The Treatment Of Ingrowing Toenails Nursing Essay

Abstract

Background: Onychocryptosis (aka ingrown toenail) has been a very common complaint that I have encountered from my patients that I have seen in the clinical setting throughout my entire military career. When it came to the management / treatment of this condition by the physician that I was working with in the past. They all seem to have their own methods and rationale when it comes to the best treatment / management depending on their experience. Now that I am going to be a physician assistant working in a clinical setting and I have seen how frustrating and debilitating this condition can be to patients. As a physician assistant I want to be able to provide the best possible treatment / management to any future patients that I may see with this common condition.

Objectives: The purpose of this paper is to compare what are the best non-surgical techniques / surgical interventions/treatments when it comes to treating a patient that is presenting with an ingrown toenail. I will also compare the recurrence rate; possible complication of each individual procedure; and compare what is the recovery time after having any of the above procedure done.

Search Methods: All information review to complete this paper was found by doing a search of Google, Google Scholar, Medline, Cochrane Database, Pub Med, Medscape, Pepid and DynaMed.

Selection criteria: I focused my search on review articles, randomized control trails, journal articles, and any systematic reviews that I was able to find that discussed the topic of onychocryptosis. My online search include key words such as onychocryptosis, ingrown toe nails, partial wedge resection, and total wedge resection, treatment of in grown toe nails, surgical procedure used in the treatment of onychocryptosis, treatment options, and prevention of ingrown toenails.

Main Results:

Author conclusions:

Introduction

I have chosen the topic of onychocryptosis (ingrown toenail) as my Evidence Based Medicine paper because onychocryptosis has been a very common complaint that I have encounter from my patients that I have seen in the clinical setting throughout my entire military career. As we all have seen when it comes to the treatment / management of this complaint / condition by the physician that we may be working with in the past. They all seem to have their own methods and rational when it comes to the best treatment / management depending on their experience. Now that I am going to be a physician assistant working in a clinical setting and I have seen how frustrating and debilitating this condition can be to patients. As a physician assistant I want to be able to provide the best possible treatment / management to any future patients that I may see in a clinical setting with this common condition.

I will start out by covering the terminology/anatomy of the toenail as a unit. It consists of the nail plate, matrix, lunula, onychodermal band as well as the proximal fold, lateral folds, eponychium. The nail itself is rectangular in shape, hard, smooth and is made up of a tough protein called keratin. The matrix is the part where the nail actually originates from and it contains nerves, lymph, and blood vessels. The lunula is part of the matrix; it is the whitish half moon shape that is visible at the proximal end of the nail plate. Onychodermal band is at the free edge of the nail, greyish in color, and is the seal between the nail plate and the hyponychium. The proximal nail fold protects the nail at the nail plate where the nail grows. The lateral nail folds protect the lateral nail folds as it grows. The eponychium is visible portion of the proximal nail fold that ends at the proximal base of the nail plate. The cuticle is a layer of skin that is shed from the eponychium and extends out from the proximal nail fold and sits on top of the nail plate.

An onychocryptosis (aka ingrown toenail) is when the nail curves or splits into the skin of the affected toe and imbeds in the surrounding soft tissue of the lateral aspect of the nail groove. Resulting in pain, redness, swelling, warmth, pus draining from infected site, sepsis, as well as a build up of granulated tissue over time. The great toe is usually affected most often and it is seen most frequently in adolescents or young adults. Ingrown toenails are regularly due to ill fitting foot wear or improper nail trimming. It maybe also be caused by hyperhidrosis, poor foot hygiene, nail abnormalities, repeated trauma, changes associated with aging, diabetes, gout, arthritis, females with Turner syndrome, obesity, poor stance or gait, subungual neoplasms and skeletal abnormalities such as hallux valgus or claw toes.

