Nail dystrophy for the surgeon.

Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.

Improvements in pincer nail deformity occur earlier and last longer when acetylcysteine gel is added to an overcurvature-correcting device: Results of a phase 3, multicenter, randomized, vehicle-controlled, investigator-blinded study.

Acetylcysteine (AC) destabilizes keratin and softens nails, reducing the time needed to correct pincer nail deformity with an overcurvature-correcting device. The objective of this phase 3, multicenter, randomized, investigator-blinded study was to evaluate the early and sustained therapeutic effectiveness and safety of 10% AC gel plus an overcurvature-correcting device to treat pincer nails. Patients aged 12 years and older with hallux pincer nail were fitted with an overcurvature-correcting device for 7 days, with a 24-h application of AC gel (n = 40) or vehicle (n = 39) on day 1. The primary end point (achievement of a distal narrowed nail width ratio ≥70% on day 8) was met by 47.5% in the 10% AC group and 25.6% in the vehicle group (difference 21.9%; p = 0.0439). Secondary end points showed a greater tendency towards improvement with 10% AC. The nail correction effect was maintained for at least 12 weeks in the majority of AC-treated patients, although the study duration was insufficient to assess the long-term probability of recurrence. No AC-related adverse events were reported. In conclusion, a single application of 10% AC gel combined with short-term device use facilitated earlier correction of pincer nails compared with the device alone, with improvements maintained after device removal.

Long-term results of nail correction with double wires for pincer nail deformity: A retrospective cohort study.

There is no consensus on the best treatment for pincer nail deformity. We developed a novel procedure that uses double wires to treat pincer nail deformity on the great toe. This study aimed to describe this technique for pincer nail deformity treatment and present the long-term findings/observations. After injecting a local anesthetic, a mini router was used to make holes on both sides of the nail plate edge, and the wire was inserted in two places, one proximal and the other distal to the great toenail. The wire was removed when it moved to the tip of the great toe as the nail grew. Patients who underwent this method were evaluated retrospectively from 2014 to 2020. Patients with less than 24 months of follow-up were excluded. If pain occurred again, it was deemed as a recurrence. A total of 27 patients (36 toes, mean age: 69.5 years) were evaluated. In all cases, the pain disappeared 1 week after the procedure. In the correction period (mean 2.7 months), six toes had complications (nail break, four toes and nail hold pain, two toes), while recurrence occurred in four toes within 2 years. Curvature (nail tip height/width of nail tip × 100%) improved significantly up to 1-year post-procedure (37.7 ± 14.4%, p < 0.05) as compared to pre-correction (53.8 ± 24.7%). The procedure time was short (approximately 10 minutes), and the treatment was completed with a single procedure. In addition, the recurrence rate was low.

Efficacy and safety of topical acetylcysteine combined with the use of an overcurvature-correcting device in patients with pincer nail deformity: a randomized, vehicle-controlled, investigator-blinded study.

BACKGROUND: While pincer nails may be treated using overcurvature-correcting devices, it takes several months to achieve successful outcomes. Nail-softening drugs may reduce the treatment duration required. OBJECTIVE: To evaluate the efficacy and safety of treatment with acetylcysteine (AC) gel added to an overcurvature-correcting device, and define the optimal AC concentration. METHODS: In this investigator-blinded study, 70 patients with hallux pincer nail were fitted with an overcurvature-correcting device for 7 days and were randomly assigned to receive a single 24-h administration of a gel containing 10%, 20% or 30% AC or vehicle. Nail improvement was objectively evaluated by calculating the distal narrowed nail width (dNNW) ratio. RESULTS: All three AC concentrations plus device showed earlier sustained improvement of pincer nails versus vehicle plus device. There was no observable correlation between AC concentration and effectiveness. No clinically problematic adverse events were observed at any AC concentration, and we recommended AC gel at a concentration of 10%. CONCLUSIONS: By adding AC gel application to an overcurvature-correcting device, early and sustained reductions in transverse curvature were produced compared with using a device alone (vehicle control). The dNNW ratio used in this study was an appropriate objective index for evaluating therapeutic effects.

High-frequency ultrasonography index in evaluation of pincer nail.

BACKGROUND: The measurements of width index, height index, and curvature index were used for assessment of the curvature severity. Nevertheless, both sides of the nail root are buried subcutaneously, impossibility in measuring the width index correctly. MATERIALS AND METHODS: We developed a technique to measure the index under high-frequency ultrasonography (HF-USG). RESULTS: There was good agreement between the HF-USG index and the result examined after surgery. CONCLUSION: The observation on HF-USG helps to distinguish between ingrown nail and pincer nail. The HF-USG index will be useful in the examination and measurement of nail roots buried subcutaneously or nail penetration under the hypertrophic lateral nail fold, and comparing the effectiveness among treatments for pincer nail objectively.

