How To Fix Pincer Nails

A pincer smash is a mutual boom deformity of toenails and is characterized by nail thickening and nail plate deformation. Information technology often causes severe pain for patients. We perform a thorough literature review and an additional review of pertinent clinical cases, aiming to provide a comprehensive review of the etiology, pathogenesis, clinical classification, differential diagnosis, and treatment of pincer nail deformity (PND). Understanding the clinical characteristics and treatment progress of a pincer nail volition provide clinicians with comprehensive and evidence-based data about PND, thus assuasive the pick of an advisable treatment co-ordinate to the patient'south request and the clinical manifestations of PND, which should maximize patient satisfaction.

1. Introduction

Pincer blast deformity (PND) is a common smash deformity first named "incurvated nail" in 1950 by Frost [i] and afterwards equally "pincer nail" by Cornelius and Shelley in 1968 [two]. The term pincer nail is generally preferred in recent literature. It has an incidence rate of approximately 0.9% and commonly affects the outside/inside/bilateral sides of the hallux toenails; other toenails and fingernails are infrequently affected [three]. PND is characterized by blast thickening and narrowing of the distal terminate of the blast bed along the longitudinal axis of the nail plate in a proximal to distal way together with an increase in the maximum transverse curvature, which causes the smash edges to descend into the lateral smash fold. The curvature that increases forth the nail'southward distal sides causes severe pain, chronic inflammation, and recurrent infections, affecting the daily lives of affected patients. PND affects the ability of patients to walk or habiliment shoes [2], and some severe cases require elective toe amputation [4].

two. Etiology and Pathogenesis

two.one. Etiology of Pincer Nail

PND's cause is non known but is suspected to be hereditary or caused. In 1973, Chapman reported three generations of patients with hereditary pincer nails that occurred in their teens and early twenties [5]. They proposed that PND was a hereditary disease that oftentimes exhibited symmetry and autosomal ascendant Mendelian characteristics [5]. Like cases were afterward reported past El-Gammal and Altmeyer, in which the toenails and fingernails of one woman were afflicted offset in early childhood [6]. In 2015, Hu et al. observed a multiple-generational Taiwanese family in which approximately half of the family members exhibited PND and symmetry deformities [7]. They also proposed that PND without nail thickening was the main indicator for Clouston syndrome, an autosomal dominant genetic illness.

Dissimilar hereditary pincer nails, caused pincer nails showroom asymmetry. Many systemic diseases are associated with PND, including gastrointestinal malignancies, renal failure, Kawasaki disease, amyotrophic lateral sclerosis, and systemic lupus erythematosus [viii, 9]. However, when these diseases are finer controlled, pincer nails resolve spontaneously. In 1996, Baran suggested that unfitting shoes cause acquired PND [10]. Long-term use of beta-blockers also causes PND, occurring after 6-12 months. Notwithstanding, spontaneous improvement is noticed afterwards stopping the drug. In addition to beta-blockers, pamidronate is another drug suspected to cause PND.

PND is a recognized iatrogenic complication later placement of the arteriovenous fistula (AVF) in the hemodialysis pathway. The pathogenesis involves the development of pseudo-Kaposi's sarcoma and venous hypertension, leading to circulatory disturbances in the microvasculature. Somewhen, tissues of the five fingers distal to the AVF become hypoxic. In 2015, Clark and Burns reported that PND occurred averagely 2 years after the formation of AVF and gradually disappeared with reversal of the fistula, indicating that local microcirculation changes and resulting ischemia or venous hypertension could cause PND [xi]. Other causes include onychomycosis, epidermolysis bullosa simplex, repeated trauma, nail avulsion, tumor of the nail [12], subungual exogenous osteophytes or peripheral pyogenic granuloma, and osteoarthritis of the distal interphalangeal finger joints.

ii.2. Pathogenesis of Pincer Smash

Although many cases of hereditary and acquired PND have been reported, the underlying pathogenesis is non known. In 2001, Baran et al. reported that the overcurvature was probably due to exostoses of the distal phalanx, leading to increased torque in the outgrowing boom plate [13]. Recent studies suggested that an osteophyte of the distal phalanx is not a cause but rather a event of nail overcurvature, and the ventral and dorsal side blast plate differences crusade PND, through nail bed shrinkage [xiv]. Similarly, Twigg et al. considered PND to exist caused past enlargement of the base of the distal phalanx [xv]. The increased tissue leads to a reduced proximal curvature and a larger distal curvature considering the smash matrix is firmly attached, resulting in PND.

