The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Comparison of Wedge Resection (Winograd Procedure) and Wedge Resection Plus Complete Nail Plate Avulsion in the Treatment of Ingrown Toenails Jia-Zhang Huang, MD, Yi-Jun Zhang, MD, Xin Ma, MD, Xu Wang, MD, Chao Zhang, MD, Li Chen, MD Department of Orthopedics, Huashan Hospital Fudan University, Shanghai, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
The present retrospective study compared the efficacy of wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion for the treatment of ingrown toenails (onychocryptosis). Two surgical methods were performed in 95 patients with a stage 2 or 3 ingrown toenail. Each patient was examined weekly until healing and then at 1, 6, and 12 months of follow-up. The outcomes measured were surgical duration, healing time, recurrence rate, the incidence of postoperative infection, and cosmetic appearance after surgery. Of the 95 patients (115 ingrown toenails) included in the present study, 39 (41.1%) underwent wedge resection (Winograd procedure) and 56 (59%), wedge resection plus complete nail plate avulsion. The mean surgical duration for wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion was 14.9 2.4 minutes and 15.1 3.2 minutes, respectively (p ¼ .73). The corresponding healing times were 2.8 1.2 weeks and 2.7 1.3 weeks (p ¼ .70). Recurrence developed in 3 (3.2%) patients after wedge resection (Winograd procedure) and in 4 (4.2%) after wedge resection plus complete nail plate avulsion. In addition, postoperative infection occurred in 3 (3.2%) patients after wedge resection (Winograd procedure) and 2 (2.1%) after wedge resection plus complete nail plate avulsion. Both of the surgical procedures were practical and appropriate for the treatment of ingrown toenails, being simple and associated with low morbidity and a high success rate. However, cosmetically, wedge resection (Winograd procedure) would be the better choice because the nail plate remains intact. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: onychocryptosis recurrence surgery treatment Winograd procedure
An ingrown toenail is a common condition, also known as onychocryptosis, and easily mistaken as an insignificant problem. It often leads to considerable discomfort and pain, with functional consequences (1). It can occur at any age; however, the incidence appears to be greatest in those aged 11 to 30 years (2). Several causes (i.e., anatomic abnormalities, improperly trimmed nails, poorly fitting shoes, and repetitive trauma) have been suggested. Three clinical stages of ingrown toenails have been described (3,4) (Table 1 and (Fig. 1A to C). A wide range of methods have been described for the treatment of ingrown toenails, ranging from simple conservative approaches to extensive surgical procedures (Table 1) (3–6). Surgical interventions aim to remove the troublesome part of the nail
Financial Disclosure: None reported. Conflict of Interest: None reported. J.-Z. Huang and Y.-J. Zhang contributed equally to the present study. Address correspondence to: Xin Ma, MD, Department of Orthopedics, Huashan Hospital Fudan University, No. 12 Wulumuqizhong Road, Jing’an District, Shanghai 200040 China. E-mail address: [email protected] (X. Ma).
(combined with matrix destruction), thus relieving the symptoms and preventing regrowth of the nail and recurrence. The surgical procedures have included radical excision of the nail fold, wedge resection (Winograd), or resection combined with application of phenol or sodium hydroxide, total nail plate avulsion, partial nail avulsion combined with matricectomy, and other methods (7). The Winograd technique is a successful surgical technique that has been acknowledged since it was first described (3). In addition, complete nail plate avulsion is common for ingrown toenails in Chinese subjects, and it can easily relieve the symptoms. These 2 procedures have been recommended for patients with stage 2 or 3 ingrown toenails in which toenail is embedded and the infected granulation tissue has proliferated. Several studies have been published regarding the results of the Winograd technique and its modifications and for complete nail plate avulsion for ingrown toenails (8–11). Almost all of these studies evaluated the effectiveness of the surgical technique according to the rate of recurrence. However, no conclusions could be drawn regarding the differences in healing time, degree of pain, frequency of infection, or the cosmetic results among the different procedures.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.08.022
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J.-Z. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Table 1 Staging, clinical manifestations, and recommended treatment of ingrown toenail Stage
Clinical Manifestations
Recommended Treatment
I
Erythema, tenderness, swelling of lateral nail fold
II
Increased symptoms, seropurulent drainage, infection Amplified symptoms, granulation tissue, marked fold hypertrophy
Conservative management: soaking the foot in warm water, topical or oral antibiotics, proper nail trimming, elevation of nail corner Conservative or surgical management