Reconstruction of a nail bed with double-layer artificial dermis for a pincer nail: A case report and literature review.

Background: A pincer nail (PN) is a type of nail deformity. Although it is a minor ailment, it can cause intractable pain, affecting daily work and life. Currently, there is no standard invention for PN. The main purpose of treatment is to correct the curvature of the nail, so we apply double-layer artificial dermis (DLAD), a novel treatment, for PN according to this aim. Case presentation: A 40-year-old man suffering from PN was treated with DLAD. After 1 year of follow-up, the patient's great toenail plate of the right foot was completely grown out. His pain was relieved, and the curvature of the toenail was corrected. Conclusion: The innovative method of using DLAD to fill the ingrown nail bed not only solves the problem of recurrent pincer nail deformity but also restores the original appearance of the toenail. It suggested that this simple procedure can be widely applied in clinical practice.

Treatment of pincer nail deformity with 1064-nm Nd:YAG laser.

Pincer nail (PN) is a nail disorder that cannot resolve spontaneously and sometimes necessitates surgical intervention. The etiological factors and gold standard treatment for the PN are still uncertain. We present a 24-year-old woman suffering from the PN and were treated with 1064-nm long-pulsed Nd:YAG laser. There were PN deformities in the left and right thumbnails. The left one was treated with four sessions of 1064-nm. Nd:YAG laser.

To Study the Outcome of Three-Flap Technique in the Management of Pincer Nail.

CONTEXT: Pincer nail deformity is a transverse overcurvature of the nail. Though various conservative and surgical techniques have been described in the literature, very few studies are based on objective measurements. This study was undertaken to evaluate the outcome of three-flap technique in the management of pincer nail. AIM: To study the outcome of three-flap technique in the management of pincer nail. SETTINGS AND DESIGN: Prospective interventional study. SUBJECTS AND METHODS: Fifteen patients with pincer nail deformity, fulfilling inclusion and exclusion criteria were enrolled for the study. Routine X-ray was carried out for all patients to detect underlying bony abnormalities such as exostoses. Width and height indices were calculated before the procedure. A three-flap technique was performed on all affected toe nails and outcome was assessed at the end of 6 months and 1 year. STATISTICAL ANALYSIS USED: Paired t-test and P value. RESULTS: Satisfactory cosmetic outcome and statistically significant improvement (P < 0.0001) were achieved in all patients. CONCLUSIONS: Three flap technique is an useful technique in the management of pincer nail.

Presence of a family history and excessive pressure on the first toe pad during walking in female subjects with pincer nails.

Pincer nails (PN) are defined as a transverse overcurvature of the nail plate. Although there have been advancements in therapeutic approaches, the precise underlying mechanisms for the development of PN are still not fully understood. Currently, PN are assumed to develop due to lack of upward mechanical force on the toes. We developed a novel wireless device to observe detailed gait motion. We analyzed trends of gait motion in healthy individuals without PN, healthy individuals with PN without a family history of PN, and healthy individuals with PN and a family history of PN. We found that a family history of PN is an independent risk factor for PN, irrespective of gait motion. Moreover, healthy individuals with PN but without a family history of PN exhibit strong and concentrated pressure on the first toe pad during walking. In sum, a family history of PN and excess upward mechanical forces on the first toe pad during walking may be risk factors for the development of PN.

Significance of Surgery to Correct Anatomical Alterations in Pincer Nails.

BACKGROUND: Pincer nail deformity and its causes can pose a therapeutic challenge. Ill-fitting shoes and subungual exostosis of the toes may be attributed to pincer nail formation. However, in some cases, the causes of pincer nail deformity could not be determined. The role of mechanobiology in nail configuration and deformities has rarely been considered. OBJECTIVE: The present study investigated the effectiveness of surgical procedures to correct pincer nail deformity, in terms of anatomical changes measured by radiographs. METHODS: Two surgical procedures, nail bed widening with matrixectomy or a dermal graft, were used on 30 nails in 20 patients with pincer deformity. Changes in the width, height, and curvature indices were assessed. Radiographs were obtained to evaluate the presence of osteophytes and measure the interphalangeal angle in terms of mechanobiology in nail configuration. RESULTS: Preoperative and postoperative assessment results revealed marked improvement objectively and subjectively. The mean width index was greater after surgery than that before surgery (84.4% vs. 64.8%). Both mean height and curvature indices were smaller after surgery than before preoperative (23.0% vs. 76.7% and 1.3% vs. 2.2%, respectively). CONCLUSION: Nail bed widening with matrixectomy, which corrects anatomical alterations in pincer nails, is suggested to be suitable for patients with pincer nail deformity.