In contrast, some clinicians reported that bedridden patients with no shoes and weight-begetting showroom a high incidence of developing PND. This suggests that mechanical forces affect the nail formation and pathophysiological process of boom deformity. In 2014, Sano and Ogawa hypothesized that mechanical forces affected the nail configuration and deformation (Effigy 1) [sixteen]. Nails naturally curve downward to permit the boom plate to conform to the daily upward mechanical forces. Nether normal conditions, the upwards daily mechanical forcefulness and downward automatic curvature forcefulness are well balanced (Effigy ane(b)). Even so, an imbalance between the two forces may lead to nail deformation. PND is genetically predisposed to the nail bending inward because of the absenteeism of upward mechanical force or increased automatic angle force (Figure one(a)). Similarly, if the up mechanical force exceeds the automatic curvature force, the nail volition bend outward, forming koilonychias (Figure 1(c)) [16].

3. Clinical Classification and Assessment Methods

iii.1. Clinical Nomenclature of Pincer Nail

PND has three types, every bit proposed by Baran et al., including the "common" pincer nail (omega or trumpet type, type ane), the plicated blast (similar to the ingrown boom, blazon 2), and the tile-shaped nail (type iii) [xiii]. Blazon i is characterized by an increase in the transverse curvature from the proximal to the distal smash, which forms an omega or trumpet shape. Type 2 presents with lateral edges that are sharply aptitude to form vertical sheets pressing into the lateral boom groove and producing granulation tissues that mimic an ingrown nail. Type 3 is rare and characterized past a larger increase in the transverse curvature along the longitudinal axis of the nail plate, forming a tile shape.

3.2. Evaluation Method

Classifying PND severity is complicated, and various terms, such every bit incurved smash, pincer smash, trumpet nail, and omega boom, accept been used to limited severity though they were not clearly defined. Moreover, vague results have been reported for the effectiveness of various pincer nail treatments, and no accurate evaluation method exists. Thus, to better assess the severity of pincer nails, Masaaki and Hiroshi in 2003 start developed an original morphological evaluation method that included measuring the width, height, and length of the nail plate [17]. From these data, the following indices were calculated: (ane) Width alphabetize: . Values closer to 100% betoken wider nails, whereas values budgeted 0% indicate more tapered nails. (2) Acme index: . Similarly, values budgeted 0% indicate flatter nails, whereas higher values indicate nails displaying a more than marked dorsal protrusion. The two indices were used to objectively appraise the severity of blast deformities (Figure 2(a)).

(a)

(b)

In 2013, Yabe proposed a ameliorate measurement of the width index than Masaaki and Hiroshi'southward method [17], which did not account for both side nail roots buried subcutaneously [18]. When the nail's shape is curved, the elevation index cannot correctly evaluate severity considering both the width and the height are reduced. As a result, they proposed a new evaluation system, the curvature index, defined every bit divided by ( ), where the width of the smash tip is and the traced length of the blast tip is (Effigy two(b)). This method allows describing the pincer nail severity and examining clinical treatment progress. However, this evaluation organization has some drawbacks including when both nail sides are cut or cached in the lateral smash fold, measurement becomes incommunicable. Consequently, it is important to develop a more effective evaluation organization.

four. Differential Diagnosis

The differences between pincer nails and ingrown nails are confusing because they are clinically related; hence, differential diagnoses are required. Ingrown nails are identified based on symptoms, while pincer nails are identified based on morphology. From the morphological perspective, the largest difference betwixt pincer and ingrown nails is that pincer nails show a transverse curvature of the nail plate'southward long axis that increases in a proximal to distal manner. Moreover, the acme of the nail gradually increases, while the nail plate shape of ingrown nails remains normal [xix].

