edges of the skin are matched, as well as the skin with the nail bed under the protrusion of the nail plate and all sutures are ligated.

A method of surgical treatment of an ingrown nail is carried out as follows: the periungual roller is bent to the side, a vertical incision of the skin and fatty tissue is made between the roller and the nail plate along the edge of the periosteum to a depth of 1.0 cm. Opposite the beginning of the nail plate, the end of the section is bent and finished on the side of the finger . The root of the nail and the matrix are not affected. The other end of the incision is completed 1.0 cm distal to the free edge of the nail with a bend down (Fig. 1, 2). An incision is made on the lateral side of the finger, parallel to the edge of the nail, the ends of the incision are connected to the previous one, and within the limits of healthy tissues, the periungual roller is excised with the adjacent skin strip and excess skin at the end of the phalanx (Fig. 3). Two cuts excise in the form of a wedge the front skin elevation in front of the nail plate. Both wounds connect and form a single T-shaped wound (Fig. 4). The remaining granulations and scar tissue under the edge of the nail are excised with the formation of a protrusion of the nail plate of at least 0.2 cm. If there is damage (defect) in the nail, its lateral edge is leveled. For this purpose, near the wound, from the root of the nail, the edge of the skin of the posterior periungual roller is separated and bent upwards. From the place of damage (defect) along the groove of the nail, a narrow protruding proximal strip of the nail plate with a sprout zone is excised and, along its extension, a strip of the root of the nail and the matrix. The lateral edge of the middle and distal ends of the nail is left untouched (Fig. 5). Cross connective tissue jumpers fixed to the periosteum. An excess of fiber is excised for optimal reduction of the edges of the wound. The first continuous combined atraumatic suture (nylon, vicryl, polypropylene 4 / 0-5 / 0) is applied without suturing the nail plate. To do this, on the side, at the level of the proximal periungual nail, a needle is injected under the edge of the nail plate and the nail ligaments are sutured half the length of the nail bed. Further, the lateral edge of the wound is sutured intracutaneously to the distal half of the length of the nail bed and 0.2 cm of the posterior edge of the skin are pierced from below in the corner of the T-joint (Fig. 6). A second continuous combined atraumatic suture is applied (capron, vicryl, polypropylene 4 / 0-5 / 0). To do this, on the opposite side, opposite the beginning of the previous suture, 0.2 cm of skin is pierced into the wound lumen and the edge of the same wound is sutured intradermally to half the length of the nail bed. The ligature of the nail is stitched with the same ligature to the distal half of the length of the nail bed. After a puncture, under the free edge of the nail, 0.2 cm of the skin of the lateral wound is punctured from below in the place of its bending downwards (Fig. 7). Impose one nodal atraumatic suture (capron, vicryl, polypropylene 4 / 0-5 / 0) on the proximal and distal end of the wound. To do this, 0.2 cm of the skin edge of the wound is stitched (Fig. 8). Sipping ligatures, matching the edges of the skin, as well as the skin with the nail bed under the protrusion of the nail plate. All seams are ligated (Fig. 9, 10, 11). Impose a napkin with 0.5% chlorhexidine solution on the postoperative wound. Bandage a finger with dosed compression. The first ligation is carried out in one day. Sutures are removed on 8-9 days after surgery.

The method allows to successfully treat an ingrown nail, reduce the number of relapses of the disease, ensure the cosmetic effect of the operation, reduce the time of postoperative treatment.

The presented method of operation has the criteria of "Novelty" for a number of signs:

1) the use of ligaments of the nail as fixing and supporting structures when suturing a wound;

2) the use of a new continuous combined atraumatic suture for suturing the ligaments of the nail, the edge of the wound with intradermal ligature;

3) the creation of a wound of a T-shape, providing the conditions for its optimal suturing;

4) the formation of the protrusion of the edge of the nail plate to facilitate optimal matching of the edge of the skin with the nail bed;

5) the use of atraumatic threads of thin section (nylon, vicryl, polypropylene 4 / 0-5 / 0) when suturing a wound.

The advantages of the proposed method:

1) the features of suturing the wound with a continuous combined atraumatic suture using nail ligaments, as well as with intradermal suturing of the wound edges, make it possible to optimally bring together and compare the edges of the skin and the nail bed under the protrusion of the nail plate;

2) a continuous combined atraumatic suture with stitching of the nail ligaments does not damage the structures forming the nail and the nail plate;

3) continuous combined atraumatic suture with suturing of the nail ligaments, skin with intradermal ligature and proper matching of the edges of the wound minimizes cases of skin slipping out from under the edge of the nail plate;

4) the sufficient depth and lack of rigidity of the edges of the wound of a T-shape allows you to easily bring its edges together and successfully apply atraumatic threads of thin section (nylon, vicryl, polypropylene 4 / 0-5 / 0) when suturing the wound;

5) excision of pathological periungual structures within healthy tissues, features of suturing the wound, matching the edges of the skin and the nail bed contributes to the healing of the wound by primary tension, provides a reduction in treatment time and temporary disability, helps to prevent the recurrence of an ingrown nail;

6) preservation of the shape of the nail plate, wound healing by first intention and the formation of a subtle scar provides a cosmetic effect of the operation.