III
Surgical management
The purpose of the present retrospective study was to focus on the treatment of onychocryptosis with bacterial infection by comparing the outcomes of wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion for ingrown toenails in terms of the surgical duration, healing time, recurrence rate, postoperative infection rate, and patient satisfaction with the cosmetic results in Chinese subjects. Patients and Methods
Wedge Resection Plus Complete Nail Plate Avulsion After wedge resection (Winograd procedure), the remaining nail plate was elevated from the nail bed and matrix. The cuticle was incised and elevated from the nail plate, and the toenail was then avulsed by grasping it with a hemostat. Postoperative Care Postoperatively, oral nonsteroidal anti-inflammatory drugs were given for pain control. In elderly patients (age >60 years) and patients with stage 3, intravenous antibiotics were prescribed (cefazolin 200 mg/d for 3 days) (12). The patients were advised to elevate the affected foot whenever possible and were told to change the dressing once daily, starting from the third postoperative day, until complete healing. After removal of the first dressing, the patients could return to normal ambulation and activity. Checks were made weekly until healing had occurred and then at 1, 6, and 12 months postoperatively (Figs. 2 and 3). Recurrence was defined as evidence of ingrowth of the nail edge or spicule formation. Statistical Analysis The data were analyzed using the Statistical Package for Social Sciences software, version 16.0, for Windows, version 20.0 (SPSS, Chicago, IL). The data are presented as averages and standard deviations. Student’s t tests were used to test the null hypothesis for continuous numeric data, and Cuzick’s test for trend was used to compare categorical data. for statistical analysis when appropriate; p < .05 was considered statistically significant.
Patients From November 2008 to September 2012, at the Department of Orthopedics, Huashan Hospital, Fudan University, we performed a surgical intervention for 95 patients with a stage 2 (n ¼ 41) or stage 3 (n ¼ 54) ingrown toenail. The present study was conducted in accordance with the Declaration of Helsinki. The ethics committee of Fudan University approved our study, and all participants provided written informed consent. Patients with diabetes mellitus or any immunodeficiency condition, including chemotherapy, coagulopathy status, peripheral vascular disease, or arteriosclerosis (determined by clinical history and physical examination findings) were excluded. Eventually, 95 patients were selected. Of the 95 patients, 39 (47 toenails, median age 31.3 7.0, range 22 to 43 years; median weight 60.3 4.4, range 55 to 70 kg; 21 males and 18 females) underwent wedge resection (Winograd procedure) and 56 (68 toenails, median age 35.3 7.0, range 26 to 49 years; median weight 63.3 2.4, range 52 to 73 kg; 32 males and 24 females) underwent wedge resection plus complete nail plate avulsion. We first compared the efficiency of the 2 procedures by evaluating the differences in surgical duration, healing time, recurrence percentage, postoperative infection percentage, and patient satisfaction with the cosmetic results. Wedge Resection (Winograd Procedure) A small incision in the soft tissue of the nail fold and eponychium (proximal nail fold) was made. Mainly by blunt dissection, the soft tissue was separated from the ingrown piece of nail until the lateral edge of the nail was reached. With small pointed scissors, the nail was cut, with the incision extending back to the end of the matrix. The loose piece of nail was retracted and separated from the nail bed. With a small surgical curette, the matrix and nail bed were destroyed to prevent recurrence.
Results A total of 115 ingrown toenails were treated in 95 patients (61 males and 34 females). Their mean age was 31.6 20.0 years (Table 2). Comparison of patient age, sex distribution, and body weight by treatment group revealed no statistically significant differences (p > .05). Recurrence was defined by pain, overgrowth of the skin fold, and infection. The unique concentration of resident microbes found in the nail folds could help explain the postoperative infections identified in the present study. The incidence of recurrence and postoperative infection is listed in Tables 3 and 4 respectively. The mean surgical duration for wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion was 14.9 2.4 minutes and 15.1 3.2 minutes, respectively (p ¼ .73), and the postoperative healing time was 2.8 1.2 weeks and 2.7 1.3 weeks, respectively (p ¼ .70). Recurrence developed in 3 patients after wedge resection (Winograd procedure) and 4 (7.7% and 7.2%, respectively) after wedge resection plus complete nail plate avulsion (p ¼ .67). Postoperative infection occurred in 3 (5.4% and 5.1%, respectively) patients after wedge resection (Winograd procedure) and 2 after wedge resection plus complete nail plate avulsion
Fig. 1. Staging and clinical manifestations for ingrown toenail: (A) stage 1, (B) stage 2, and (C) stage 3.