v. Managements

The aim of PND treatment is to correct the curve that pinches the toes and fingers and yield a cosmetically normal nail [17]. Although conservative, surgical, and combination therapies have been used, at that place is no standardized PND treatment. Conservative treatment involves a uncomplicated operation and is associated with recurrence/temporary remission. Alternatively, the surgical option has a lower recurrence merely causes astringent hurting, poor corrective advent, secondary infection, wound necrosis, and sensory disturbance [xx]. Female patients are sensitive to aesthetic problems related to invasive surgery [21]. If acquired PND is accompanied past systemic affliction, treating the main illness improves the symptoms [15]. Antibacterial treatment, boom avulsion, and surgical debridement tin can treat PND accompanied past secondary infections [4]. Pang et al. reported that PND accompanied by chronic inflammation or recurrent suppurative infection requires regular X-ray examinations to detect early on potential osteomyelitis for early intervention [4].

five.1. Conservative Handling (Tabular array ane)

No. Authors and references Year Cases Age (years) Sex activity Location Treatment Complexity Outcome Limitations one Effendy et al. [22] 1993 3 NM F/3 Halluces Pliant braces after flattening with a grinder NM Good NM 2 Chiacchio et al. [23] 2006 27 53, average M/2, F/25 Halluces Plastic device No Good Longer treatment period; required several plastic caryatid adjustments 3 Kim and Park [24] 2009 19 38.8, average NM Toenails Shape-memory alloy (the K-D) 6% recurrence rate Good NM 4 Kim et al. [14] 2013 21 51.9, average M/3, F/xi Halluces Shape-memory alloy device No Proficient Eczema lesions; sensitivity of the shape-retention alloy device 5 Lee et al. [25] 2014 1 27 F Hallux Shape-memory blend brace Superficial necrosis Bad NM 6 Yang et al. [26] 2011 ane 32 Yard Halluces Shape-retentivity alloy and removal of excess skin and subcutaneous fat No Good NM 7 Roh et al. [27] 1997 1 threescore F Fingers Nail grinding method, 3 times weekly No Good NM 8 Sano and Ogawa [28] 2015 one 55 1000 Left hallux Reduce the hardness and thickness of nails using a boom grinder NM Good NM nine El-Gammal and Altmeyer [6] 1993 1 39 F Almost toenails, all fingernails 40% uric acrid ointment NM Good NM x Baran et al. [29] 2002 NM NM NM NM 3% salicylic acrid NM Proficient NM 11 Won et al. [thirty] 2018 68 46, boilerplate 1000/21,F/47 Toenails Superelastic nickel-titanium Early on wire detachment (4/68), discomfort (2/68), torn stockings (3/68) Expert NM

NM: not mentioned; F: female; M: male.

Conservative treatment comprises of auxiliary stents and grinding tools to change the upwards mechanical daily force, thickness and growth direction of the nail plate.

5.ane.ane. Plastic Devices

The "clyp organisation" is a semirigid, flexible plastic material in an elliptical shape. When subjected to pressure level, they are malleable [23]. In 1993, Effendy et al. used pliant plastic braces to treat PND in the halluces of three women [22]. In 2006, Nilton et al. used the plaster mold to follow the blast widening during and later on treatment to evaluate its efficacy (Figure 3) [23]. Similar to Effendy et al., after slight grinding of the nail plate with sandpaper, the nail surface was degreased with acetone to increase its adhesiveness to the plastic device. A suitable plastic device was then fixed to the nail plate with liquid cyanoacrylate glue. The larger axis of the plastic device matched the horizontal axis of the boom and was close to the costless edge. During a follow-up, an alginate mold was applied to the afflicted hallux. Then, the mold was filled with stone plaster and removed the next 24-hour interval, and the caliper on the plaster mold measured the distance between the lateral nail sides. The biggest drawback for this method is the lengthened treatment period and frequent adjustments of the plastic brace [23].

