TITLE: Teenage Patients with Ingrown Toenails: Treatment with Partial Matrix Excision or Segmental Phenolization

  ABSTRACT.BACKGROUND:
Ingrown toenails (IT) is a very common problem leading to significant associated morbidity. The articles related to phenolization for matrix removal in teenagers with IT are not enough in the foot surgery literature.

ABSTRACT.AIMS:
To compare the postoperative recovery periods, complication rate, and tolerability of partial matrix excision and segmental phenolization in teenagers with IT.

ABSTRACT.MATERIALS AND METHODS:
Thirty-nine patients (13-17 years) with 48 IT were randomly divided into two groups and were treated with partial matrix excision (Group I) and segmental phenolization (Group II). We assessed the recurrence rates, postoperative complications, duration of analgesic usage, and time to return to daily activities.

ABSTRACT.RESULTS:
There was no significant difference between the demographic and clinical data of the two groups. Three patients in Group I and two patients in Group II experienced moderate pain postoperatively. These patients used analgesics for 3 days. The rates of postoperative complications and recurrences between the two groups showed no statistically significant difference (P = 0.688). The time to return to normal daily activities was significantly shorter in Group II patients than in Group I patients (P < 0.05).

ABSTRACT.CONCLUSIONS:
Partial matrix excision is a very safe model of therapy in the surgical treatment of teenagers with IT. It has low recurrence rate and minimal postoperative morbidity. We concluded that segmental phenolization is also as safe as partial matrix excision in the treatment of IT and patients return to their daily activities in less time with this treatment modality.

BODY.INTRODUCTION:
What was known?IT is a very common problem in adults and teenagers. The surgical procedures used with confidence are classical wedge excision, partial matrix excision, and cauterization with liquefied phenol.  Ingrown toenails (IT) is a very common problem and cause significant associated morbidity.[12] Several options for the treatment of IT are available, ranging from simple conservative approaches to extensive surgical procedures.[3] Surgery can be performed either by a classical surgical wedge excision followed by selective matrix destruction or by cauterization with liquefied phenol of the lateral matrix portion.[4] The articles related to phenolization for matrix removal in teenagers with IT are not enough in the foot surgery literature.[45] The teenagers mostly wear closed footwear and experienced with recurrent trauma. The purpose of this study was to compare the duration of analgesic usage, postoperative complication rates (any adverse effect of the chemical agent, infection, and scar tissue), time to return to daily activities, and the recurrence rates of partial matrix excision and segmental phenolization in teenagers with IT.

BODY.MATERIALS AND METHODS:
Thirty-nine patients (28 males and 11 females) with 48 IT sides were randomly divided into two groups and were treated with partial matrix excision (Group I) and segmental phenolization (Group II). Exclusion criteria were as follows: (a) Peripheral vascular disease, (b) hypersensitivity to the chemical solution, (c) serious systemic diseases, (d) serious digital diseases, and (e) diabetes mellitus infection. Group I had mean ages of 16.1 ± 1.9 years and Group II had mean ages of 17.0 ± 1.0 years. Antibiotic therapy was given in 33 (68.7%) infected cases before surgical intervention.  Group I patients were draped under sterile conditions following injection of local anesthetic agent (2% plain prilocaine) to cause digital anesthesia. A finger tourniquet was applied with a rubber ring. In all patients, vertical incision was performed along the lateral or medial border of the nail with No. 11 blade. The incision was extended 1-2 cm distally than proximally. Nail matrix and infected and hypertrophic tissues were partially excised. The cortex over the distal phalanx was purged by a curette. This incision was sutured with 3-0 or 4-0 nonabsorbable material. No technical difficulty was encountered in putting sutures. Compression bandage was applied on the toe. Elevation and prophylactic antibiotics were applied after surgery. Only patients with complaints of moderate pain received analgesic drugs [Table 1]. Daily dressing was performed and all sutures were removed after 1 week of operation [Figure 1]. The mean follow-up period was 3.2 ± 1.2 years. In Group II, the preoperative preparation and anesthesia like in Group I were performed. The lateral or medial nail strips were freed from the overlying proximal nail fold, nail bed, and matrix. A 2-3 mm lateral nail segment was cut free along the length of the lateral fold and hypertrophic granulation tissue was curetted. Phenol was applied with partially stripped cotton applicators saturated with 88% liquid phenol by vigorously massaging it into the matrix area. The cotton applicator was changed twice during an application time of 90 s. The patients were followed up for a period of 2.1 ± 0.9 years.   Table 1 Demographic data   Figure 1Partial matricectomy, (a) preoperative image, (b) intraoperative image, and (c) postoperative image  The demographic and clinical data of both groups were compared. Postoperative morbidity was evaluated clinically according to the severity of pain and soft tissue infection. Pain was graded as mild, moderate, and severe. Soft tissue infection consisted of cellulitis, purulent discharge, and abscess formation. Duration of analgesic usage, time to return to normal daily activities, and recurrence rate at least at the end of 1 year were assessed.  Statistical Package for the Social Sciences (SPSS 15.0: USA) was used for statistical analysis and the variables were compared using Chi-square and Mann–Whitney U tests. (P < 0.05) were considered as significant.