For us as a clinician, diagnosis is made clinically in office but sometimes you may have to utilize an x ray to rule out that it is not an exostosis or a tumor of the nail bed. According to the American Family of Physicians Onychocryptosis can be divided into 3 stages according to its severity; Stage 1 is characterized by pain when pressure applied to the affected area, swelling, and erythema; Stage 2 will present with an increase in all of stage 1 symptoms along with the presentation of purulent discharge from the affected site and infection; Stage 3 will present with magnified stage 1 symptoms, the present of hypertrophy of the affected wall and present of granulation tissue. (Heidelbaugh J. & Lee, H. 2009)

The treatment of a patient presenting with an onychocryptosis depends on the stage in which the condition has progressed. There are several suggested methods of treatments but no set standardized treatment. Most physician that I have worked with in the past have preferred surgical treatment over non-surgical. Options that you may conceder for the management / treatment for ingrown toenail are as follows for each stage of classification.

Stage 1 is usually treated conservatively with non-surgical treatments:

warm water foot soaks 2-3 times a day

topical or oral antibiotic therapy such as polysporin or Keflex

patient education when it comes to nail trimming/foot care/footwear

as well as elevation of the nail with a cotton wick

shape memory alloy devices may be use (orthonyxia)

nail splinting/wiring technique

gutter splint or sleeve technique

band aide method

dental floss technique

angle correction technique

super elastic wire technique

Stage 2 and 3 can be treated surgically with any of the following procedures:

Vandenbos procedure which is a radical excision of the nail fold

rotational flap technique

Winograd procedure (wedge resection of the toenail) this procedure may be combine with caustic liquid such as phenol or sodium hydroxide

wedge excision or wedge segmental excision these procedures may be combine with caustic liquid as well

with excision of the total nail avulsion combined matrix (Zadik procedure)

partial nail avulsion ( Ross procedure) combine with surgical matricectomy, or combine with chemical matricectomy with phenol or sodium hydroxide

The purpose of this paper is to compare what are the best non-surgical techniques / surgical interventions when it comes to treating a patient that is presenting with an ingrown toenail. I will also look at the recurrence rate; possible complication rate of each individual procedures; and compare what is the recovery time after having any of the above procedure done.

Review of literature

For all the materials that I review with regards to ingrown toe nails (onychocryptosis) I found by conducting a search of Google, Google Scholar, Medline, Cochrane Database, Pub Med, Medscape, Pepid and DynaMed. I focused my search on review articles, randomized control trails, journal articles, and any systematic reviews that I was able to find that discussed the topic of Onychocryptosis. My online search used key words such as Onychocryptosis, ingrown toe nails, partial wedge resection, and total wedge resection, treatment of in grown toe nails, surgical procedure used in the treatment of Onychocryptosis, treatment options, and prevention of ingrown toenails.

Below is listed a brief description of some of the conservative non-surgical technique as well as the surgical procedures that may be used in the treatment of an ingrown toenail.

Conservative techniques

Gutter splint or sleeve technique: is when a small piece of sterilized vinyl intravenous tubing is taken and split down the side with the one end of the tube being cut diagonally for smooth insertion. Patients may be given a local anesthesia for patient comfort during the procedure. The tube is inserted on the lateral aspect of the nail plate, by pushing proximally until it covers the spicule. It is then secured in place with a band aid, steri-strips. (Khunger, N., & Kandhari, R. 2012) (Abby N., Roni P., Amnon B., & Yan P. 2002) (Arai H., Arai T., Nakajima H., & Haneke E. 2004) (Lee J., Kim S., Park K., & Son S. 2008)

Elevation of the nail with a cotton wick technique: with this method a cotton wick is place under the lateral edge of the ingrown nail. It is simple, easily performed, and repeated daily by the patient themselves usually after soaking their affected toe. (Khunger N. & Kandhari R. 2012)

Band-aid Method: with this method one end of the adhesive band-aid is placed on the lateral side of the affected toe. Then the rest of the band-aid is twisted around the toe so that it crosses where you first started on the lateral aspect of the affected toe. (Khunger N. & Kandhari R. 2012)

Dental floss technique: a string of dental floss is inserted obliquely under the ingrown nail corner and it is pushed proximally. By doing this the lateral edge of the nail and the spicule is separated by this technique. (Khunger N. & Kandhari R. 2012)

