RELAPSE CAUSES ANALYSIS AND OPTIMATION OF THE RESULTS OF INGROWN TOENAIL SURGICAL TREATMENT: VIEW OF THE PROBLEM

Abstract

Relevance of the problem of ingrown nail (onychocriptosis, unguis incarnatus) in urgent outpatient purulent surgery is caused by the increased frequency of its occurrence, chronicity, complications, not uncommon early and late postoperative relapses. Conservative and orthopedic treatments of unguis incarnatus are not very effective while Dupuytren’s contracture, Emmert- Schmiden surgeries are very traumatic, disfi gure nail bone, distort anatomic and functional unity of a fi nger and in 2-20% cases (depending on absence or presence of onychocriptosis and fungal agents) cause relapse. Methods and results of ingrown nail surgical correction have been studied to improve the results of complex treatment. Over a fi ve-year period (2010-2015) 325 unguis incarnates surgeries in 198 men and 127 women aged 12-67 were performed. In 82 patients late relapses of onychocriptosis were confi rmed after previous surgeries at other clinics. Conservative treatment was recommended only at early stages of ingrowing. Surgical treatment was conducted with regard for pathological changes in eponychial fold according to recommendations for combining surgical treatment and conservative therapy. Upon subnychial scraping analysis of onychomycotic nails with secondary nail incarnation it was possible to confi rm dominance of dermatophytes (red trichophitia), while one third of cases were associated with mold and yeast-like fungi. Hyperkeratosis, erosion and destruction of central nail with secondary incarnation of the edges were typical for 89.1 % of trichophitis cases. Operative treatment consisted in nail excision or nail plate removal. Excision of pathologically changed epochonial tissues and partial marginal matricectomy in ingrown area were used as anti-relapse measures. Types of operative treatment applied may be divided into fi ve main groups: 1 – Emmert-Schmiden type surgeries (marginal excision of nail plate and eponychia with marginal removal of the growing part via partial matricectomy); 2 – Dupuytren’s contracture type surgeries (onychectomy – complete removal of nail plate); 3 – Bartlett type surgeries (local tissue plastic reconstruction); 4 – marginal resection of marginal section of nail plate; 5 – Meleshevych surgery; 6 – our modifi cations (with previous block-type eponychectomy). We have studied results of onychocriptosis surgeries of post-surgical type 1 correction in 84 patients, type 2 – in 66 patients, type 3 – in another 50 cases, type 4 – in 42 persons, type 5 – in another 27 patients, type 6 – in 56 patients (with the use of our modifi cation of surgical treatment). Three types of trichophytosis have been differentiated: frontal central – with erosion of up to 25% of nail area, subtotal – from 25 to 70% (without touching upon growth area), total – from 70 to 90% (with affected growth area). In 65 mycotic trichophitis patients with secondary nail incarnation a standard itraconazole pulse therapy was applied. Presence of onycholytic focuses and degradation of hyperkeratotic areas which results in lamination of a part of nail plate, proves feasibility of performing lowtrauma onychectomy on patients with trichophyton onychomycosis with secondary incarnation via onycholized structure with single-stage sequential removal of dermatophyte and ingrowth areas with changed eponychial folds. Relapse causes after Meleshevych, Emmert-Schmiden, Bartlett surgeries were technical faults of surgical tools, intraoperative nail bed trauma, faults of postoperative anti-relapse treatments, surgical area trauma, wearing of tight shoes, non-compliance with doctor’s recommendations as to correction of orthopedic pathology, onychomycosis.

Keywords

• ingrown nail, onychomycosis, dermatophyte, surgical treatment, relapses of ingrowing