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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
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Approach for Nail Bed Ablation
Position of the Patient
Landmarks and Incisions
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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Nail bed ablation is commonly performed for ingrown toenails as well
as for onychogryphosis. Nearly all of these surgeries are carried out on
the hallux.
Nail bed ablation involves excision of the entire nail bed and
should result in complete removal of the nail without any recurrence.
All surgical procedures, however, carry a significant risk of leaving a
small part of the germinal matrix of the nail bed behind. Thus,
recurrence rates in most series are approximately 25% to 30%.
Nail bed ablation has decreased in popularity in recent years with
the increased use of chemical treatment of the nail bed.
The presence of acute infection is a contraindication to nail bed
ablation. In such cases, lesser surgical procedures—such as partial
wedge resection and local treatment—are indicated. Once the infection
is treated, a nail bed ablation can be carried out.
Position of the Patient
Place the patient supine on the operating table. After exsanguination, place
a tourniquet on the middle of the thigh. Alternatively, use a soft rubber
bandage to exsanguinate the foot, then wrap the leg tightly just above the
ankle (see Fig. 1-1). The use of a rubber tourniquet around the base of the
toe is indicated when a digital ring block is used for anesthesia.
Landmarks and Incisions
Palpate the interphalangeal joint of the hallux, flexing and extending the
joint to confirm its position. Observe the lunula of the nail. This marks the
distal extension of the nail bed.
Make two oblique incisions. Begin at the base of the nail on either the
medial or lateral edge and extend the skin incision across the dorsal aspect
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of the distal phalanx, ending them at the level of the interphalangeal joint of
the hallux (Fig. 50-1).
Figure 50-1. Make two oblique incisions. Begin at the base of the nail on either
the medial or lateral edge and extend the skin incision across the dorsal aspect
of the distal phalanx, ending them at the level of the interphalangeal joint of the
hallux.
Internervous Plane
No true internervous plane exists during this surgical approach. No muscles
or muscle tendons are present within the field of dissection.
Superficial Surgical Dissection
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Insert a pair of scissors with one blade between the nail and underlying
tissue and the other blade on the dorsal surface of the nail (Fig. 50-2).
Divide the nail longitudinally through its entire length. Take a pair of stout
artery forceps and attach them to the cut edge of the nail. Rotate the forceps
—in doing so, avulse the nail from the underlying tissues. Take care to
ensure that the nail is completely avulsed (Fig. 50-3).
Cut through subcutaneous tissue down to the nail bed in the line of the
original skin incision. Now, carefully elevate the flap of skin and
subcutaneous tissue developing the plane superficial to the nail bed (Fig.
50-4). This flap should terminate just distal to the interphalangeal joint.
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Figure 50-2. Insert a pair of scissors with one blade between the nail and
underlying tissue and the other blade on the dorsal surface of the nail.
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Figure 50-3. Divide the nail longitudinally through its entire length. Take a pair
of stout artery forceps and attach them to the cut edge of the nail. Rotate the
forceps, avulsing the nail from the underlying tissues. Take care to ensure that
the nail is completely avulsed.
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Figure 50-4. Carefully elevate the flap of skin and subcutaneous tissue
developing the plane superficial to the nail bed.
Deep Surgical Dissection
Incise the germinal nail bed tissue down to the periosteum of the distal
phalanx. Make a transverse incision through this tissue at the level of the tip
of the lunula. Continue developing a plane between the periosteum and the
nail bed down to the level of the interphalangeal joint (Fig. 50-5). If
possible, try to avoid incising the thin dorsal capsule of the interphalangeal
joint. Note that the most common reason for failure of nail ablation is
leaving part of the nail bed behind. The most frequent sites of failure are on
the lateral and medial edges of the wounds at the level of the
interphalangeal joint.
Wound closure consists of suturing back the elevated flap (Fig. 50-6). It
may be transposed 2 to 3 mm distally to facilitate wound closure.
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Figure 50-5. A: Incise the germinal nail bed tissue down to the periosteum of
the distal phalanx. Make a transverse incision through this tissue at the level of
the tip of the lunula. B: Continue developing a plane between the periosteum
and the nail bed down to the level of the interphalangeal joint.
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Figure 50-6. Wound closure consists of suturing back the elevated flap.
Dangers
The leading danger in this procedure is leaving part of the nail bed behind.
Take care that you do not leave any nail bed remnants behind at the level of
the interphalangeal joint at either edge of the wound.
Incision of the interphalangeal joint is potentially hazardous because the
field is frequently contaminated by previous infection. Try to avoid incision
of this joint, if possible.
How to Enlarge the Approach
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The approach cannot usefully be enlarged, as it is designed purely for the
local nail pathology.
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