Angle correction technique: with this technique the whole anterior surface of the nail is basically filed down to reduce the thickness of the nail itself. This technique is repeated by the patients themselves making the nail soft and thin. (Ozdil B. & Eray I. 2009)

Shape memory alloy devices may be use (orthonyxia): this technique involves using a device that is made up of shape memory alloy. The procedure requires you to trim the end of the ingrowing toenail that is piercing the lateral nail fold. Then by placing the shape memory device on the end of the nail it basically forces the nail to straighten by using the recovery force of the device. (Ishibashi M., et al. 2008)

Super elastic wire technique: this technique is done by drilling two holes in the distal/lateral free edges of the nail plate using a 18 or 20 gauge needle. Then an elastic wire is treated through the holes that have been drilled until the degree of the nail is less than sixty degrees. The wire is then bent forward toward the distal free end of the nail plate and sniped of so that they do not protrude from under the nail. The small holes that have been drilled are then fills with an adhesive agent that assist in ensure the wire stays in place. (Moriue T., et al. 2008).

Surgical procedures

Radical excision of the nail fold or Vandenbos procedure: this procedure is done under a sterile field, using a ring block technique for to freeze the toe and a tourniquet is the secured around at the base of the toe. An in incision is made proximally at the base of the nail, ensuring to leave the nail bed itself intact. Then the incision is continued in an elliptical manner and ends just beneath the tip of the nail at the distal end of the toe. The flap is then removed at the base. With this technique you may have to use light cauterization to control small bleeds along the edges of the open skin margins. Then it is cover with a bactigras mesh, telfa, and a bulky gauge dressing. (Khunger N. & Kandhari R. 2012)

Wedge excision, wedge segmental excision or wedge resection also known as Winograd procedure: This procedure is done under a sterile field, using a ring block technique for to freeze the toe and then tourniquet is the secured around at the base of the toe. Then the affected portion of the nail plate is cut down to the base of the toe using a longitudinal incision, then a partial matricectomy and wedge extirpation of the affected nail fold and portion of the bed itself. This procedure in many cases is combined with the application of a caustic liquid such as phenol. Then it is cover with a bactigras mesh, telfa, and a bulky gauge dressing. (Peyvandi H. Et al. 2011)

Total nail avulsion also known as Zadik procedure: this procedure is done under a sterile field, using a ring block technique for to anesthesia and a tourniquet is the secured around at the base of the toe. This is the easy way to relieve the pain/discomfort caused by an ingrown toenail. With this surgical procedure the whole nail is removed and if a granuloma is present it maybe excised as well. This procedure in many cases is combined with excision of the matrix or some physicians may apply an application of a caustic liquid such as phenol. It is then covered with a bactigras mesh like dressing, telfa, and a bulky gauge dressing. (Eekhof J., Van Wijk B., Knuistingh Neven A., & van der Wouden J. 2012)

Partial nail avulsion also known as the Ross procedure: this procedure is done under a sterile field, using a ring block technique for anesthesia to the toe and then tourniquet is the secured around at the base of the toe. Then an incision is made down the longitudinal axis and the troublesome portion of the affected nail is remove using forceps. This procedure as well in many cases is combined with other techniques or maybe combined with the application of a caustic liquid such as phenol. (Eekhof J., Van Wijk B., Knuistingh Neven A., & van der Wouden J. 2012)

The first article that I reviewed, look at the Vandenbos procedure being used in the treatment of a classic presentation of an ingrown toe nail or over grown toe skin. The paper was written by a Dr Henry Chapeskie who did the review on his own practise when it came to him treating onychocryptosis. In the paper he describes the Vandenbos procedure in great detail and how it was performed in his own patients that he had treated over a 20 year time frame. In the 20 year that he had used this procedure he stated that he treated 500 ingrown toe nails in 440 patients. In all the cases the Vandenbos procedure was used; patients were followed up at the 2 and 6 week post operative; and he states that no cases of recurrences were report or neither were there any reported cases of osteomyelitis / infection. Total healing time after the procedure was 6 week time frame and his patients were back to normal activity. (Chapeskie H. 2008)