five.i.2. The Shape-Retention Blend

The shape-retentivity blend has a nickel-titanium central rod and bilateral hooks that appoint the nail sides (Effigy 4(a)) [31]. The central bar is flexible at <25°C, making information technology easy to bend and utilize to severely deformed nails. At >25°C, the bar's solidity increases which corrects the nails. Considering that the foot temperature is approximately 27°C to 28°C, the bar retains its house nature [24]. In 2009, Kim and Park applied the shape-memory alloy device to care for severely incurved symptomatic toenails and achieved positive outcomes [24]. From 2010 to 2012, they used information technology on 14 patients with mild and severe PND and accomplished satisfactory results (Figures 4(b) and four(e)). They used a mosquito clamp to remove function of the nail embedded into the periungual skin. Ane side of a claw was applied to one side of the nail, while the other side of the hook was applied to the opposite side (Figures 4(c) and four(d)). The hook was moved to the position on the nail respective to the starting signal of the boom deformity. Finally, one/two similar devices were used depending on toenail size and PND severity. The device was removed later on 10 days but can stay for ii or 3 weeks depending on the toenail changes [14]. Thereafter, in 2014, Lee et al. used this treatment for a single case, and 4 weeks after surgery, skin necrosis adult on the back of the toe [25]. They concluded that it was acquired past local infection from self-adherent bandages. Furthermore, the patient had ischemia in the submuscular grade of the first dorsal metatarsal avenue (FDMA) which may have contributed to necrosis. They concluded that educating the patient on skincare routine minimizes complications. Although Young Joo et al. considered the shape-memory blend device to be inconvenient [20], the technique is used to improve the PND symptoms [24]. This technique was combined with surgical procedures on patients with hypertrophic nail fold skin [26].

5.i.iii. Boom Grinding

Nail grinding is a noninvasive technique, used to treat PND since 1990 [27]. From early studies, Sano and Ichioka reported that the toenails of PND patients were approximately 0.eight mm thicker and stronger bending than those of salubrious adults [32]. In 2015, they reported a example of severe PND treated by nail grinding (Figure five), thereby reducing the automated curvature force of the nail which balanced the mechanical force and automatic curvature [28]. This technology is prove that mechanical stimulus-based treatments are effective. Nail deformities can exist treated by balancing the automatic curvature force of the nail and the upwardly mechanical strength from the finger/toe pad. Moreover, they suggested that farther research is needed to determine the long-term results of this treatment and to establish an optimal and effective thinning method. In addition, massage, machine stimulation, and adjusting the walking posture can be effective. The nail tin be softened or thinned using an external training, such equally forty% urea paste [6] or iii% salicylic acid [29], which reduces the hardness and thickness of nails.

5.1.4. Superelastic Nickel-Titanium

From previous reports, superelastic nickel-titanium enabled bending of ingrown nails to their normal shape, providing a low-cost and effective treatment. Recently, Won et al. used dental correction principles and superelastic nickel-titanium to treat PNDs (Effigy 6) [30]. This approach has three advantages. Kickoff, it tin can be tailored to the patient's needs. Second, information technology can be performed on the nail of the hallux, other toenails, and even fingernails. Tertiary, it is noninvasive and does not limit the patient's lifestyle, enabling prolonged handling in patients with frequently recurring PND without compliance issues.

five.ii. Surgical Treatment

In the case of PND with exogenous osteophytes of the distal phalanx or severe dorsal hyperosteogeny, the removal of osteophytes is of import [33]. Nonetheless, for those with no severe bony deformity, operation of the distal phalanx is not necessary [34]. Among the treatments suggested previously, several surgical procedures can be divided into ii groups: surgical procedures that destroy the blast matrix and those that preserve the blast matrix (Table 2).

