Study Sparks Debate About Treatment Options For Ingrown Toenails

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Patients commonly present with ingrown toenails and treatments range from chemical matrixectomy to the newer orthonyxia procedure. A new study in the Journal of the American College of Surgery concludes that orthonyxia, using a metal brace for the toe, is superior to partial matrix excision in terms of recovery and patient satisfaction.
Researchers randomized 105 consecutive patients with 109 toenails, excluding patients with diabetes and/or paronychias. Fifty-eight patients underwent partial matrix excision, which included 5 to 10 mL of lidocaine 1%, according to the study. Fifty-one patients underwent orthonyxia via the Fraser procedure, which researchers say entails attaching a small metal brace to the dorsum of the nail.
The 12-month follow-up revealed four ingrown toenail recurrences in the partial matrix excision group and eight in the orthonyxia group. Both treatments were similarly effective, according to the study, but orthonyxia was superior when it came to aspects such as postoperative morbidity, recovery time, post-op symptoms and patient satisfaction.
For example, patients who had the orthonyxia procedure, on average, were able to wear shoes one day after the procedure, whereas patients treated with the partial matrixectomy were not able to wear shoes until four days after the procedure on average.

Does Orthonyxia Have A Role?
John Mozena, DPM, says orthonyxia is a not a new concept for ingrown toenail control. Several years ago, Dr. Mozena says there was a plastic brace that one could glue on the nail in an attempt to change the nail’s shape over time.
“I have not seen any brace that has worked well enough to stand the test of time,” notes Dr. Mozena, who is in private practice in Portland, Ore.
Alexander Reyzelman, DPM, has used orthonyxia and believes it has merit as a conservative option for treating ingrown toenails.
“Orthonyxia is indicated in patients who do not want or cannot have a surgical or chemical procedure due to peripheral vascular disease (PVD), etc.,” explains Dr. Reyzelman, an Assistant Professor and Chairman of the Department of Medicine at the California College of Podiatric Medicine at Samuel Merritt College. “If the patient has a first occurrence of the ingrown toenail without significant inflammation and would like to be treated conservatively, orthonyxia is a good choice.”

Debating The Merits Of Surgical Excision Versus Chemical Matrixectomy
However, Dr. Reyzelman notes that the study’s reported recurrence rate for orthonyxia (16 percent) was higher than the recurrence rate for partial matrix excision (8 percent) at one year. He also expresses reservations about the study’s design and conclusion. Dr. Reyzelman finds it interesting that the researchers compared orthonyxia to surgical excision of the matrix as opposed to phenol chemical matrixectomy.
“Surgical excision matrixectomy is not the standard procedure that is performed these days,” notes Dr. Reyzelman. “The surgical matrixectomy is outdated and has limited use at this time.”
Dr. Reyzelman also questions the study’s exclusion of patients with paronychias and wonders how bad the ingrown toenails were for the patients who were included in the study. He is also the co-author of a soon to be published study, which shows a 3 percent recurrence rate after performing chemical matrixectomies in patients with paronychias due to ingrown toenails.
Overall, Dr. Reyzelman says the partial chemical matrixectomy with phenol “works very well” for ingrown toenails in his clinical experience. “The typical recurrence rate with chemical matrixectomies is no more than 5 percent if the procedure is done correctly,” maintains Dr. Reyzelman.
While John Mozena, DPM, notes that chemical matrixectomy has long been considered the gold standard for ablation of the nail matrix, he cites variable results with this procedure. Dr. Reyzelman concedes that currently published studies show recurrence rates with chemical matrixectomy ranging from 4 to 20 percent.
Dr. Mozena, a Fellow of the American College of Foot and Ankle Surgeons, says the varied results may be partly due to multiple formulas for application times of phenol for matrixectomy. He also cites the chemical nature of phenol. “We are dealing with a chemical that has a half life and can oxidize. We also use this chemical on different tissue densities depending on age and hydration,” points out Dr. Mozena. Dr. Mozena says physicians should strive for more than resolving infection if an ingrown toenail has progressed to that point. In addition to resolving any infection, Dr. Mozena encourages podiatrists to achieve a good cosmetic result with a smooth nail edge and no regrowth or spiculization.
“The only way to get this is via the surgical approach with cold steel or a predictable device such as a laser,” claims Dr. Mozena. “ … I think it is high time we think of ourselves as the surgical experts in this area and quit using such an antiquated technique such as phenol. We should leave the unpredictable phenol to our primary care brothers and sisters.”

What About Ingrown Toenails Among Patients With Diabetes?
Drs. Mozena and Reyzelman also disagree about the use of chemical matrixectomies to treat ingrown toenails in the diabetic population.
With these patients, Dr. Mozena usually “restricts my matrixectomies to surgical techniques only.” The challenge in healing usually lies with the patient’s blood sugar control, according to Dr. Mozena. If the patient’s blood sugar is high, he will do an avulsion only until the patient’s blood sugar is under control and will proceed with the matrixectomy once the patient’s A1C is normal.
However, Dr. Reyzelman says he frequently performs chemical matrixectomies in diabetic patients. He points out that a study by Giacolone supported the use of chemical matrixectomies in patients with diabetes as long as they have decent arterial perfusion. Dr. Reyzelman does caution physicians to avoid using this procedure altogether when patients have significant PVD.

For further reading, see “Current Concepts In Performing Matrixectomies” in the December 2005 issue of Podiatry Today.