The next article I reviewed was written by Di Chiacchio N., Belda W., Kezam Gabriel F., & de Farias, D. in 2010. They looked at the treatment of onychocryptosis with partial wedge resection with Phenolization of the nail matrix. In the article they describe the technique used in a very precise matter and post operative care instructions give to the patients were identical for each case. The study was done from April 2003 to February 2005 in which 172 patients were referred to the same specialist for partial wedge resection with phenolization of the nail matrix. The same procedure was use by the same specialist on all 172 patients throughout this given time frame. Once the procedure was completed patients were followed up on the 10, 30, and 60 day mark. The total time period for this study extended from 6 to 33 months. They reported there were no post operative complications reported but five out of the one hundred and seventy two patients treated did report that they had recurrent of the ingrown toenail in the four to six month time frame following the procedure. All of the patients??? returned to full activities just two weeks after having the procedure done. (Di Chiacchio N., Belda W., Di Chiacchio N., Kezam Gabriel F., & de Farias D. 2010)

Segmental phenolization for the treatment of ingrowing toenails was a retrospective study that I also reviewed. This study was carried out from January 1996 to Dec 2001 in which 764 patients were treated with segmental (partial) wedge resection procedure with phenolization of the nail bed. The technique used was described in great detail. Patients were followed up at the 24 hrs, 7 days, and weekly until fully healed. Out of the 764 patients that were treated there were only 33 patients (4.3%) that had recurrent of the ingrown toe nail. There were no reported cases of postoperative complications such as spreading of the sepsis or osteomyelitis. All of the patients??? returned to work/ full activities same day or 24 hours later after having the procedure done. (Andreassi A., Grimaldi L., D'Aniello C., Pianigiani E., & Bilenchi R. 2004)

In 2011 Peyvandi H., et al. conducted a randomly selected clinical trial where they compared the Winograd procedure (wedge resection of the toenail) to Sleeve method in the treatment of ingrown toe nails. This trial was carried out between April 2008 to March 2009 and the procedures were performed by the same trained medical resident under the careful supervision of experience surgeons. The results of this clinical trial were based on 100 patients that were treated, fifty patients with the Winograd procedure and fifty patients with the sleeve method. The techniques used to perform each procedure were described in great detail and carried out in the identical way in the treatment of each individual patient whether they receive the Winograd or the sleeve procedure. Patients were followed up at the 1 week, 1 month and six month time frame. Out of the 100 patients that received treatment: fifty with the Winograd and fifty with the sleeve method. There were only 5 patients (10%) that had recurrent of the ingrown toe nail after having the sleeve method performed. There were 4 cases (8%) of postoperative complications such as incidence of infection that had to be treated. As for the patients having the Winograd procedure there were 6 patients (12%) that had recurrent of the ingrown toe nail. There were 3 cases (6%) of postoperative complications such as incidence of infection that had to be treated. All of the patients??? returned to work/ full activities 24-48 hours after the procedures. (Peyvandi H., et al., 2011).

In 2010 Vaccari S., et al. conducted a randomly selected clinical trial where they use a partial excision of the matrix and phenolic ablation in the treatment of ingrown toe nails. This trial was carried out between June 2002 to November 2006 and the procedure was performed on 197 ingrown toe nails of 139 patients all of which were stage 2 or 3. If any infection or inflammation was present it was treated with a topical therapy and the surgical procedure was carried out as soon as it was resolved. The techniques used to perform each procedure was described in great detail and carried out in the identical matter in the treatment of each individual patient whether it was stage 2 or 3 of ingrown toe nail. The only exceptions that were used in this trial was if the patient presented with history vascular disease they were excluded and post operatively if the patient was elderly they were put on azithromycin 500 mg once a day for three days. Post operatively patients were followed up at the 1 week, 1, 3, 6,12,24 and 36 month marks. After the procedure was done the average healing time was 2-4 weeks and all patients were back to full activity. There were only three cases of recurrent out of the 197 ingrown toenails that were removed. The surgical success rate after having this procedure done was proven by the low rate of 1.5 % of recurrent. There were 0% postoperative complications such as incidence of infection that had to be treated. (Vaccari S., et al. 2010).