The method of surgical treatment of ingrown nail is illustrated by the following figures:

Fig. 1 - view of the phalanx of a finger with an ingrown nail.

Fig. 2 - view of the phalanx of the finger during a vertical section along the border of the ingrown nail.

Fig. 3 is a view of the phalanx of the finger during a side incision during excision of the periungual roller.

Fig. 4 is a view of the phalanx of a finger during excision of the anterior skin elevation and the creation of a T-shaped wound;

Fig. 5 is a view of the phalanx of a finger during the excision of a narrow protruding proximal strip of the nail plate with a sprout zone and, in its continuation, the strips of the root of the nail and the matrix.

Fig. 6 is a view of the phalanx of the finger after applying the first continuous combined atraumatic suture (nylon, vicryl, polypropylene 4 / 0-5 / 0) without suturing the nail plate.

Fig. 7 - view of the phalanx of the finger after applying the first and second continuous combined atraumatic suture (nylon, vicryl, polypropylene 4 / 0-5 / 0) without suturing the nail plate.

Fig. 8 is a view of the phalanx of the finger after applying the first and second continuous combined atraumatic suture without suturing the nail plate, applying one nodal atraumatic suture (capron, vicryl, polypropylene 4 / 0-5 / 0) to the proximal, distal end of the wound.

Fig. 9, 10, 11 - view of the phalanx of the finger during sipping ligatures, matching the edges of the skin, skin with the nail bed under the protrusion of the nail plate and ligation of all sutures.

Clinical example:

Patient B., 21 years old, turned to a polyclinic surgeon on December 14, 2015 about an ingrown nail of the 1st toe of the right foot of stage 3, with pyogenic granuloma in the nail phalanx of a flattened shape, bilateral ingrowth, and relapse of the disease. After preoperative preparation for 2 days, including foot baths 2 times a day for 10 minutes with a solution of ammonia (based on 1 teaspoon of ammonia per 1 liter of chilled boiled water), the operation was performed. Operation December 16, 2015. Conducted anesthesia according to Lukashevich-Oberst with 2% solution of 4.0 ml lidocaine on the first toe of the right foot. Two cuts dissected the inner and outer periungual ridges with granulomas, the adjacent strip of skin and the anterior skin elevation within healthy tissues. The incisions were continued distal to the free end of the nail by 1.0 cm with a bend down and excision of the excess strip of skin. Two T-shaped wounds are formed. The edges of the middle and distal ends of the nail are left untouched. The edges of the nail are aligned. To do this, only damage (defect) of the proximal edge of the nail, the root and the matrix in the form of a narrow strip of 0.2 cm, were excised from the left. The remaining granulations and scar tissue under the edges of the nail were dissected to form a protrusion of the nail plate of 0.2 cm on both sides. Crossed connective tissue jumpers fixed to the periosteum. An excess of fiber was excised for optimal reduction of wound edges. The wounds were sutured with atraumatic sutures (Vicryl 4/0) according to the presented method. When ligating sutures, the edges of the skin are compared, as well as the edges of the skin and the nail bed under the protrusion of the nail plate. A napkin with 0.5% chlorhexidine solution was applied to the postoperative wound. Finger bandaging with metered compression. The first ligation was performed in one day. The sutures were removed on December 25, 2015, on the 9th day after the operation. Examined after 6 months and 1.5 years. There is no relapse of the disease.

Sources of information

1. Yezhov Yu.I. The operational method of treating ingrown nail / Yu.I. Yezhov, A.V. Melgunov, P.N. Komlev // RU 2138216 IPC 6 А61В 17/56, 1999.

2. Pautkin Yu.F., Malyarchuk V.I. “Outpatient. Surgery ”- Moscow, 2005, p. 233-234.

3. Prishvin A.P. Relapse of nail ingrowth. Reasons and methods of treatment / A.P. Prishvin, S.B.Singaevsky, E.N. Demin, S.S. Kudrevatykh, S.D. Trukhmanov // Outpatient surgery, 2004.- N 1-2. - S. 80-81.

4. Trukhmanov S.D. Relapse of nail ingrowth. Reasons, treatment methods / S.D. Trukhmanov, S.B. Singaevsky, E.N. Demin, S.S. Kudrevatykh, A.P. Prishvin // http://www.piroqovclinic.ru. 03/11/2014.

Claims (1)

A method of surgical treatment of an ingrown nail, including excision of the periungual platen and excess skin at the end of the phalanx, anterior skin elevation, suturing and ligation, characterized in that they form a T-shaped wound, excising only damage (defect) of the proximal edge of the nail, root and matrix in the form of a narrow strip, with the first atraumatic suture, segments half the length of the nail bed, the nail ligaments are distally sutured, the lateral edge intradermally pierced and the posterior edge of the wound pierced, the skin is pierced into the wound with the second atraumatic suture against the beginning of the first suture, and distal intradermally sutured with half the length of the nail the lateral edge of the wound, the nail ligament, are punctured under the free edge of the nail and pierce the lateral edge of the wound, the proximal and distal ends of the wound are sutured with a nodal suture, sip ligatures, displace and align the edges of the skin and skin with the nail bed under the protrusion of the nail plate, and the sutures are ligated.

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