Nail Avulsion and Matrixectomy

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Nail avulsion is a commonly performed procedure in which all or a portion of the nail plate is removed from the nail bed. Avulsions may be done for both diagnostic and therapeutic indications. Avulsing the nail plate allows examination and visualization of lesions in the underlying nail bed and matrix. Nail avulsions are sometimes performed when treating onychomycosis to relieve pain from collection of subungual debris. Avulsions are most frequently done for ingrown and incurved nails. 
Ingrown nails (onychocryptosis) is a common problem encountered in primary care practice. Individuals with ingrown nails often present in the second or third decades of life with pain, drainage, and difficulty walking. Ingrown nails are due to abnormal fit of the nail plate in the lateral groove, resulting in a foreign body reaction that produces edema, infection, and granulation tissue. This propensity may be exacerbated by the factors shown in Table 63-1. Some ingrown nails exhibit a laterally pointing spicule of nail that digs into the lateral tissue. 
Three stages have been described for the progression of ingrown nails. In stage I, the lateral nail fold exhibits erythema, mild edema, and pain when pressure is applied. In stage II, individuals experience increased symptoms, drainage, and infection. Stage III is characterized by magnified symptoms, the presence of granulation tissue in the lateral nail fold, and lateral wall hypertrophy. 
Many management options have been proposed for ingrown nails. Soaks, topical or systemic antibiotics, and insertion of a cotton wick into the lateral nail groove have all been used for stage I disease (Table 63-2). Surgical intervention is advocated for stage II and more often for stage III disease. Historically, simple nail avulsion or wedge resection of the distal corner of the nail has been performed. Because ingrown nails represent an abnormal lateral nail groove fit, removal of more than the lateral one fourth of the nail is unnecessary. High recurrence rates are associated with these simple nail excision procedures. 
Matrixectomy of the lateral nail matrix is required to permanently ablate lateral nail-forming tissue and to narrow the width of the nail plate to better fit the lateral nail fold. Many physicians prefer to perform chemical matrixectomy with sodium hydroxide or more commonly with phenol. Phenol produces adequate nail bed ablation, but it is associated with a pungent odor, lateral nail fold damage, excessive wound discharge, and infection. Electrosurgical ablation of the nail bed is a highly successful alternative that produces less discharge. Special high-frequency-unit matrixectomy electrodes with one coated side can be used to avoid injury to the overlying normal tissue of the proximal nail fold (i.e., cuticle) while ablating the nail bed. Laser matrixectomy is another option, but it is less attractive (to most primary care practices) because of the high capital and upkeep costs. 
 
Table 63-1
Factors Associated with Ingrown Nails
The granulation tissue produced by the foreign body reaction can produce lateral wall hypertrophy. Because this tissue is abnormal, some physicians advocate removal at the time of nail surgery. Removal of lateral wall hypertrophy can be accomplished with scalpel excision or with electrosurgical excision or ablation. Tissue removal can produce a scooped-out defect in the lateral tissue at the time of surgery. This defect fills in over several weeks as the remaining normal lateral tissue grows to the newly formed lateral nail edge. 

Equipment

  • Syringe (3 mL or 5 mL) with long (1- or 1.5-inch) 25- or 27-gauge needle

  • Local anesthetic without epinephrine

  • Narrow periosteal elevator (nail elevator)

  • Sterile scissors with straight blades (or nail splitter)

  • Two straight hemostats

  • Alcohol swabs

  • Sterile gauze and tubular gauze dressing

  • Topical antibiotic ointment

  • Phenol solution (88%) and a radiofrequency electrosurgical unit with a Teflon-insulated matrix tip or a low-frequency unit with a needle tip (if performing a matrixectomy)

 
Table 63-2.
Management Options for Ingrown Toenails

Indications

  • Onychocryptosis (ingrown nail), especially stage II or stage III

  • Onychomycosis (fungal infection of the nail) when pressure on the nail causes pain)

  • Onychogryposis (deformed, curved nail)

  • Pincer nails

Contraindications (Relative)

  • Diabetes mellitus.

  • Peripheral vascular disease, especially if digital ischemia exists.

  • Coagulopathy or bleeding diathesis.

  • Uncooperative patient.

  • Overt bacterial infection of the operative site is a relative contraindication to matrixectomy. However, most “infected” ingrown nails do not contain bacteria; they have a sterile inflammatory reaction to the trauma.

The Procedure

Step 1

Position the patient in the supine position, with the knees flexed and the foot flat on the table or the leg extended and the foot hanging off the end of the table. The physician wears nonsterile gloves. Perform a digital block as described in Digital Nerve Block Anesthesia. After adequate time has elapsed (5 to 10 minutes), test the patient’s ability to sense pain in the digit. 
  • PEARL: Some physicians prefer to place a tourniquet (a rubber band or Penrose drain placed around the digit and held with a hemostat) in an attempt to limit bleeding during the procedure. There is no evidence this actually works, and many providers perform the procedure without this step with identical outcomes.