J.-Z. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
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Table 2 Patient data (N ¼ 115 ingrown toenails in 95 patients) Surgical Intervention
Patients Sex Male Female Laterality Bilateral Unilateral Age (y)
Wedge Resection Plus Complete Nail Plate Avulsion (n ¼ 68)
Wedge Resection (Winograd procedure) (n ¼ 47) 39
56
25 (26.3) 14 (14.7)
36 (37.9) 20 (21.1)
8 (7) 31 (27) 31.0 20.5
12 (10.4) 44 (38.3) 32.8 19.7
Data presented as n (%) or mean standard deviation.
Fig. 2. Views of a stage 2 ingrown toenail in a 40-year-old male who underwent wedge resection (Winograd procedure). (A) Preoperative view and (B) 6-month postoperative view.
(p ¼ .81). Of the 95 patients, 88 (92.6%) were satisfied with the outcome and 5 complained of the cosmetic results because the nail plate did not regrow well.
Discussion An ingrown toenail is a disorder that negatively affects the quality of life, in particular, of young adults, causes severe loss of labor, and can result in psychological disturbances (13). Although several treatment modalities have been used, it has been proved that the recurrence rates are lower with surgical treatment than with conservative treatment (13). The Winograd procedure is a classic surgical procedure for ingrown toenails. It consists of partial plate excision and subjacent growth center destruction (3). In contrast to what one might think, this is a very delicate surgery, because complete dissection of the lateral horn from the underlying periosteum is not easy. With skilled nail surgeons, this type of surgery can produce excellent results (14),
because such surgeons will know the anatomic bounds of the lateral horns of the matrix perfectly. Thus, they will curve the incision proximally and perform a lateral longitudinal biopsy (15,16). This is the main reason for the various recurrence rates observed in different studies. Gerritsma-Bleeker et al (17) reported a 21% recurrence rate €log lu et al (9) described a new techafter partial matrix excision. Co nique termed the “lateral fold advancement flap” and compared their new technique with partial matrix excision in their prospective study. They found an 8.1% recurrence rate in the partial matrix excision group. Aydin et al (1) reported a 6.5% recurrence rate in their series. Nail plate avulsion is a required step in many nail surgeries (18). Traditional teaching has advocated total plate avulsion, either performed distally to proximally (distal) or proximally to distally (proximal) (19), with the goal of achieving maximum exposure of the nail bed and matrix, but the recurrence rate was as great as 83% (20). In the present study, patients treated using wedge resection (Winograd procedure) experienced almost the same healing time and surgical duration as those who underwent wedge resection plus complete nail plate avulsion. Similarly, the total postoperative infection rate was 5.4% for wedge resection (Winograd procedure) and 5.1% for wedge resection plus complete nail plate avulsion. The corresponding total recurrence rates were 7.7% and 7.2%, lower than the reported recurrence rate. A previous study reported that patients who underwent wedge resection (Winograd procedure) were able to perform normal activities by the end of the second postoperative week and had complete healing by the end of the fourth week (5). In our study, we found the healing time was almost 3 weeks. However, 5 patients had unsatisfactory cosmetic results because the nail plate could not regrow well. All those patients had undergone wedge resection plus complete nail plate avulsion. The best treatment of ingrown toenails should be an effective, simple, inexpensive outpatient procedure with little postoperative discomfort and a rapid return to normal activities. Moreover, low complication and recurrence rates with acceptable cosmetic outcomes are of great importance (6,17,21).In this regard and from our study findings, wedge resection (Winograd procedure) will result in greater nail plate preservation and allow regrowth of the normal nail with fewer signs of previous surgery, providing excellent cosmetic results and immediate pain relief. Thus, we suggest that wedge
Table 3 Incidence of recurrence at 1 week and 1, 6, and 12 months of follow-up
Fig. 3. Views of stage 3 ingrown toenail in a 45-year-old female who underwent wedge resection plus complete nail plate avulsion. (A) Preoperative view and (B) 6-month postoperative view.
Method
Week 1
Month 1
Month 6
Month 12
Total
Wedge resection (Winograd procedure) (n ¼ 47) Wedge resection plus complete nail plate avulsion (n ¼ 68) Total
0
2 (5.1)
1 (2.6)
0
3 (7.7)
0
2 (3.6)
2 (3.6)
0
4 (7.2)
0
4 (4.2)
3 (3.2)
0
7 (7.4)
Data presented as n (%).