In 2010 Chapeskie H. & Kovac J wrote a retrospective study that looked at 124 patients with ingrown toe nails that underwent a soft tissue nail fold excision also known as Vandenbos procedure. The period of the study was from 1988 to 2004 and a total of 212 surgical sites were analyzed. The surgical procedure was described in great detail and carried out in the identical matter in the treatment of each individual patient whether it was stage 2 or 3 of ingrown toe nail. Dr H Chapeskie performed or supervised all the surgical procedures. Post operatively patients were instructed to soak their toe in a warm bath three times a day for 15-20 minutes for 4-6 weeks. Post operatively patients were followed up once a week, for six weeks. After the procedure was done the average healing time was 4-6 weeks and all patients were back to full activity. There were no cases of recurrence out of the 212 surgical sites that were performed. The surgical success rate after having this procedure done was proven by the low rate of 0% of recurrence in all of the patients treated. There were no postoperative complications such as incidence of infection or osteomyelitis that had to be treated. Although 2 patients did complain of loss of sensation around the area of the surgery. (Chapeskie H. & Kovac J., 2010).

Bernard Noel in 2008 looked at surgical treatment of ingrown toe nails without having a matricectomy done. This study looked at 23 patients that were treated from January 2002 to August 2005 who had severe ingrown toe nails. Patients were instructed to use a foot bath with sodium hypochlorite solution prior to and the surgery was done in clinic within one week of resolution of the acute inflammatory process being resolved. No topical or oral antibiotics were used. The surgical procedure was described in great detail and patients were treated with the same operational protocol no matter the severity of the ingrown toe nail toe nail for all 23 patients. The surgical procedure used was similar to that of a Vandenbos procedure. The area that was to be excised was to the lateral aspect of the nail plate on both side of the affected toe. A wedge shape elliptical incision was made deep enough to ensure a large volume of soft tissue was removed and care was taken to ensuring that no injure was done to the nail bed or matrix. Then the incision was closed with interrupted sutures. It was dressed daily for seven days and the sutures came out at 14 days post op. All the patients were followed up for a 1 year period. After the procedure was done the average healing time was 2 weeks and most patients were back to full activity and able to wear normal foot wear. There were no cases of recurrence out of the 23 patients that under when this surgical technique. There were no postoperative complications such as incidence of infection or osteomyelitis that were reported with in the 12 months of follow up. (No??l B. 2008).

Kim Y. Et al, in 2003 wrote a study that looked at nail splinting technique for treatment of ingrown toe nails. This study covered a period from August 1999 to August 2000. There were 57 patients in total who under when the nail splinting procedure. The surgical procedure was described in great detail and carried out in the identical matter in the treatment of each individual patient whether it was stage 1, 2 or 3. There was one difference and that was in the time the splint was left in place. To control this they were divided into two groups. Group 1(28 pers) had the splint removed after 3 days (72 hours). Group 2 (29 pers) had the splint removed 14 days after Treatment. All the patients were followed up at the 3rd day group1 only, then 1, 2, 4th weeks, and 1 year after receiving the treatment. There were no postoperative complications such as incidence of infection that were reported with in the 12 months of follow up. Out of the 57 patients treated only 5 had recurrences of the ingrown toenail during the 1 year follow (three in group 2 and two in group 1). After the procedure was done the average healing time was 24 hours and all patients were back to full activity and able to wear normal foot wear even while they had the splint in place. (Kim Y., Ko J., Choi K., Lee C., & Lim K. 2003)

Ishibashi M. et al, wrote an article that discusses the treatment of an ingrown toe nail with a shape memory device. This device was used on 14 patients that had an ingrown toenail. The device was applying in office the first initial time and done in the exact procedure for all. There were no reports of any complication and patients were back to full active the same day. Follow up period was every 2 weeks for a 3 month period. There were no cases of recurrence within the time frame of the study. (Ishibashi M. et al, 2008).

