Resin splint as a new conservative treatment for ingrown toenails

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1 321 ORIGINAL Resin splint s new onservtive tretment for ingrown toenils Kzuy Mtsumoto 1, Ihiro Hshimoto 2, Hideki Nknishi 2, Yoshiki Kuo 3, Kzutoshi Muro 3, nd Seiji Arse 3 1 Setion of Plsti nd Reonstrutive Surgery, Kitjim Tok Hospitl ; 2 Deprtment of Plsti nd Reonstrutive Surgery, nd 3 Deprtment of Dermtology, Institute of Helth Biosienes, the University of Tokushim Grdute Shool, Tokushim, Jpn Astrt : Severl onservtive s well s surgil methods re used for the tretment of ingrown toenils until dte. The onservtive methods re either sed on nil splinting or on orthonyxi, ut no methods employing oth priniples hve een reported thus fr. Moreover, surgil methods usully involve postopertive pin, prolonged wound heling nd restrited tivities of dily living. Therefore, onsidering the need of simplified, non-invsive method, in this study, we pplied novel splint to tret ptients with ingrown toenils nd estimted the linil effiy s well s rte of reurrene following tretment. The splint is plte mde of resin tht is tthed to the lterl edge of the nil using ndge. We studied 61 ptients (19 men nd 42 women ; men ge 36 yers), with n verge pplition durtion of 9.3 months nd n verge follow-up period of 10 months in ll ptients. All ptients experiened pin relief within week of splint pplition nd derese in the degree of nil deformity. Moreover, follow-up reveled reurrene rte of 8.2%. Therefore, we elieve tht this new devie is n exellent onservtive tretment method for ptients with ingrown toenils. J. Med. Invest. 57 : , August, 2010 Keywords : Bre, ingrown nil, nil deformity, orthonyxi, splint INTRODUCTION An ingrown toenil is one of the most ommon onditions enountered in the outptient lini nd it frequently ffets dolesents nd young dults (1, 2). This ondition, whih is often onsidered trivil nd inonsequentil, my led to onsiderle disomfort, pin nd inonveniene, nd restrits Reeived for pulition June 10, 2010 ; epted July 29, Address orrespondene nd reprint requests to Kzuy Mtsumoto, Setion of Plsti nd Reonstrutive Surgery, Kitjim Tok Hospitl, 30-1 Az-Kwkuo, Tihm, Kitjimho, Itno- gun, Tokushim , Jpn nd Fx : tivity (1). Conservtive nd surgil methods re ville for treting this ondition. Surgil tretments, however, risk postopertive pin nd neessitte postopertive rest nd wound dressing, therey hindering tivities of dily living, often ginst the ptient s preopertive wishes. Consequently, simplified onservtive method ws developed (1). A fine polyethylene tue with slit ws used s gutter to protet the lterl nil groove from the trum used y the irregulr or ingrowing lterl nil edge. Susequently, severl onservtive nilsplinting tehniques me to e developed sed on the gutter tretment priniple (2-4). Another onservtive method (re tretment) in whih the The Journl of Medil Investigtion Vol

2 322 K. Mtsumoto, et l. A new tretment for ingrown toenils shpe of the over-urved nil is orreted using dynmi orthonyxi tehniques ws lso developed (5-7). However, thus fr, no method hs employed the priniples of oth nil splinting nd orthonyxi. Therefore, we hve developed novel tretment method in whih unique resin plte ts s re s well s splint to ptients ingrown toenils. MATERIALS AND METHODS We performed retrospetive study of 61 ptients with ingrown toenils [19 men nd 42 women ; men ge 36 yers (rnge 9-69 yers)]. All ptients omplined of pin in the ffeted toe. Ptients in whom the soft tissue hd grown round the nil were exluded from the study. We used novel splint, whih ws mde of resin (Pediglss Corp. ; Osk, Jpn) nd ws folded k to 2 mm width t one end (Fig. 1). After lening the nil nd the djent tissue with n ntisepti, the distl setion of the lterl edge of the nil ws hooked using the tip of the folded prt of the splint nd ndge ws tthed only to the lterl edge of the nil. The splint ws then tilted y pplying dequte fore so s to orret the urvture of the ffeted nil nd fixed in this position using quik-drying dhesive. The superfluous prt of the splint, inluding the Figure 2. Resin plte tthed to the nil edge. The superfluous prt of the splint, inluding the thik hndle setion, ws removed using nippers () nd grinder (). After grinding, prt of the plte remins dhered to the nil (). Figure 1. nils. The new resin splint for the tretment of ingrown thik hndle setion, ws removed using nippers nd grinder (Fig. 2), nd the entire surfe of the nil, inluding the splint, ws overed with sheet of glss fire nd dhesive gel (Fig. 3). During tretment, dily tivities of living were unrestrited nd the ptients were instruted to use nil file insted of nil lipper for nil re. The splint ws repled every 6 weeks. The verge durtion of splint plement ws 9.3 months (rnge 3-33 months) nd the verge follow-up ws 10.0 months (rnge 3-65 months).