4
J.-Z. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Table 4 Incidence of postoperative infection at 1 week and 1, 6, and 12 months of follow-up Method
Week 1
Month 1
Month 6
Month 12
Total
Wedge resection (Winograd procedure) (n ¼ 47) Wedge resection plus complete nail plate avulsion (n ¼ 68) Total
1 (1.8)
2 (3.6)
0
0
3 (5.4)
2 (5.1)
0
0
0
2 (5.1)
3 (3.2)
2 (2.1)
0
0
5 (5.3)
Data presented as n (%).
resection (Winograd procedure) should be a valuable option in the treatment of the ingrown toenail. However, the present study had its limitations. It was a retrospective analysis, and the patients were not randomized. In addition, the subjects of the study did not include children or older patients; thus, we could not determine whether these procedures would be appropriate for such patients. Therefore, additional studies are needed to identify the appropriate patients with ingrown toenails for wedge resection (Winograd procedure). References 1. Murray WR. Onychocryptosis: principles of non-operative and operative care. Clin Orthop Relat Res 142:96–102, 1979. 2. Keeman JN. The ingrown nail. Ned Tijdschr Geneeskd 130:1431–1434, 1986. 3. Winograd AM. A modification in the technic of operation for ingrown toenail. 1929. J Am Podiatr Med Assoc 97:274–277, 2007. 4. Zuber TJ, Pfenninger JL. Management of ingrown toenails. Am Fam Physician 52:181–190, 1995. 5. Peyvandi H, Robati RM, Yegane RA, Hajinasrollah E, Toossi P, Peyvandi AA, Ourang ZB, Shams A. Comparison of two surgical methods (Winograd and sleeve method) in the treatment of ingrown toenail. Dermatol Surg 37:331–335, 2011.
6. Richert BB, Dahdah MM. Complications of nail surgery. In: Complications in Dermatologic Surgery, pp. 137–158, edited by K Noury, Mosby, Philadelphia, 2008. 7. Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev 4:CD001541, 2012. lu B, Esemenli T. Partial removal of nail matrix in the treatment of 8. Aydin N, Kocaog ingrowing toe nail. Acta Orthop Traumatol Turc 42:174–177, 2008. € log lu H, Koc¸er U, Sungur N, Uysal A, Kankaya Y, Oruc¸ M. A new anatomical repair 9. Co method for the treatment of ingrown nail: prospective comparison of wedge resection of the matrix and partial matricectomy followed by lateral fold advancement flap. Ann Plast Surg 54:306–311, 2005. 10. Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev 18:CD001541, 2005. 11. Vaccari S, Dika E, Balestri R, Rech G, Piraccini BM, Fanti PA. Partial excision of matrix and phenolic ablation for the treatment of ingrowing toenail: a 36-month follow-up of 197 treated patients. Dermatol Surg 36:1288–1293, 2010. 12. Karaca N, Dereli T. Treatment of ingrown toenail with proximolateral matrix partial excision and matrix phenolization. Ann Fam Med 10:556–569, 2012. 13. Matsumoto K, Hashimoto I, Nakanishi H, Kubo Y, Murao K, Arase S. Resin splint as a new conservative treatment for ingrown toenails. J Med Invest 57:321–325, 2010. € rbu € z Y, Ademog lu Y. Results of partial 14. Kayalar M, Bal E, Toros T, Ozaksar K, Gu matrixectomy for chronic ingrown toenail. Foot Ankle Int 32:888–895, 2011. 15. Haneke E, Richert B, di Chiacchio N. Surgery of the whole nail unit. In: Nail Surgery, pp. 133–148, edited by B Richert, N di Chiacchio, E Haneke, Informa Heathcare, London, 2010. 16. Krull E. Exploration of nail tissue. In: Nail Surgery, pp. 49–53, edited by E Krull, E Zook, R Baran, E Haneke, Lippincott Williams & Wilkins, Philadelphia,, 2001. 17. Gerritsma-Bleeker CL, Klaase JM, Geelkerken RH, Hermans J, van Det RJ. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 137:320–325, 2002. 18. Jellinek NJ. Primary malignant tumors of the nail unit. Adv Dermatol 21:33–64, 2005. 19. Zaias N. Surgical procedures. In: The Nail in Health and Diseaseed 2, Appleton & Lange, Norwalk, CT, 1990, pp. 67–80. 20. Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toenails. J Bone Joint Surg Br 73:131–133, 1991. 21. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 79:303–308, 2009.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Comparison of Wedge Resection (Winograd Procedure) and Wedge Resection Plus Complete Nail Plate Avulsion in the Treatment of Ingrown Toenails Jia-Zhang Huang, MD, Yi-Jun Zhang, MD, Xin Ma, MD, Xu Wang, MD, Chao Zhang, MD, Li Chen, MD Department of Orthopedics, Huashan Hospital Fudan University, Shanghai, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