Erdogan F. (2006) wrote an article that suggested a simple, pain-free treatment for ingrown toenails complicated with granulation tissue (stage 3). In this study they apply stainless steel dental wire with 2 hooks on each end to seven patients with ingrown toe nail. This device was then placed on each side of the lateral / medical aspect of the toe and secure in place with a dental string in the middle. Granulation tissue on the effected side was cauterized by silver nitrate on a weekly basis until the tissue was removed. The patients were instructed to soak their foot twice a day for 10 days in diluted potassium permanganate solution. Once they were treated they followed up on 3rd day, 1,2,3,4 weeks. They were called at the 1st and 6th month after cessation of treatment. There were no reports of any complications and patients were back to full active the same day. There were no cases of recurrence within the time frame of the study reported. (Erdogan F. 2006).

Dr B Ozdil and Dr Ismail Cem Eray wrote an article that looked at the angle correction technique. They based their finding on the treatment outcome of eight patients that they had seen in their clinic. Any of the patients that presented initial with stage 2 symptoms were treated medically with antibiotics and told to wear open shoes. The angle correction technique was performed on all eight patients and they were taught / instructed to do this at home once every two months. Patients were followed up over the next six months. In all cases patients were pain free after 3-4 days and any infection was gone after seven days of having the procedure done. (Ozdil B. & Eray I. 2009).

Discussion

In this review of the literature, the articles / studies that I have read, confirmed to me that there is no set standard of care when it comes to the treatment / management of a patients that presents with an onychocryptosis. There are several different methods that I have reviewed which suggest a conservative non-surgical or surgical interventions depending on what stage (1, 2, and 3) the patient presents with. ???The object of performing a surgical intervention on an ingrown toe nail is to cure the actual problem and to prevent its regrowth and recurrences.??? Whereas. ???The object of performing a non-surgical intervention is to cure the problem and prevent recurrences, but not to prevent regrowth. Therefore, the primary outcome measures are the relief of symptoms, prevention of recurrence and / or regrowth (including nail spikes/spicule).??? The treatment chosen mostly by the physicians/ health care provider depends on their own personal experience, preference, and skills in performing some of the procedures that are used in their clinical setting. It also depends on the patient???s consent. They may not want to have a surgical procedure done due to their fears of having long term alteration of the nail anatomy, healing time involved and postoperative pain / possible complications. Non surgical interventions could be used in stage 1 or even sometimes stage 2 but most times the physician will choose to treat an ingrown toe nail surgically. Depending on the physician / surgeon they may use different pre or post operative measures such as having the patients take oral antibiotics, foot soaks, topical antibiotics, covering it with special medicated gauge, etc. (Eekhof J., Van Wijk B., Knuistingh Neven A., & van der Wouden J. 2012)

