RU2761411C1 - Method for surgical treatment of ingrown nail - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely surgery, and can be used to treat an ingrown nail. The method includes the treatment of the surgical field with 0.5% alcohol solution of chlorhexidine and the subsequent application for 10 minutes of a disposable gauze wipe moistened with 0.9% sodium chloride solution. Then, at the border of the pathological area and the area associated with hyponychia, the 1-3 mm nail plate is dissected using scissors with a rounded end in the longitudinal direction and towards the proximal edge of the nail. The pathological area is removed using a surgical clamp with a blunt end in the direction of the proximal edge of the nail plate. The pathological fragment is removed to the border with unchanged hyponychium. A disposable gauze wipe with 0.9% sodium chloride solution or 0.05% chlorhexidine digluconate solution and a self-adhesive bandage are applied to the operated field for 1-2 days. When the stratum corneum thickens or is affected by the fungus, a disposable gauze wipe moistened with 0.9% sodium chloride solution is applied for 30 minutes. With a bilateral nail lesion, similar manipulations are performed simultaneously on both sides.

EFFECT: method ensures the exclusion of traumatization of the nail fold, nail bed and nail matrix, shortening the duration of both surgical treatment and rehabilitation period, cosmetic effect and makes it possible to simultaneously perform operations with bilateral nail damage by applying a hydrophilic solution to the damaged nail plate.

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Description

The invention relates to medicine, in particular to methods for the surgical treatment of an ingrown nail.

An ingrown toenail (onychocryptosis) is one of the most common outpatient surgical diseases and is an urgent problem all over the world. According to the available literary sources, pathology occurs in 6-10% of the population. The disease is recorded in all age groups of the population, especially of the working age. The disease is characterized by pathological ingrowth of the edge of the nail into the lateral periungual ridge, in which a chronic wound develops over time. Inflammation joins with serous and serous-purulent discharge. Hypergranulation and pain syndrome are formed in the distal phalanx of the finger.

Today, an ingrown nail is considered as a polietiologic chronic disease arising from a number of reasons and accompanied by a combination of morphological and functional changes on the part of the nail plate, its matrix and soft tissues of the finger [1, 2, 3].

The onset of the disease is influenced by many factors that can be conditionally divided into hereditary and acquired. Of course, numerous etiological aspects described in the literature play an important role in the development of nail incarnation, however, the team of authors of this application believes that the development of an ingrown nail is based on genetically determined disorders of the development of the nail plate. The hereditary predisposition to onychocryptosis is discussed in numerous foreign publications [4, 5, 6, 7].

The lack of pathogenetic substantiation and the polyetiological nature of the causes of onychocryptosis determine the fact that in the overwhelming majority of cases, therapeutic measures are aimed not at eliminating the causes, but at eliminating the consequences of the disease. The lack of unified and systematic approaches to the treatment of this category of patients leads to long-term treatment, complications and relapses of the disease, up to the formation of disability. Despite the seeming simplicity of the problem, the initiative and irrationality of a number of existing methods, which, sometimes, from the very beginning, are doomed to failure, annually lead to huge economic losses among the able-bodied part of the population. The terms of disability with an ingrown nail are often comparable to those after major surgical operations [8].

All existing methods of treating an ingrown nail, including conservative and orthopedic techniques, are often ineffective and lead to a relapse of the disease. This is due to the fact that with some methods, the nail matrix is removed, with others, part of the soft tissues is excised together with a portion of the nail plate with the imposition of primary sutures while maintaining defective granulations. Classical operations according to Dupuytren, Schmiden and their numerous modifications are quite traumatic, disfigure the nail phalanx, disrupt the anatomical and functional integrity of the finger, and in half of the cases lead to relapses [9].

A known method of surgical treatment of an ingrown nail - the operation of V. Schmiden, which consists in a longitudinal marginal resection of the nail plate from the ingrowth side, departing from the edge of the affected periungual roller by 3-5 mm. The incision is continued by cutting the eponychium up to 5 mm and deepened to the periosteum. The resected edge of the nail plate is unscrewed with a clamp and removed. Then, the edges of the wound are connected with an arcuate incision along the periungual ridge, and the resulting wedge-shaped flap is removed in a single block, the edges of the resulting wound are not sutured, but brought together with a tight bandage [10].