The present retrospective study compared the efficacy of wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion for the treatment of ingrown toenails (onychocryptosis). Two surgical methods were performed in 95 patients with a stage 2 or 3 ingrown toenail. Each patient was examined weekly until healing and then at 1, 6, and 12 months of follow-up. The outcomes measured were surgical duration, healing time, recurrence rate, the incidence of postoperative infection, and cosmetic appearance after surgery. Of the 95 patients (115 ingrown toenails) included in the present study, 39 (41.1%) underwent wedge resection (Winograd procedure) and 56 (59%), wedge resection plus complete nail plate avulsion. The mean surgical duration for wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion was 14.9 2.4 minutes and 15.1 3.2 minutes, respectively (p ¼ .73). The corresponding healing times were 2.8 1.2 weeks and 2.7 1.3 weeks (p ¼ .70). Recurrence developed in 3 (3.2%) patients after wedge resection (Winograd procedure) and in 4 (4.2%) after wedge resection plus complete nail plate avulsion. In addition, postoperative infection occurred in 3 (3.2%) patients after wedge resection (Winograd procedure) and 2 (2.1%) after wedge resection plus complete nail plate avulsion. Both of the surgical procedures were practical and appropriate for the treatment of ingrown toenails, being simple and associated with low morbidity and a high success rate. However, cosmetically, wedge resection (Winograd procedure) would be the better choice because the nail plate remains intact. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: onychocryptosis recurrence surgery treatment Winograd procedure
An ingrown toenail is a common condition, also known as onychocryptosis, and easily mistaken as an insignificant problem. It often leads to considerable discomfort and pain, with functional consequences (1). It can occur at any age; however, the incidence appears to be greatest in those aged 11 to 30 years (2). Several causes (i.e., anatomic abnormalities, improperly trimmed nails, poorly fitting shoes, and repetitive trauma) have been suggested. Three clinical stages of ingrown toenails have been described (3,4) (Table 1 and (Fig. 1A to C). A wide range of methods have been described for the treatment of ingrown toenails, ranging from simple conservative approaches to extensive surgical procedures (Table 1) (3–6). Surgical interventions aim to remove the troublesome part of the nail
Financial Disclosure: None reported. Conflict of Interest: None reported. J.-Z. Huang and Y.-J. Zhang contributed equally to the present study. Address correspondence to: Xin Ma, MD, Department of Orthopedics, Huashan Hospital Fudan University, No. 12 Wulumuqizhong Road, Jing’an District, Shanghai 200040 China. E-mail address: [email protected] (X. Ma).
(combined with matrix destruction), thus relieving the symptoms and preventing regrowth of the nail and recurrence. The surgical procedures have included radical excision of the nail fold, wedge resection (Winograd), or resection combined with application of phenol or sodium hydroxide, total nail plate avulsion, partial nail avulsion combined with matricectomy, and other methods (7). The Winograd technique is a successful surgical technique that has been acknowledged since it was first described (3). In addition, complete nail plate avulsion is common for ingrown toenails in Chinese subjects, and it can easily relieve the symptoms. These 2 procedures have been recommended for patients with stage 2 or 3 ingrown toenails in which toenail is embedded and the infected granulation tissue has proliferated. Several studies have been published regarding the results of the Winograd technique and its modifications and for complete nail plate avulsion for ingrown toenails (8–11). Almost all of these studies evaluated the effectiveness of the surgical technique according to the rate of recurrence. However, no conclusions could be drawn regarding the differences in healing time, degree of pain, frequency of infection, or the cosmetic results among the different procedures.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.08.022
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J.-Z. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Table 1 Staging, clinical manifestations, and recommended treatment of ingrown toenail Stage
Clinical Manifestations
Recommended Treatment
I
Erythema, tenderness, swelling of lateral nail fold
II
Increased symptoms, seropurulent drainage, infection Amplified symptoms, granulation tissue, marked fold hypertrophy
Conservative management: soaking the foot in warm water, topical or oral antibiotics, proper nail trimming, elevation of nail corner Conservative or surgical management
III
Surgical management
The purpose of the present retrospective study was to focus on the treatment of onychocryptosis with bacterial infection by comparing the outcomes of wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion for ingrown toenails in terms of the surgical duration, healing time, recurrence rate, postoperative infection rate, and patient satisfaction with the cosmetic results in Chinese subjects. Patients and Methods