When it came to surgical options in the treatment of an ingrown toe nail that I had reviewed, the best results were found with the use of the Vandenbos procedure which is recommended for use in stage 2 or 3. There were 3 articles that support this procedure when it came to the treatment of an ingrown toe nail. The first was written by Dr Henry Chapeskie H. 2008, where he reported treating 500 ingrown toe nails on 440 patients with the Vandenbos procedure over a 20 year time frame. The follow up period was only 6 weeks post operative but there were no cases of (0%) recurrence in all of the 500 cases that he used the procedure on. When it came to complication post operatively there were no reported cases of infection or osteomyelitis (0%). All Patients were back to normal activities of their daily living within 4-6 weeks. The only disadvantage to this procedure for most patients is the long recovery time. The second article was written by Chapeskie H. & Kovac J. wrote a retrospective study that looked at 124 patients with ingrown toe nails that underwent a soft tissue nail fold excision also known as Vandenbos procedure. The procedures were all done within a 16 year period and 212 surgical sites in total were analyzed on 124 patients. When it came to complication post operatively there were no reported cases of infection or osteomyelitis. But two patients did complain of loss of sensation around the area of the surgery. All Patients were back to normal activities of their daily living within 4-6 weeks. There were no reported cases of recurrence out of the 212 surgical sites that were performed. The third paper was written by Bernard Noel in 2008 that looked at surgical treatment of ingrown toe nails without having a matricectomy done. The surgical procedure used was similar to that of a Vandenbos procedure. The area that was to be excised was to the lateral aspect of the nail plate on both side of the affected toe. A wedge shape elliptical incision was made deep enough to ensure a large volume of soft tissue was removed and care was taken to ensuring that no injury was done to the nail bed or matrix. Then the incision was closed with interrupted sutures. There were twenty three patients that were treated with this surgical technique from January 2002 to August 2005 who had severe ingrown toe nails presenting in stage 2 or 3. Patients were followed up over a 1 year time frame. There were no cases of recurrence out of the 23 patients that under when this surgical technique. There were no postoperative complications and after the procedure was done the average healing time was 2 weeks and most patients were back to full activity. (Chapeskie H. 2008) (Chapeskie H. & Kovac J., 2010) (No??l B. 2008).

In the treatment of onychocryptosis using partial wedge resection three of the articles I reviewed used phenolization of the nail matrix in conjunction with it. The first was written by Di Chiacchio N., Belda W., Kezam Gabriel F., & de Farias, D. in 2010. They looked at the treatment of onychocryptosis with partial wedge resection with phenolization of the nail matrix. The study was done from April 2003 to February 2005 in which 172 patients were referred to the same specialist for partial wedge resection with phenolization of the nail matrix. Once the procedure was completed patients were followed up on the 10, 30, and 60 day mark. They reported there were no post operative complications such as infection or osteomyelitis reported with in the first 60 day mark. But 5 out of the 172 patients treated did report that they had recurrent of the ingrown toenail in the 4-6 months time frame following the procedure. All of the patients??? returned to full activities just two weeks after having the procedure done. A second article written by Andreassi A., Grimaldi L., D'Aniello C., Pianigiani E., & Bilenchi R. in 2004 looked segmental phenolization for the treatment of an ingrown toe nail. This study was carried out from January 1996 to Dec 2001 in which 764 patients were treated with segmental (partial) wedge resection procedure with phenolization of the nail bed. The followed up period was done at the 24 hrs post operatively and then weekly until patients were fully healed. Out of the 764 patients that were treated there were only 33 patients (4.3%) that had reported recurrence of the ingrown toe nail. There were no reported cases of postoperative complications and all patients returned to full activities same day or 24 hours later after having the procedure done. The third study written by Vaccari S., et al. conducted a randomly selected clinical trial where they use a partial excision of the matrix and phenolic ablation of the nail bed. It was carried out from June 2002 to November 2006 and the procedure was performed on 197 ingrown toe nails of 139 patients all of which all were in stage 2 or 3. Prior to the procedure if infection was present it was treated with topical antibiotics and post operatively if the patient was elderly they were put on azithromycin 500 mg once a day for three days. After the procedure was done the average healing time was 2-4 weeks and all patients were back to full activity. There were only 3 cases of recurrence out of the 197 ingrown toenails that were removed and no postoperative complications such as incidence of infection. (Di Chiacchio N., Belda W., Di Chiacchio N., Kezam Gabriel F., & de Farias D. 2010) (Andreassi A., Grimaldi L., D'Aniello C., Pianigiani E., & Bilenchi R. 2004) . (Vaccari S., et al. 2010)