BODY.RESULTS:
There was no significant difference between the two groups in demographic and clinical data. Both groups' data are shown in Table 1. Staging of IT is shown in Table 2.   Table 2 Clinical results   Postoperatively, none of the patients had severe pain. Three patients (17.6%) in Group I and two patients (9.0%) in Group II experienced moderate pain. Only these patients received analgesic for 3 days. Differences in pain were not statistically significant between the groups (P > 0.05). In both groups, none of the patients had soft tissue infection.  A return to normal daily activities was the criterion for treatment success. The time to return to daily activities was significantly shorter in Group II than in Group I (P < 0.05) [Table 1].  The rates of postoperative recurrences showed no significant difference between the two groups (P = 0.688) [Table 2]. In both groups, none of the patients had postoperative complications.

BODY.DISCUSSION:
IT causes significant discomfort for both teenagers and adults. IT in children occur most commonly in the age group of 10-13 years.[6] In this study, we want to compare the effectiveness of partial matrix excision and segmental phenolization in teenagers (13-17 years) with IT.  Many treatment methods have been advocated, ranging from conservative and surgical procedures to phenolization. Surgical approach is usually preferred rather than conservative treatment. Many surgical procedures and treatment methods have been used.[7] In adults, partial matrix excision is one of the most preferred treatment methods for IT. Currently, segmental phenolization is also a frequently used method in this condition. But this procedure carries a risk for a chemical burn on the skin.[5] In contrast, in this study, no cosmetic problem (such as skin burn) was observed in both groups.  The use of segmental phenolization in the treatment of IT has shown statistically significant reduction in recurrence rates of IT compared to partial matrix excision procedure.[8910] But none of the observed differences in wound healing, postoperative pain, and recovery were statistically significant.[41112] Also in our study, recurrence rates were detected as low in both groups. Pain severity and analgesic usage in postoperative period showed no significant differences between both groups. The period of return to normal daily activities was significantly shorter in Group II than in Group I.  Islam et al. demonstrated that effectiveness of phenolization was similar both in children and in adults. This study showed that number of recurrences were significantly different (42% recurring after partial matrix excision and only 4% after segmental phenolization).[13] None of the segmental phenolization patients had any skin burn in the surrounding area. Complications did not differ between the two groups.[1113] In our study, similar results were obtained. Despite the use of chemical substances, no serious complication was seen in Group II.  Most of the studies showed that segmental phenolization is a procedure which causes less pain and has an effect of relieving pain earlier.[8] Partial matricectomy has also been shown to have less painful recovery times in some other researches.[4] On the other hand, none of the observed differences in the two methods such as wound healing, postoperative pain, and recovery were seen in some of the related studies.[11] In this study, in terms of pain and the period of analgesic usage, there was no difference between the two groups.  In the research study of Aydin et al., patients who were operated with the partial matrix method returned to normal daily activities after a mean of 12 days (range: 10-16 days).[14] Another study demonstrated that the time to return to normal daily activities in both the methods was equal as a mean of 3.5 days.[11] In this study, we achieved a favorable result in that the patients in the group of phenol method returned to normal daily activities in a significantly earlier time.  Partial matrix excision is a very safe model of therapy in the surgical treatment of teenagers with IT. It has low recurrence rate and minimal postoperative morbidity. We concluded that segmental phenolization is also as safe as partial matrix excision in the treatment of IT and patients return to their normal daily activities in less time with this treatment modality. We recommend that both techniques can be considered for treating IT in teenagers.  What is new?Partial matrix excision and segmental phenolization are very safe modes of therapy in the treatment of IT in teenagers. Segmental phenolization is a very effective treatment modality in terms of patients returning to their normal daily activities rapidly in teenagers with IT.

Question: Compared to Segmental phenolization what was the result of Partial matrix excision on Ingrown toenails recurrence ?
Evidence: Differences in pain were not statistically significant between the groups (P > 0.05). In both groups, none of the patients had soft tissue infection.
Answer: no significant difference