Current Concepts In Performing Matrixectomies
Ingrown toenails are one of the most common presenting pedal foot maladies with an estimated 20 percent of those who present seeking foot care for this problem.1,2 Chemical matrixectomy is one of the most common surgical procedures podiatrists perform. Although the technique for the matrixectomy procedure is fairly simple and straightforward, there are many modifications to the procedure and there are controversial issues including the use of adjunctive antibiotics and postoperative care.
In order to understand the evolution of the procedure, one must start with the initial description of this procedure in the literature. In 1945, Otto Boll was the first to discuss the use of phenol in treating ingrown toenails. He described removing the nail edge and swabbing the root with pure phenol for 30 seconds, and subsequently pouring alcohol on the wound. In 1953, Gottlieb described removing the entire nail plate and applying phenol for 30 seconds. In 1956, Nyman reported using two small cotton-tipped applicators to apply phenol for 30 to 40 seconds each. Suppan and Ritchlin described applying phenol for two minutes and following it with a three-minute application of alcohol. In 1965, Cooper reported that alcohol lavage was painful and the length of phenol application made no significant difference regarding healing.
As we know, the phenol matrixectomy procedure has been referred to as a phenol and alcohol matrixectomy. The recommendation for using alcohol comes from the fact that phenol is soluble in alcohol and alcohol will accordingly lavage the excess phenol from the nail groove. The initial belief was that alcohol would minimize the chemical burn that is created by applying phenol. However, Greene believed that using alcohol can create more postoperative drainage and inflammation, leading to prolonged healing time.
In reviewing the history of the phenol matrixectomy, there is no scientific evidence to suggest that using alcohol after phenol application will decrease the healing time. At this time, using alcohol to wash out the phenol is purely anecdotal. Furthermore, the decision to use two or three applications of phenol for 30 or more seconds is purely based on the practitioner’s experience.
Pertinent Treatment Tips
That said, let us take a closer look at the technique we teach in the Department of Medicine at the California School of Podiatric Medicine.
Anesthetize the hallux with local infiltration of 1% plain xylocaine in a standard ring block fashion. Then swab the nail with isopropyl alcohol. One would exsanguinate the digit with a 1/2 inch Penrose drain wrapping from the apex to the base of the toe in a winding, overlapping fashion. Secure it at the base of the toe with a hemostat. Free the offending nail border from its soft tissue attachments with an elevator and cut it with an English anvil nail splitter and a #62 or #64 blade. Proceed to remove the nail plate with a hemostat. Excise any exuberant granulation tissue present along the periungual area.
Using narrow cotton swabs, proceed to apply three applications of 89% phenol to the nail matrix for approximately 30 seconds each. Take care to hold the swabs at a 45-degree angle to the skin in order to avoid exposure of the nail bed to the phenol. Release the tourniquet. Then dress the nail groove with plain 2 X 2 inch gauze and a self-adherent bandage.
In regard to the follow-up visit, the patient should return four to seven days later. The patient removes the dressing two to three days after the procedure at home. Instruct patients to cleanse the nail bed in the shower or bath per their normal routine and to apply a band-aid over the toe. The postoperative care will vary from one clinician to another.