During this operation, the wound that is not sutured is healed by secondary intention, which contributes to the risk of early purulent complications, frequent relapses of the disease and wound healing with poor cosmetic effect, in addition, the patient's disability period is lengthened.

There is also known a method of conservative treatment of dysfunction or disorders of the structure of nails and nail bed, in which a patch is used, including a layer made with the possibility of direct contact with the nail and, optionally, with the surrounding skin, which contains an adhesive, at least one penetration enhancer through skin and / or nail, and a therapeutically effective amount of sertoconazole. Moreover, the said layer additionally contains at least one additive selected from the group including additional pharmaceutically active agents, binders, crosslinkers, softeners, a solvent, a filler and / or antioxidants (US Pat. RU No. 2310441, publ. 03/10/2008).

The disadvantage of this method is the low, due to the limited therapeutic focus, the effectiveness of the treatment.

There is also known a method of treating patients with an ingrown nail, including resection of the ingrown part of the body, the nail root and devitalization of the growth part of the matrix zone, while additionally devitalizing the lateral and medial regions of the proximal groove of the nail bed, the inner surface of the periungual ridge and the longitudinal segment in contact with the removed part of the nail root the nail bed, providing the formation of a buffer zone between the resected edge of the nail plate and the periungual roller, using a radio wave electrode (pat.RU No. 2618203, publ. 02.05.2015).

The disadvantage of this method is the low efficiency of surgical treatment and a long painful healing period.

The technical result, which the invention is aimed at, consists in reducing the trauma of the surgical intervention, ensuring the cosmetic effect of the operation, reducing the time before and postoperative treatment, eliminating the recurrence of the disease, and the possibility of simultaneous operation in case of bilateral nail damage.

To achieve the named technical result in the proposed method, which provides for the standard treatment of the operating field and the subsequent application of a disposable gauze napkin moistened with saline for 10 minutes, and with a modified nail plate - thickening of the nail layer or partial fungal infection - for 30 minutes, then free at the border the lying area of the nail and the area associated with hyponychia, the nail plate is dissected with a length of 1-3 mm using scissors with a rounded end, in the longitudinal direction, towards the proximal edge of the nail, with a slight movement, the pathological area is removed using a surgical clamp with a blunt end having a wide working surface for gripping the nail plate in the direction of the proximal edge of the nail plate, while the pathological fragment is removed at the border with unchanged hyponychia and with a visual definition of a "thorn", after the operation, the surgical field is applied for 1-2 days a disposable gauze napkin moistened with an antiseptic solution (hypertonic solution of sodium chloride or chlorhekidinabigluconate 0.05%, etc.) and a self-adhesive bandage, and in case of bilateral nail damage, similar manipulations are performed simultaneously.

The proposed method for the surgical treatment of an ingrown nail is simple and effective, as has been shown by the practice of its use for more than 3 years.

The proposed method makes it possible to carry out operations without anesthesia in a polyclinic with a minimum set of surgical instruments, to reduce the invasiveness of surgery, to provide a cosmetic effect, to reduce the treatment time to 2 hours, and the rehabilitation period to 10 hours. In addition, the method is universal, it can be used to simultaneously carry out operations with bilateral nail damage.

The nail (Fig. 1) is known to consist of three main parts: the nail plate, the nail bed and the matrix. The nail bed is an area of the epidermis lying under the nail plate, starting with the nail plate and ending at its distal edge. The continuation of the nail bed is the area of the skin that is not connected to the nail plate and is located under its free edge. It is called hyponychia. The matrix or root of the nail is the growth zone from where both the plate and the bed of the nail begin. The matrix starts under the proximal nail fold and continues until the beginning of the nail plate. The edge of the matrix zone, protruding from under the proximal ridge, looks like a white crescent-shaped strip and is called a lune. The growth of the nail plate occurs constantly, throughout a person's life. New tissue of the nail plate is formed in the so-called nail germinal zone, located at its base. Thus, the nail grows in the caudal direction - from the base to the apex. The growth of the nail in the lateral direction in the form of a "thorn" to the sides of the direction of growth of the nail plate is considered a pathology. Ingrown nails are found mainly on the big toes, usually on one, rarely on both feet, in right-handers more often on the right foot than on the left. Most often, the outer edge grows in, sometimes both lateral edges of the nail plate. It is much less common for an ingrown nail to develop on other toes, even less often on the thumbs and other fingers [11,12].