Treatment of pincer nails / 中华皮肤科杂志

Pincer nails are a kind of nail deformity characterized by abnormal thickening and distal transverse overcurvature of the nail plate,whose etiology and pathogenesis are still unclear.According to the morphology of the nail plate,pincer nails can be divided into three subtypes:common pincer nail (trumpet nail),tile-shaped nail,and plicated nail.Width index,height index and curvature index are objective indicators to evaluate the severity and therapeutic effect of the pincer nails.According to the classification and severity of the pincer nails,appropriate treatment methods can be adopted to improve the appearance of the nail plate and relieve clinical symptoms of patients.This review systematically summarizes the classification of,evaluation of the severity of and several therapeutic methods for pincer nails.

Nail Plate and Bed Reconstruction for Pincer Nail Deformity.

Pincer nail deformity is a severe condition in which the nail bed becomes compressed and the nail shows an overcurvature. We retrospectively analyzed 13 pincer nail deformities treated using our nail plate and bed reconstruction technique. Visual analogue scale scores, the width of nail root, width of nail tip, height of nail tip, width index, and height index were assessed before and after surgery. The overcurvature was corrected after detachment of the nail plate. The nail fold was pushed underneath the nail plate and then fixed. The width of nail tip significantly increased after surgery (p < 0.05) and was maintained during follow-up. The height of nail tip decreased after surgery (p < 0.05). This nail plate and bed reconstruction technique is a simple and quick surgical method for correcting deformities and reduces risks of complications such as skin necrosis and infection compared to other existing surgical techniques. We recommend this efficient surgical technique for the treatment of pincer nails.

Nail Plate and Bed Reconstruction for Pincer Nail Deformity

Pincer nail deformity is a severe condition in which the nail bed becomes compressed and the nail shows an overcurvature. We retrospectively analyzed 13 pincer nail deformities treated using our nail plate and bed reconstruction technique. Visual analogue scale scores, the width of nail root, width of nail tip, height of nail tip, width index, and height index were assessed before and after surgery. The overcurvature was corrected after detachment of the nail plate. The nail fold was pushed underneath the nail plate and then fixed. The width of nail tip significantly increased after surgery (p < 0.05) and was maintained during follow-up. The height of nail tip decreased after surgery (p < 0.05). This nail plate and bed reconstruction technique is a simple and quick surgical method for correcting deformities and reduces risks of complications such as skin necrosis and infection compared to other existing surgical techniques. We recommend this efficient surgical technique for the treatment of pincer nails.

Pincer nail in a lupus patient.

Pincer nail is a transverse overcurvature of the nail plate that may appear in association with a variable number of diseases. We present a case report of a 28-year-old woman with pincer nail deformity associated with systemic lupus erythematosus. A renal biopsy confirmed class V lupus nephritis and treatment had included systemic steroids and cyclophosphamide. After 6 months there was a marked improvement of nail deformities.

Surgical Correction Of Pincer-Nail Deformity Using Autologous Full Thickness Skin Graft: A Case Report

Pincer nail deformity is often undertreated although it is a cause of pain and disfigurement.This may be attributed to underdiagnosis and lack of awareness of the available treatmentoptions especially surgical options. Not many centres offer surgical correction of pincer naildeformity in Malaysia. We would like to describe a surgical method of correcting this deformity.

Foot loading is different in people with and without pincer nails: a case control study.

BACKGROUND: Recent studies suggest that pincer nails are caused by lack of upward mechanical forces on the toe pad. However, clinically significant pincer nails are also often observed among healthy walkers. It was hypothesized that in these cases, the affected toes do not receive adequate physical stimulation from walking and loading. To test this, the gait characteristics of pincer nail cases were assessed by measuring plantar pressure during walking. METHODS: In total, 12 bilateral pincer nail cases (24 affected feet) and 12 age- and sex-controlled healthy control subjects (24 ft) were enrolled in this prospective case-control study. Plantar pressure during free ambulation in both the barefoot and shod state was assessed using a digital pressure-plate system named S-Plate platform (Medicapteurs Co. France). First toe pressure and the frequencies of peak pressure in the first toe, metatarsal head, or other foot areas were calculated. RESULTS: In both the barefoot and shod state, the pincer nail group had significantly lower pressure on the first toe than the control group. In both the barefoot and shod state, the peak pressure area was mostly the metatarsal head area in the pincer nail group, whereas it was mostly the first toe area in the control group. Binomial logistic regression analysis revealed that peak pressure area was a significant risk factor for pincer nail development. CONCLUSION: Walking behavior appears to contribute to pincer nail development. Pincer nails of walkers could be treated by correcting the walking behaviour so that more pressure is placed on the toe pad.