3 The Journl of Medil Investigtion Vol. 57 August RESULTS All ptients reported pin relief t the 1-week follow-up. In ses where inorret trimming of the toenil hd used pin, pplition of our splint relieved pin immeditely nd enled the nil to grow over the lterl nil fold (Fig. 4). The verge Figure 3. The left hllux of 36-yer-old femle ptient shown efore () nd fter () pplition of the splint, sheet of glss fire, nd dhesive gel. The splint ws fixed to the lterl side of the left hlf of the nil (rrow). The degree of nil deformity ws estimted y referring to our lssifition tle (Tle 1). A nil with no urvture ws lssified s 0 wheres ylindril nil ws lssified s 100. Nils with urvture etween these extreme vlues were lssified in the rnge of All ptients were evluted for the degree of nil urvture nd pin intensity t 1 week fter splint fixtion nd t 3 months fter the ompletion of tretment. Tle 1. The lssifition tle used to estimte the degree of nil deformitiy. Degree of deformity Referene shpes d Figure 4. The left hllux of 19-yer-old femle ptient. The lterl orner of the nil tht ws ut too short exerted sustntil pressure on the nil wll nd this used pin ( nd ). After 10- month tretment period, the degree of nil deformity ws redued to 30 from 40 nd the pressure ws distriuted long the lterl edge of the nil. During 5- yer follow- up period, there ws no reurrene ( nd d).

4 324 K. Mtsumoto, et l. A new tretment for ingrown toenils nil urvture ws 55.4 nd 34.4 t the initition nd termintion of tretment, respetively. In ptients with severe degree of nil urvture, longterm pplition ws required (Fig. 5). Of the 61 ptients, only 5 reported reurrene. d Figure 5. The right hllux of 56-yer-old femle ptient shown efore ( nd ) nd fter ( nd d) 3-month onservtive tretment using the resin splint. The degree of nil deformity ws redued to 30 from 60. DISCUSSION Mny possile uses of ingrown toenils hve een proposed (8) ; nonetheless, there seems to e generl onsensus tht inresed pressure etween the lterl order of the nil nd the nil wll uses pin nd promotes development of pronyhi (5). All therpeuti mesures used for ingrown nils im to relieve this pressure. These tehniques n e lssified s surgil or onservtive. Although mny surgil pprohes suh s lssi wedge exision nd prtil mtrix phenoliztion hve evolved, these surgil modlities hve mny disdvntges, suh s prolonged wound heling nd restrition of tivities of dily living, srring nd deformtion (1). Moreover, surgil tretments for ingrown toenils re thought to e extremely ggressive nd unneessry euse they involve destrution of the nil mtrix nd onsequent nil disfigurement (4). Thus, severl uthors prefer onservtive methods to invsive surgil ones (1-5). These noninvsive onservtive tretment methods n e divided into two groups. The first group inludes tehniques sed on nil splinting. The gutter tretment is representtive of this group (1). Although vrious types of mterils hve een used s the gutter in studies of nil-splinting tehniques, the si priniple remins the sme. Nil splinting seprtes the nil plte from the soft tissue so s to provide hnnel for the nil to grow (3). Ari et l. used vinyl intrvenous drip infusion tue s the gutter splint. Simultneously, they lso used sulptured nil (ryli rtifiil nil) on n ingrown nil with nil loss nd no grnultion tissue s prostheses nd suitle fixtion for gutter splints. They ttriuted the effiy of the splints nd sulptured nils to their protetion of the surrounding soft tissue ginst distl penetrting spiules nd lterl serrted nil edges (4). The seond group inludes methods sed on orthonyxi tht employs diret fore to orret the deformity of n over-urved nil plte. This priniple is dynmi in ontrst with the splint tehnique, whih is sed on stti priniple. Hrrer et l. suessfully used new orthonyxi devie in ptients with ingrown toenils (2). Two metl hooks on ilterl sides of the nil plte re fixed in ple under tension y twisting onneting wire etween the hooks. The edges of the nil re lifted from the nil fold nd the pressure exerted on the inflmed soft tissue is relesed immeditely. A modified devie in whih dentl string is used insted of the