The steps of the method are shown in FIG. 1-4

FIG. 1 shows a longitudinal section of the distal phalanx of the nail;

FIG. 2, the dotted line indicates the cut line of the nail plate with scissors with a rounded end, in the longitudinal direction to the proximal edge of the nail;

FIG. 3, the dotted line indicates the volume of tissues to be removed;

FIG. 4 shows a pathological fragment;

On the presented figures are numbered: 1 - hyponychium;

2 - nail plate;

3 - the bed of the nail;

4 - eponychium;

5 - proximal nail fold;

6 - nail matrix;

7 - the border between the pathological and unchanged areas of the nail plate;

8 - pathological area of the nail plate;

9 - a surgical forceps with a blunt end ;,

10 - pathological fragment;

11 - demarcation line.

The method of surgical treatment of an ingrown nail is as follows.

Surgical treatment of an ingrown nail according to the proposed method is carried out without anesthesia. First, the surgical field is treated with standard antiseptic solutions regulated by the Ministry of Health of the Russian Federation (chlorhexidine alcohol 0.5% and others).

Then they begin to apply a disposable napkin soaked in 0.9% sodium chloride solution or 0.05% chlorhexidine bigluconate solution or water for injection or another hydrophilic solution on the nail plate (use antiseptics with a tanning effect, for example, based on iodine and others, categorically not recommended, since maximum plasticity of the nail plate can be achieved only by using hydrophilic solutions.) This is very important, since a healthy nail plate fully absorbs water, becomes plastic, while the pathological section of the nail plate remains denser.

The exposure of the napkin with an aqueous solution on the surface of the nail plate is 5-10 minutes. In practice, we use 0.9% sodium chloride solution. Other aqueous solutions can also be used. With a modified nail plate with thickening of the stratum corneum, partial fungal infection, when the hydrophilic properties of the nail plate decrease, the exposure time of the napkin is increased to 30 minutes.

Further, at the border of the pathological area and the area associated with hyponychia 1 (Fig. 3), the nail plate 2 is dissected using scissors with a rounded end, in the longitudinal direction, towards the proximal edge of the nail 6, 1-3 mm long (Fig. 2). The pathological area 8 is taken with a surgical clamp 9 with a blunt end and towards the proximal edge of the nail, removed with a slight movement. The pathological fragment 10 (Fig. 4) of the nail plate must be removed at the border with unchanged hyponychia 7 (due to the demarcation line 11, which runs at the border of the pathological and unchanged sections of the nail plate), which allows further restoration of nail plastics without scar and granulation. The volume of the removed fragment does not depend on the actions of the surgeon - "where it is thin, there it breaks." The body itself "rejects" the changed area of the nail plate, leaving healthy tissue. On the removed fragment of the nail plate, a pathological "thorn" is always determined. With bilateral lesion, similar manipulations are performed. The operation time with a preparatory stage is 30 minutes. After the operation, a disposable gauze napkin with an antiseptic solution (hypertonic sodium chloride solution or chlorhexidineabigluconate 0.05%) is applied for 1-2 days. The detected pathological outgrowth ("thorn") is a guarantee that the patient (and as practice has shown) will forget about his illness in 10 hours.

Clinical examples:

Example # 1. Patient N., 45 years old, turned to the surgeon at the Arbat medical center on September 30, 2020 with complaints of pain in the area of the first toe of the left foot, skin hyperemia in the area of the medial lateral nail ridge. Considers himself ill for the last 6 months. Conservative measures did not bring the expected effect. In the conditions of the dressing room of the polyclinic, the operation was performed according to the above method. After 1 hour, the patient was discharged home. Examination after 3 months - no recurrence of the disease, a good clinical and cosmetic effect was achieved.

Example No. 2. Patient Ch., 21 years old, turned to the surgeon at the MKDTs polyclinic on July 25, 2020 with complaints of soreness in the area of the first toe of the right foot when walking, edema of the lateral nail fold. In the dressing room, the operation was performed according to the described method. Within an hour, the patient went home. Examination after 2 months - no recurrence of the disease, a good clinical and cosmetic effect was achieved.

