Nail Surgery - Need, Procedure and Complications

Introduction:

The nail complex (perionychium) is the structural and functional unit of the fingernail. The nail unit protects the structures from external injury and helps in the movements of the fingers. Nail surgery is performed when any severe abnormality is seen in the nails.

The nail complex is made up of:

1. Matrix - Produces the nail plate.

2. Nail Plate - It is the rigid outer structure that firmly sticks to the nail bed below.

3. Nail Bed - The soft tissue between the bone and the nail plate. Rich in blood supply.

4. Proximal Nail Fold (PNF) - A skin fold on the sides of the nail plate. It acts as a seal.

5. Hyponychium - It is the junction between the sides of the nail bed and the fingertip's skin. It seals the virtual space between the skin and the nail.

What Are the Diagnostic Tests to Perform Nail Surgery?

Radiography remains the gold standard for imaging. It is easy, non‐invasive, and cheap; examination may reveal alterations of the bony structure. It is not sufficiently often performed before nail surgery.

Dermoscopy magnifies all external nail structures. It is of great help in determining the limits of a tumor.

Magnetic Resonance Imaging (MRI) may give a precise location of a tumor that is not clinically visible. Its main indications are vascular and cystic lesions. Thin section computed tomography is of great help in osteoid osteoma.

Ultrasound is not a preoperative diagnostics but provides preoperative photographs of the diseased nail.

Biopsy: biopsy of the nail is used to diagnose dystrophies of nail apparatus, such as lichen planus or psoriasis; early diagnosis of malignancies.

What Are Preoperative Precautions Taken?

• Patient history, information on the surgical procedure, and return to work are gathered.

• Screening for underlying diseases and blood vessel damage of the extremities (diabetes, Raynaud's disease, smoking, arteriopathy).

• Current medication.

• Potential allergies (latex, povidone‐iodine, antibiotics, painkillers, anesthetics).

• The patient is reassured about the management of postoperative pain and the removal of the dressing.

Premedication:

• Short-acting hypnotic and anxiolytic molecules given orally or sublingually before surgery effectively reduce anxiety.

• Antibiotic prophylaxis is only indicated for patients with high‐risk cardiac conditions, prosthetic joint patients, poorly monitored diabetic patients, surgical site infection, and lower extremity procedures.

• Patients more prone to dust accumulation beneath the nails are advised to soak their hands/feet in soap water and scrub and clean them for several days before surgery.

• Ladies are advised to remove their nail polish.

• A footbath with chlorhexidine gluconate 20 minutes before surgery is recommended as it reduces intraoperative and postoperative bacterial growth.

• Incorporating alcohol and povidone‐iodine into the preoperative nail preparation may help reduce the bacterial load.

When Is Nail Surgery Done?

Total surgical removal should be discouraged, and partial nail avulsion should always be preferred.

A partial avulsion is done for the following:

• As an adjuvant treatment in onychomycosis (fungal infection of the nail), it reduces the fungal mass.

• In ingrowing toenails, part of chemical matricectomy (complete removal of the nail matrix).

• Drain an acute paronychia.

• To explore pigmented lesions within the nail matrix.

How Is Nail Surgery Done?

Position the patient supine, with the knees bent and foot flat on the table or stretched and the foot hanging off the table. The surgical area is disinfected with a povidone-iodine solution. The operating site is anesthetized with a local anesthetic nerve block. Wait for five to 10 minutes to completely numb the area. A sterilized rubber band is placed near the surgical site, or pressure along the sides of the toe, or a tourniquet is set to control bleeding and maintain a dry operative field.

The area is rewashed with a surgical solution, and a window-cut drape is placed, exposing the surgical site through the cut window. A nail elevator or a scissor is glided under the cuticle to separate and elevate the nail plate from the curved sides of nail folds. With a nail splitter or bandage scissors, the free ends on the sides of the nail folds are cut to produce straight, smooth nail plate edges.

Sometimes the free ends are grasped with a hemostat or clamp and removed by pulling out directly, exposing the sides of the nail bed and matrix. If the nail plate breaks, the remaining nail is grasped and pulled out until no fragments are left.Electrocautery ablation is used to damage the nail-forming matrix beneath the nail plate removed area and remove any granulation tissue. An adequately treated nail bed appears white after electrocautery.

What Are Postoperative Care to Be Followed?

• Antibiotic ointment is applied and covered with a large gauze dressing until healing is complete. Disposable surgical slippers are given.

• The patient is given the postoperative instruction sheet and advised for mild painkillers for postoperative pain.

• Daily cleansing with warm water is encouraged, and strenuous exercise is discouraged for at least one week.

• Postoperative pain management relies on the elevation of the limb and painkillers.

• Elevate the limbusing a sling or stool for two days. This will ease throbbing, facilitate healing, and avoid swelling.

• The patient is given the postoperative instruction sheet and advised for mild painkillers for postoperative pain. A combination of analgesics with opioid drugs is prescribed for moderate to severe pain.

What Are the Complications in Nail Surgery?

Postoperative complications of nail surgery include:

• Intraoperative Pain may be due to improper anesthesia techniques or insufficient time for the anesthetic to work.

• Dysesthesia is the numbness or loss of sensation, and tingling is observed.

• Postoperative Bleeding within the wound may lead to hematoma. Bleeding is prevented by 35 % Aluminum chloride and Oxidized cellulose or simply by applying direct pressure.

• Infection mostly results from poor home care and/or lack of hygiene.

• Necrosis is an unpredictable complication involving the whole extremity or a minimal area.

• Spicules are crushed injuries that leave many small pieces beneath the nail. If these fragments are not removed, they may grow, resulting in nail horns or spicules.

• Temporary Abnormalities after surgery, the nail grows slow and fast alternately for 50 days resulting in swelling and later becoming flat.

  • A linear nail fissure may be observed.

  • A pseudo-matrix hernia is a swollen matrix above the nail bed that appears due to loss or reduction of the overlying nail plate.

• Permanent Abnormalities like nail deformities, longitudinal erythronychia or leukonychia, longitudinal nail fissure, and lateral deviation of the nail plate.

• Implantation Cyst is an epidermoid inclusion cyst that may appear in a postoperative scar due to suturing, and needle complex regional pain syndrome (CRPS) is pain, sensory, and motor disturbances, along with soft tissue changes.

• Hypertrophic Scar and Keloid may involve the proximal nail fold or the nail bed.

Conclusion:

Nail surgery is necessary to diagnose and treat the nail unit's neoplastic and some inflammatory diseases. Nail surgery is not troublesome but often delicate. Careful preoperative preparation of the patient and consistent postoperative care are necessary.