5 The Journl of Medil Investigtion Vol. 57 August onneting wire in the originl devie hs lso een reported (6). Moreover, super-elsti wire hs lso een used s soure of dynmi restortion fore (7). Two holes re mde t the distl free edge of the nil plte in the white portion. The wire is inserted into these holes nd then ut with lippers so tht it does not protrude from the nil. The ovementioned dynmi tretments n improve the shpe of the nil itself s well s relese the pressure on the nil fold ; this improvement of nil shpe my result from ontinuous long-term tension on the nil plte. Our method using the resin plte is sed on the priniple of nil splinting. The plte is integrted with the nil nd funtions s sulptured nil. Simultneously, diret fore deresing the degree of nil urvture is exerted upon the nil plte. This is the first proedure tht uses the splinting nd dynmi orthonyxi tehniques together. With regrd to reurrene rtes, onsiderle vrition is oserved mong onservtive tretments. In nil-splinting studies, the rte ws 8.7% with the flexile plsti tue (3), 13.3% with the vinyl tue nd the ryli rtifiil nil (4) nd 44-48% with the fine polyethylene tue (1). In the dynmi orthonyxi studies, the reurrene rte ws 19% in the proedures using the hooks nd wire (5) nd 28.6% with the hooks nd the dentl string (6). In the present study, pin reurred in 5 of 61 ptients (8.2%). We reommended the ptients to ontinue with the splinting till the urvture of the deformed nil ws redued to less thn 30 nd most ptients epted this reommendtion. This resulted in lower reurrene rte thn for other reported methods. We exluded ptients with grnultion tissue formtion euse the exudte from the grnultion tissue hindered dhesion etween the splint nd the nil plte. We nnot deny the possiility tht this seletive exlusion my hve led to the exlusion of ritil ses nd ould thus e responsile for our good results. However, the use of our method provides erly relief from pin nd the proedure itself is pinless. It is lso superior with respet to esthetis euse the resin devie eomes lmost pelluid nd invisile fter the proedures. In our opinion, it is n exellent proedure euse of its linil effiieny nd the low reurrene rte. This proedure is indited in ptients with ingrown toenils without grnultion formtion, espeilly in those who hd ut their toenils too short during nil trimming. However, the intensity of the restortion fore is weker in our methods thn in the other dynmi orthonyxi tretments. This my prolong the pplition period. We hope tht inresing the elstiity of the resin plte my inrese its ility to orret the defet, nd onsequently, shorten the pplition period of the devie. ACKNOWLEDGEMENTS Finnil support : NONE, Conflit of Interest : NONE. REFERENCES 1. Wlle WA, Milne DD, Andrew T : Gutter tretment for ingrowing toenils. Br Med J 21 : , Nzri S : A simple nd prtil method in tretment of ingrown nils : splinting y flexile tue. J Eur Ad Dermtol Venereol 20 : , Kim YJ, Ko JH, Choi KC, Lee CG, Lim KJ : Nil-splinting tehnique for ingrown nils : the therpeuti effets nd the proper removl time of the splint. Dermtol Surg 29 : 745-8, Ari H, Ari T, Nkjim H, Hneke E : Formle ryli tretment for ingrowing nil with gutter splint nd sulptured nil. Int J Dermtol 43 : , Hrrer J, Shöffl V, Hohenerger W, Shneider I : Tretment of ingrown toenils using new onservtive method. A prospetive study ompring re tretment with Emmert s proedure. J Am Poditr Med Asso 95 : 542-9, Erdogn FG, Erdogn G : Long-term results of nil re pplition in dieti ptients with ingrown nils. Dermtol Surg 34 : 84-87, Moriue T, Yoned K, Moriue J, Mtsuok Y, Nki K, Yokoi I, Niu N, Miymoto I, Kuot Y : A simple therpeuti strtegy with super elsti wire for ingrown toenils. Dermtol Surg 34 : , Sher RK : Toenil disorders. Clin Dermtol 1 : , 1983