Wedge Resection Plus Complete Nail Plate Avulsion After wedge resection (Winograd procedure), the remaining nail plate was elevated from the nail bed and matrix. The cuticle was incised and elevated from the nail plate, and the toenail was then avulsed by grasping it with a hemostat. Postoperative Care Postoperatively, oral nonsteroidal anti-inflammatory drugs were given for pain control. In elderly patients (age >60 years) and patients with stage 3, intravenous antibiotics were prescribed (cefazolin 200 mg/d for 3 days) (12). The patients were advised to elevate the affected foot whenever possible and were told to change the dressing once daily, starting from the third postoperative day, until complete healing. After removal of the first dressing, the patients could return to normal ambulation and activity. Checks were made weekly until healing had occurred and then at 1, 6, and 12 months postoperatively (Figs. 2 and 3). Recurrence was defined as evidence of ingrowth of the nail edge or spicule formation. Statistical Analysis The data were analyzed using the Statistical Package for Social Sciences software, version 16.0, for Windows, version 20.0 (SPSS, Chicago, IL). The data are presented as averages and standard deviations. Student’s t tests were used to test the null hypothesis for continuous numeric data, and Cuzick’s test for trend was used to compare categorical data. for statistical analysis when appropriate; p < .05 was considered statistically significant.
Patients From November 2008 to September 2012, at the Department of Orthopedics, Huashan Hospital, Fudan University, we performed a surgical intervention for 95 patients with a stage 2 (n ¼ 41) or stage 3 (n ¼ 54) ingrown toenail. The present study was conducted in accordance with the Declaration of Helsinki. The ethics committee of Fudan University approved our study, and all participants provided written informed consent. Patients with diabetes mellitus or any immunodeficiency condition, including chemotherapy, coagulopathy status, peripheral vascular disease, or arteriosclerosis (determined by clinical history and physical examination findings) were excluded. Eventually, 95 patients were selected. Of the 95 patients, 39 (47 toenails, median age 31.3 7.0, range 22 to 43 years; median weight 60.3 4.4, range 55 to 70 kg; 21 males and 18 females) underwent wedge resection (Winograd procedure) and 56 (68 toenails, median age 35.3 7.0, range 26 to 49 years; median weight 63.3 2.4, range 52 to 73 kg; 32 males and 24 females) underwent wedge resection plus complete nail plate avulsion. We first compared the efficiency of the 2 procedures by evaluating the differences in surgical duration, healing time, recurrence percentage, postoperative infection percentage, and patient satisfaction with the cosmetic results. Wedge Resection (Winograd Procedure) A small incision in the soft tissue of the nail fold and eponychium (proximal nail fold) was made. Mainly by blunt dissection, the soft tissue was separated from the ingrown piece of nail until the lateral edge of the nail was reached. With small pointed scissors, the nail was cut, with the incision extending back to the end of the matrix. The loose piece of nail was retracted and separated from the nail bed. With a small surgical curette, the matrix and nail bed were destroyed to prevent recurrence.
Results A total of 115 ingrown toenails were treated in 95 patients (61 males and 34 females). Their mean age was 31.6 20.0 years (Table 2). Comparison of patient age, sex distribution, and body weight by treatment group revealed no statistically significant differences (p > .05). Recurrence was defined by pain, overgrowth of the skin fold, and infection. The unique concentration of resident microbes found in the nail folds could help explain the postoperative infections identified in the present study. The incidence of recurrence and postoperative infection is listed in Tables 3 and 4 respectively. The mean surgical duration for wedge resection (Winograd procedure) and wedge resection plus complete nail plate avulsion was 14.9 2.4 minutes and 15.1 3.2 minutes, respectively (p ¼ .73), and the postoperative healing time was 2.8 1.2 weeks and 2.7 1.3 weeks, respectively (p ¼ .70). Recurrence developed in 3 patients after wedge resection (Winograd procedure) and 4 (7.7% and 7.2%, respectively) after wedge resection plus complete nail plate avulsion (p ¼ .67). Postoperative infection occurred in 3 (5.4% and 5.1%, respectively) patients after wedge resection (Winograd procedure) and 2 after wedge resection plus complete nail plate avulsion
Fig. 1. Staging and clinical manifestations for ingrown toenail: (A) stage 1, (B) stage 2, and (C) stage 3.