  • PEARL: When checking the patient’s ability to sense pain in the digit, ask them if they “feel pain,” not if they “feel anything.” Remember, local anesthetics do not block touch receptors.

  • PITFALL: If using a tourniquet, avoid pulling the rubber band too tightly and damaging the tissues. Limit the amount of time that the tourniquet is placed. It is advisable to withdraw the tourniquet after 10 minutes of application to limit vascular injury from interrupted blood flow to the digit.

Step 2

Prep the toe (see Appendix E). Free the lateral nail plate from the overlying proximal nail fold (i.e., cuticle). A Freer septum elevator or hemostat can be used to lift the cuticle off the nail plate. Create a tunnel between the nail plate and bed with the elevator or one jaw of a hemostat to allow passage of a nail splitter and removal of the lateral one fifth to one third of the nail. 

Step 3.

If performing a partial nail avulsion, cut the nail with nail splitters or bandage scissors, placing the thin blade beneath the distal (free) edge of the nail. Cut the nail straight back beneath the proximal nail fold. As the proximal edge of nail is cut, a “give” is often felt by the operator. 
  • PITFALL: Avoid damaging the nail bed when cutting the nail plate. If the scissors are used, the blade placed beneath the nail plate can traumatize the nail bed. Advance the scissors by cutting just with the tips of the scissors, and angle the tips of the scissors upward away from the nail bed.

  • PITFALL: Do not cut the ventral fold, because this area may be slow to heal.

Step 4

Grasp the lateral nail with straight hemostats and lift the nail out using a side-to-side rocking combined with a twisting motion that pulls outward and laterally. Part or all of the nail plate may be removed in this manner. 
  • PITFALL: Grasp as much of the lateral nail in the hemostats before attempting withdrawal. If just the end of the nail plate is grasped, the nail frequently breaks on removal.

Step 5

After the nail has been removed, examine the lateral sulcus beneath the proximal nail fold to ensure no pieces of nail remain within the corner. Also examine the part of the nail removed. If part of the nail plate is missing, it must be found and removed or it will slow healing and cause pain. 

Step 6

Matrixectomy can be performed chemically or electrosurgically, as demonstrated here. Place the electrode over the lateral nail bed with the Teflon-coated portion upward. Lift the electrode about 1 mm, creating a small gap. Make sure the lateral horn of the matrix is ablated by moving the electrode laterally beneath the proximal nail fold. Activate the electrode for 3 to 10 seconds, gently bouncing the electrode against the nail bed to produce ablation of the tissue. A short sizzling sound and a small puff of smoke may be seen. A properly treated nail bed appears white after thermal ablation. 
  • PITFALL: Avoid prolonged activation of the electrode against the nail bed. Prolonged burning can damage the deep tissues (i.e., extensor tendon insertion beneath the nail bed) and cause excessive time (months) for healing.

  • PITFALL: If the lateral horn of the matrix is not destroyed, a new spicule of nail will grow into the new lateral nail fold, with recurrence of symptoms in the months after the procedure.

Step 7

If needed, the hypertrophied lateral tissue can be cut away or ablated with an electrode or scalpel. Place a thin film of antimicrobial ointment on the exposed nail bed and cover it with a nonadherent dressing. Wrap the digit with 1- or 2-inch rolled gauze. Disposable surgical slippers or open toe shoes can be worn by the patient on leaving the office. 

Complications

  • Infections (treat with soaks and appropriate antibiotics).

  • Regrowth of nail and return of symptoms. (The regrowth rate following phenol cauterization is 4% to 25%; for radiofrequency, <5%.)

  • Permanent loss of nail plate (mainly with bilateral matrixectomy).

  • Damage to underlying structures due to excessive application of electrosurgical matrixectomy.

Pediatric Considerations

The conditions that lead to this procedure are rare in the preadolescent population. Adolescent patients are treated in the same manner as adults. 

Postprocedure Instructions

The foot should be rested and preferably elevated during the first 12 to 24 hours. Because matrixectomy ablates the nerve endings of the nail bed, pain should be minimal when it is used. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for discomfort. 
The dressing should be changed in 24 hours, at which point normal ambulation may fully resume. The toe should be soaked and cleaned in warm water to help remove the bandage, and topical antibiotics may be recommended until healing is complete. The dressing change should be repeated daily. Tell the patient to expect a sterile exudate from the nail bed for several weeks. Emphasize proper nail hygiene to the patient. 

Coding Information and Supply Sources

Code 11750 is most commonly reported when partial avulsion and matrixectomy are performed for permanent nail removal. Simple avulsion without matrixectomy is reported with 11730 or 11730 and 11732. 
The Freer septum elevator, bandage scissors or nail splitters, and hemostats are available from surgical supply stores or instrument dealers. Disposable surgical slippers are available from surgical supply houses. Matrixectomy electrodes and electrosurgical equipment are available from Ellman International, Hewlett, NY (phone: 1-800-835-5355; Web site: http://www.ellman.com). A suggested anesthesia tray that can be used for this procedure is listed in Appendix G

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