Example No. 3. Patient 3., 15 years old, applied to the Arbat Medical Center on 11.10.2020. Diagnosis: ingrown nail of 1 toe of the right foot. On the day of treatment, according to the proposed method, the operation was performed. Control examination after 2 months: no recurrence of the disease, good clinical and cosmetic effect was achieved.

The observation of patients during these 3 years showed an excellent therapeutic and cosmetic effect, there were no relapses during these 3 years.

Thus, the proposed method for the surgical treatment of an ingrown nail makes it possible to exclude trauma to the nail fold, nail bed and nail matrix, and this is the key to good healing and prevention of disease recurrence. The patient is already at home 1-2 hours after the operation and can return to the usual rhythm of life, without interrupting work and other daily activities, in addition, the proposed method is absolutely painless and easy to perform.

Bibliography:

1. Chambers D. Ingrown toenails. Australian Family Physician. 2015; 7: 438.

2. Dukin B.B. and other Problems of the forefoot and ingrown toenail: surgical correction and prevention. Plastic surgery and cosmetology. 2013; 2: 293-297.

3. Chambers D. Ingrown toenails. Australian Family Physician. 2015; 7. P.438.

4. De Lauro, T.M. Onychocryptosis / T.M. De Lauro // Clin. Podiatr. Med. Surg. 1995. Vol. 12, N2. - P. 201-213.

5. Lazar, L. A conservative treatment for ingrown toenails in children / L. Lazar, I. Erez, S. Katz // Pediatr. Surg. Int. - 1999. - Vol. 15, No. 2. - P. 121-122.

6. Hyder, N. Ingrowing toe nails: the extent of the germinal matrix / N. Hyder // J. Bone Joint. Surg. Br. - 1994.- Vol.76, N 3.- P.501-502.

7. Parrinello, J.F. Incurvated nail. Does the phalanx determine nail plate shape? / J.F. Parrinello, C.J. Japour, D. Dykyj // J. Am. Podiatr. Med. Assoc. - 1995. - Vol.85, N 11. -c P.696-698.

8. Surgical infections of the skin and soft tissues. Russian national recommendations. M .: Borges, 2009.

9. Gain, Yu.M. Ingrown nail surgery: monograph / Yu.M. Gain [and others]. - Minsk, 2007 .-- P. 6.

10. Pautkin Yu.F., Malyarchuk V.I. "Polyclinic surgery" Moscow, 2005. S. 233-234.

11. Sonis A.G., Stolyarov E.A., Suslin S.A., Alekseev D.G., Bezrukova M.A. Ingrown toenail - history, relevance and modern approaches to treatment. Science and innovation in medicine. 2018; (3): S. 64-72.

12. Local and combined therapy of onychomycosis. A guide for doctors. Sergeev Yu.V., Mokina E.V., Sergeev A.Yu., Burtseva G.N., Baranova M.O., Savchenko N.V., Sergeev V.Yu. M .: Nat. acad. mycology. 2013. - S. 5-7

Claims (3)

1. A method of surgical treatment of an ingrown nail, including the treatment of the operating field with a 0.5% alcohol solution of chlorhexidine and the subsequent application for 10 minutes of a disposable gauze napkin moistened with 0.9% sodium chloride solution; then on the border of the pathological area and the area associated with hyponychia, scissors with a rounded end cut the nail plate 1-3 mm long in the longitudinal direction and towards the proximal edge of the nail, the pathological area is removed using a surgical clamp with a blunt end towards the proximal the edge of the nail plate, remove the pathological fragment to the border with unchanged hyponychia, apply a disposable gauze napkin with 0.9% sodium chloride solution or 0.05% chlorhexidine digluconate solution and a self-adhesive bandage on the operated field for 1-2 days. 2. The method according to claim 1, characterized in that in case of thickening of the stratum corneum or infection with a fungus, a disposable gauze napkin moistened with 0.9% sodium chloride solution is applied for 30 minutes. 3. The method according to claim 1, characterized in that in case of bilateral nail damage, similar manipulations are performed simultaneously on both sides.

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