J.-Z. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
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Table 2 Patient data (N ¼ 115 ingrown toenails in 95 patients) Surgical Intervention
Patients Sex Male Female Laterality Bilateral Unilateral Age (y)
Wedge Resection Plus Complete Nail Plate Avulsion (n ¼ 68)
Wedge Resection (Winograd procedure) (n ¼ 47) 39
56
25 (26.3) 14 (14.7)
36 (37.9) 20 (21.1)
8 (7) 31 (27) 31.0 20.5
12 (10.4) 44 (38.3) 32.8 19.7
Data presented as n (%) or mean standard deviation.
Fig. 2. Views of a stage 2 ingrown toenail in a 40-year-old male who underwent wedge resection (Winograd procedure). (A) Preoperative view and (B) 6-month postoperative view.
(p ¼ .81). Of the 95 patients, 88 (92.6%) were satisfied with the outcome and 5 complained of the cosmetic results because the nail plate did not regrow well.
Discussion An ingrown toenail is a disorder that negatively affects the quality of life, in particular, of young adults, causes severe loss of labor, and can result in psychological disturbances (13). Although several treatment modalities have been used, it has been proved that the recurrence rates are lower with surgical treatment than with conservative treatment (13). The Winograd procedure is a classic surgical procedure for ingrown toenails. It consists of partial plate excision and subjacent growth center destruction (3). In contrast to what one might think, this is a very delicate surgery, because complete dissection of the lateral horn from the underlying periosteum is not easy. With skilled nail surgeons, this type of surgery can produce excellent results (14),
because such surgeons will know the anatomic bounds of the lateral horns of the matrix perfectly. Thus, they will curve the incision proximally and perform a lateral longitudinal biopsy (15,16). This is the main reason for the various recurrence rates observed in different studies. Gerritsma-Bleeker et al (17) reported a 21% recurrence rate €log lu et al (9) described a new techafter partial matrix excision. Co nique termed the “lateral fold advancement flap” and compared their new technique with partial matrix excision in their prospective study. They found an 8.1% recurrence rate in the partial matrix excision group. Aydin et al (1) reported a 6.5% recurrence rate in their series. Nail plate avulsion is a required step in many nail surgeries (18). Traditional teaching has advocated total plate avulsion, either performed distally to proximally (distal) or proximally to distally (proximal) (19), with the goal of achieving maximum exposure of the nail bed and matrix, but the recurrence rate was as great as 83% (20). In the present study, patients treated using wedge resection (Winograd procedure) experienced almost the same healing time and surgical duration as those who underwent wedge resection plus complete nail plate avulsion. Similarly, the total postoperative infection rate was 5.4% for wedge resection (Winograd procedure) and 5.1% for wedge resection plus complete nail plate avulsion. The corresponding total recurrence rates were 7.7% and 7.2%, lower than the reported recurrence rate. A previous study reported that patients who underwent wedge resection (Winograd procedure) were able to perform normal activities by the end of the second postoperative week and had complete healing by the end of the fourth week (5). In our study, we found the healing time was almost 3 weeks. However, 5 patients had unsatisfactory cosmetic results because the nail plate could not regrow well. All those patients had undergone wedge resection plus complete nail plate avulsion. The best treatment of ingrown toenails should be an effective, simple, inexpensive outpatient procedure with little postoperative discomfort and a rapid return to normal activities. Moreover, low complication and recurrence rates with acceptable cosmetic outcomes are of great importance (6,17,21).In this regard and from our study findings, wedge resection (Winograd procedure) will result in greater nail plate preservation and allow regrowth of the normal nail with fewer signs of previous surgery, providing excellent cosmetic results and immediate pain relief. Thus, we suggest that wedge
Table 3 Incidence of recurrence at 1 week and 1, 6, and 12 months of follow-up
Fig. 3. Views of stage 3 ingrown toenail in a 45-year-old female who underwent wedge resection plus complete nail plate avulsion. (A) Preoperative view and (B) 6-month postoperative view.
Method
Week 1
Month 1
Month 6
Month 12
Total
Wedge resection (Winograd procedure) (n ¼ 47) Wedge resection plus complete nail plate avulsion (n ¼ 68) Total
0
2 (5.1)
1 (2.6)
0
3 (7.7)
0
2 (3.6)
2 (3.6)
0
4 (7.2)
0
4 (4.2)
3 (3.2)
0
7 (7.4)
Data presented as n (%).