Study Examines Foot Ulcer Prevalence In RA Patients
By Brian McCurdy, Senior Editor

How prevalent are foot ulcers in patients with rheumatoid arthritis (RA)? A recent study in Arthritis and Rheumatism found that a significant number of RA patients present with ulcers at multiple sites on the lower extremity.
In a United Kingdom-based survey of approximately 880 patients who were receiving care for RA, researchers found the overall prevalence of foot ulcerations in those patients was 9.73 percent. Thirty-three percent of these patients reported multiple ulceration sites with the most common sites of ulcers being the dorsal aspect of hammertoes, metatarsal heads and the metatarsophalangeal joint (MPJ) in patients with hallux abducto valgus, according to the study.
In addition, researchers found that patients with foot ulcers had RA for a significantly longer period of time. Nathan Wei, MD, FACP, FACR, the Clinical Director of the Arthritis and Osteoporosis Center in Frederick, Md., is not surprised by this finding as longstanding RA is a known risk factor for foot ulcers.
Molly Judge, DPM, says the study’s findings fall in line with current estimates that approximately 10 percent of RA patients will experience ulcers during their lives and most will occur in the forefoot due to digital deformities. Accordingly, these patients may develop bunion deformities, subluxations of the MPJs, hammertoes and malalignment associated with flatfoot deformity.
How do such ulcers complicate the treatment of lower extremity RA? As Dr. Judge says, ulcerations are often associated with areas of bony prominence or rheumatoid nodules.
“Therefore, they can heal slowly or may not heal due to the poor health of the underlying wound bed,” explains Dr. Judge, the Director of Externship Programs and the Coordinator of Residency Selection and Marketing for St. Vincent Charity Hospital in Cleveland.
The presence of foot ulcers indicates more severe disease and Dr. Wei says rheumatologists may consider using more aggressive therapy. However, Dr. Wei, a Fellow of the American College of Rheumatology, says the flipside is that more aggressive therapies like biologic agents also affect the immune system and may make the patient more prone to developing infection.
Since RA is the result of a compromised immune system, Dr. Judge notes the patient will not mount the same type of inflammatory response that a healthy person would. She says these patients may develop an infection without significant outward changes and the ususal cardinal signs for infection (erythema, calor or unusual swelling) may not be impressive if present at all.
Dr. Judge says RA is generally a cool inflammatory process. She adds that chemotherapy agents such as methotrexate may further blunt the inflammatory response so ulcers and infections may go for prolonged periods of time without treatment.
“After all, if the ulcer does not look infected, why should they come in?” comments Dr. Judge, a Fellow of the American College of Foot and Ankle Surgeons. “Patients in this category of disease can lose perspective about what does and what does not look important. They have such bizarre deformity that at times they lose their sense of what normal truly is.”
Ambulation is a significant issue as well. Dr. Wei notes that foot ulcers may indicate the presence of peripheral neuropathy. He says these patients may be more prone to falls, which can lead to fractures and more complicated management. Dr. Wei adds that reduced ambulation in patients with RA and foot ulcers can lead to poor conditioning that further complicates rehabilitation and the possibility of more advanced disability.

A New Approach To Plantar Plate And Hammertoe Repair
By Brian McCurdy, Senior Editor
Can a combined surgical procedure treat chronic plantar plate tears with secondary instability of the lesser MPJs? A recent study in the Journal of Foot and Ankle Surgery examines combined plantar plate and hammertoe repair with flexor digitorum longus transfer.
Study authors retrospectively reviewed 18 patients (20 feet) who underwent the combined surgery to address their severe, chronic sagittal plane instability of the lesser MPJs. Using the Lesser Metatarsophalangeal-Interphalangeal Scale from the American Orthopedic Foot and Ankle Society to evaluate the procedure, researchers noted that patients had an average score of 83.2 (of 100) one year after the procedure. The authors added that all patients were satisfied with the surgical results.
The combined surgical procedure offers several advantages, according to Richard Bouché, DPM, the lead author of the study. He says the surgery addresses the pathology of the ruptured plantar plate and also facilitates a corrective force, a “dynamic tether,” which allows the digit to touch the ground.
However, he does note some downsides. Patients require a significant amount of surgery that uses a combined dorsal and plantar surgical approach, according to Dr. Bouché, a Fellow of the American College of Foot and Ankle Surgeons. Furthermore, he notes that the surgery is contraindicated in patients with questionable circulation and those who cannot be non-weightbearing in the postoperative period.
What should be the focus of future research? Dr. Bouché suggests a prospective randomized study to validate the various proposed surgical procedures to address lesser MPJ instability. He says the aforementioned procedure for addressing severe instability should be one of the procedures studied.

In Brief
The Food and Drug Administration (FDA) recently announced that it is conducting an ongoing safety review of becaplermin (Regranex, Johnson and Johnson).
The review is based on the findings of a study reviewing a health insurance plan database of patients with diabetes who were at least 19 years old, with no history of cancer and were either prescribed Regranex or not. According to the FDA, the study noted that among patients who were prescribed Regranex three or more times, there was an increase in the number of patients who died as a result of cancer.
However, the FDA notes there was not enough information to determine whether there was an increase in the number of patients who developed new cancers.
Hollister Wound Care has been awarded a Novation contract under the Novation New Technology Program. The award includes Hollister Wound Care’s new wound care products featuring TRIACT Technology, according to the company.