I only found one article that compared nonsurgical to surgical procedures for the treatment of ingrown toe nails. It was written by Peyvandi H., et al in 2010 where he conducted a randomly selected clinical trial where they compared the Winograd procedure (wedge resection of the toenail) to Sleeve method in the treatment of ingrown toe nails. It was based on 100 patients and carried out from April 2008 to March 2009 under the careful supervision of experience surgeons. The patient were divided into two groups (50/50) with half having the Winograd procedure and the other half having the sleeve method performed for the treatment of their ingrown toenail. Patients were followed up over a six month time frame. Out of 50 there were only 5 patients (10%) that had recurrent of the ingrown toe nail after having the sleeve method performed. There were 4 cases (8%) of postoperative complications such as incidence of infection that had to be treated with antibiotics. As for the patients having the Winograd procedure there were 6 patients (12%) that had recurrent of the ingrown toe nail. There were 3 cases (6%) of postoperative complications such as incidence of infection that had to be treated. In both procedures all of the patients??? returned to work/ full activities 24-48 hours after the procedures. (Peyvandi H., et al., 2011).

When it came to nonsurgical techniques for the treatment of ingrown toenails I looked at several articles / papers on the different techniques that are recommended but only could find a select few studies that gave me any stats on recurrence, complication and recover time. One study written in 2003 by Kim Y. Et al, looked at nail splinting technique for treatment of ingrown toe nails. This study covered a period from August 1999 to August 2000 and 57 patients in total who under when the nail splinting procedure. It looked at the time the splint should be left in place (3 or 14 days) and to control this they were divided into two groups. Group 1(28 pers) had the splint removed after 3 days (72 hours). Group 2 (29 pers) had the splint removed 14 days after treatment. All the patients were followed up at the 3rd day group1 only, then 1, 2, 4th weeks, and 1 year after receiving the treatment. After the study was complete there were no postoperative complications such as incidence of infection that were reported. Out of the 57 patients treated only 5 had recurrences of the ingrown toenail during the 1 year follow (three in group 2 and two in group 1). After the procedure was done the average healing time was 24 hours and all patients were back to full activity. Another article looked at the use of a shape memory device but only had 14 patients that it was used on and the follow up period was short (3months). There were no cases of recurrence, no reports of any complication, and patients were back to work the same day. (Kim Y., Ko J., Choi K., Lee C., & Lim K. 2003) (Ishibashi M. et al, 2008).

Conclusion

There is no set standard of care when it comes to the treatment / management of patients that presents with an onychocryptosis. There are several different articles that I have reviewed which suggest a conservative non-surgical technique or surgical interventions depending on what stage (1, 2, and 3) the patient presents with. But when it comes to the actual treatment it depends on the physician/surgeon and their own personal experience, preferences, skill level/comfort at performing these procedures.

I compared non- surgical interventions to surgical interventions in the treatment of onychocryptosis. Surgical intervention techniques that are used most commonly show that they are better at preventing the recurrence or regrowth of ingrown toe nails. Most of the surgical techniques I have looked at used the application of phenol in conjunction with the technique such as the Winograd or the Zadik procedure. By adding phenol to these techniques it proved to be more effective in preventing the regrowth and decrease the chances of recurrences. But when it came to using the Vandenbos procedure this proved to be the best treatment from the materials I have reviewed. This surgical procedure yielded the best results when it came to preventing the regrowth or recurrence of ingrown toe nails as well as preserving the nail bed itself. But healing time was much longer for the patients it ranged anywhere from 4 ??? 6 weeks compared to the Winograd or Zadik procedure.

When it came to non- surgical treatments such as the gutter splint / sleeve method techniques the studies I reviewed showed that after the study was complete there were no postoperative complications such as incidence of infection that were reported. Out of the 57 patients treated only 5 had recurrences of the ingrown toenail during the 1 year follow (three in group 2 and two in group 1). The average healing time was 24 hours and all patients were back to full activity. The biggest difference here was how long to leave the splint in place. If it was left in for 3 or 14 days it did not make a big difference in the difference in number of patients that had recurrences.

As for nonsurgical technique such as the elevation of the nail with a cotton wick technique, band-aid method, and dental floss technique etc there was not allot of studies that I could find to support the use of these methods. From the literature I did read they suggested that these only provide a temporary relieve of the symptoms and have a very high percentage rate of recurrence when use.