4
J.-Z. Huang et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Table 4 Incidence of postoperative infection at 1 week and 1, 6, and 12 months of follow-up Method
Week 1
Month 1
Month 6
Month 12
Total
Wedge resection (Winograd procedure) (n ¼ 47) Wedge resection plus complete nail plate avulsion (n ¼ 68) Total
1 (1.8)
2 (3.6)
0
0
3 (5.4)
2 (5.1)
0
0
0
2 (5.1)
3 (3.2)
2 (2.1)
0
0
5 (5.3)
Data presented as n (%).
resection (Winograd procedure) should be a valuable option in the treatment of the ingrown toenail. However, the present study had its limitations. It was a retrospective analysis, and the patients were not randomized. In addition, the subjects of the study did not include children or older patients; thus, we could not determine whether these procedures would be appropriate for such patients. Therefore, additional studies are needed to identify the appropriate patients with ingrown toenails for wedge resection (Winograd procedure). References 1. Murray WR. Onychocryptosis: principles of non-operative and operative care. Clin Orthop Relat Res 142:96–102, 1979. 2. Keeman JN. The ingrown nail. Ned Tijdschr Geneeskd 130:1431–1434, 1986. 3. Winograd AM. A modification in the technic of operation for ingrown toenail. 1929. J Am Podiatr Med Assoc 97:274–277, 2007. 4. Zuber TJ, Pfenninger JL. Management of ingrown toenails. Am Fam Physician 52:181–190, 1995. 5. Peyvandi H, Robati RM, Yegane RA, Hajinasrollah E, Toossi P, Peyvandi AA, Ourang ZB, Shams A. Comparison of two surgical methods (Winograd and sleeve method) in the treatment of ingrown toenail. Dermatol Surg 37:331–335, 2011.
6. Richert BB, Dahdah MM. Complications of nail surgery. In: Complications in Dermatologic Surgery, pp. 137–158, edited by K Noury, Mosby, Philadelphia, 2008. 7. Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev 4:CD001541, 2012. lu B, Esemenli T. Partial removal of nail matrix in the treatment of 8. Aydin N, Kocaog ingrowing toe nail. Acta Orthop Traumatol Turc 42:174–177, 2008. € log lu H, Koc¸er U, Sungur N, Uysal A, Kankaya Y, Oruc¸ M. A new anatomical repair 9. Co method for the treatment of ingrown nail: prospective comparison of wedge resection of the matrix and partial matricectomy followed by lateral fold advancement flap. Ann Plast Surg 54:306–311, 2005. 10. Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev 18:CD001541, 2005. 11. Vaccari S, Dika E, Balestri R, Rech G, Piraccini BM, Fanti PA. Partial excision of matrix and phenolic ablation for the treatment of ingrowing toenail: a 36-month follow-up of 197 treated patients. Dermatol Surg 36:1288–1293, 2010. 12. Karaca N, Dereli T. Treatment of ingrown toenail with proximolateral matrix partial excision and matrix phenolization. Ann Fam Med 10:556–569, 2012. 13. Matsumoto K, Hashimoto I, Nakanishi H, Kubo Y, Murao K, Arase S. Resin splint as a new conservative treatment for ingrown toenails. J Med Invest 57:321–325, 2010. € rbu € z Y, Ademog lu Y. Results of partial 14. Kayalar M, Bal E, Toros T, Ozaksar K, Gu matrixectomy for chronic ingrown toenail. Foot Ankle Int 32:888–895, 2011. 15. Haneke E, Richert B, di Chiacchio N. Surgery of the whole nail unit. In: Nail Surgery, pp. 133–148, edited by B Richert, N di Chiacchio, E Haneke, Informa Heathcare, London, 2010. 16. Krull E. Exploration of nail tissue. In: Nail Surgery, pp. 49–53, edited by E Krull, E Zook, R Baran, E Haneke, Lippincott Williams & Wilkins, Philadelphia,, 2001. 17. Gerritsma-Bleeker CL, Klaase JM, Geelkerken RH, Hermans J, van Det RJ. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 137:320–325, 2002. 18. Jellinek NJ. Primary malignant tumors of the nail unit. Adv Dermatol 21:33–64, 2005. 19. Zaias N. Surgical procedures. In: The Nail in Health and Diseaseed 2, Appleton & Lange, Norwalk, CT, 1990, pp. 67–80. 20. Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toenails. J Bone Joint Surg Br 73:131–133, 1991. 21. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 79:303–308, 2009.