No. Authors and references Year Cases Age (years) Sex Location Treatment Complication Issue Limitations i Zadik [35] 1950 16 NM NM NM Advancement flap subsequently destroying the nail matrix Little epithelial thickening over the nail bed; necrosis of the flap Satisfactory Permanent nail eradication, loss of fingertip dexterity, and aesthetic differences 2 Iida and Ohsumi [36] 2004 14 67.5, average 1000/4, F/10 Halluces, fingers Modified Zadik method with artificial pare No Good Wound took longer to epithelialize iii Suzuki et al. [37] 1979 NM NM NM NM Preserving the nail matrix with a split-thickness pare graft NM NM Nail did non adhere to the divide-thickness skin graft, resulting in a floating, distorted nail four Dark-brown and Zook [38] 2000 6 52, average Grand/one, F/5 Halluces (ii/6), thumb (iv/6) Implanting dermal grafts betwixt the distal phalanx and nail bed to restore the nail bed profile NM NM Shrinkage of the full-thickness skin grafts 5 Hatoko et al. [39] 2003 i 25 1000 Bilateral halluces Difficult-palate mucosal graft after flattening the digital bone No Adept No six Masaaki and Hiroshi [17] 2003 27 NM NM Halluces (40) Widening the nail bed with a zigzag flap No Good No 7 Mutaf et al. [40] 2007 viii 17 to 48 M/ii, F/half-dozen Toenails Modified v-flap Z-plasty technique to enlarge the distal part of the nail bed subsequently removing the osteophyte Infection and fractional wound dehiscence (1/8) Good Limited ability to flatten the distal stop of the nail bed [66] 8 Cho et al. [twenty] 2015 12 43, average Chiliad/3, F/9 Toenails Modified double Z-plasty No Proficient No 9 Ozawa et al. [21] 2005 7 41.5, average 1000/2, F/five Right hallux (four/9), left hallux (1/ix), bilateral halluces (4/9) Splinting device composed of an aspiration tube Ingrowth of the nail (1/9) Good No 10 Ghaffarpour et al. [41] 2010 11 60, average One thousand/2, F/9 Toenails Widening the nail bed with the combination of splint and nail bed cutting No Skillful No 11 Leshin and Whitaker [42] 1988 9 NM NM NM Carbon dioxide (CO2) laser for permanent nail ablation via matricectomy No Good No 12 Lane et al. [34] 2004 ane 63 Yard Left thumbnail CO2 laser to ablate the boom plate and lateral horns of the matrix; functioning of a fractional matricectomy; satisfactory results were achieved No Proficient No 13 Miller and Levitt [43] 2011 1 sixteen M Left 3rd finger Pulsed dye laser No Good No 14 Shin et al. [44] 2018 11 61.seven, boilerplate Thou/7, F/4 Halluces Nail plate and bed reconstruction Balmy ischemic changes on the incision, merely with healed wounds (ii/xi) Practiced No 15 Altun et al. [nine] 2016 i 64 F Right hallux Removal of osteophytes and correction of the depressed areas of both sides of the nail bed (lateral nail fold) with dermal flaps prepared from the side No Good No 16 Yabe [18] 2013 ane 51 F Right hallux Removal of the nail plate, raising the nail bed with a periosteum as a flap, flatting the distal phalanx, and trimming excessive skin of both sides of the nail No Good No 17 Fuchsbauer et al. [33] 2007 1 46 M Right hallux Removal of the nail plate, meridian of the blast bed, flattening of the distal dorsal bony excrescence, placing a dermal graft, and placing silicon sheeting No Practiced No 18 Majeski et al. [viii] 2005 ane 29 F All fingernails Resection of the nail plate and matrix NM Good NM 19 Brown and Zook [12] 1988 1 45 F Correct thumb Removal of the cyst and ii corners of the matrix to reduce the width of the boom No Expert No

NM: not mentioned; F: female; Thou: male.

five.2.1. Pare Grafts and Other Tissue Grafts

In 1950, Zadik reported this technique for the treatment of ingrown and pincer nails [35]. Afterward blast avulsion, the matrix and epithelium of the posterior wall of the nail were excised completely, and the posterior nail wall was sutured without tension to the nail bed, performance as an advocacy flap. However, two cases of flap necrosis occurred due to flap suturing nether tension. In 2004, Iida and Ohsumi introduced a modified version of Zadik'due south method [36]. Later removal of the nail matrix, including approximately 3 mm of the boom bed connected to the distal border of the matrix, artificial skin material was used to embrace the boom bed instead of an advancement flap. It was not successful because of poor wound healing. In both cases, the procedures involved destroying the boom matrix, and the terminal results were not cosmetically/functionally satisfying. Many patients requested preservation of the nail unit and a good cosmetic outcome. Consequently, almost surgeries are aimed at preserving the boom matrix.

In 1979, Suzuki et al. first reported a PND surgical procedure with preservation of the smash matrix [37]. After removal of the blast, a median longitudinal incision was created in the smash bed to spread the tissue on the medial and lateral sides, leaving a center triangular defect. Side by side, a separate-thickness skin graft from the forearm was sutured to this defect. During a follow up, the nail did not adhere properly and became discrete. In 2000, Dark-brown and Zook reported a long-term correction of PND past surgically implanting a dermal graft taken from the groin into the affected distal phalanx and nail bed to restore the nail bed contour [38]. However, this method was not positive due to the occurrence of full-thickness skin graft shrinkage [39].

To reduce the floating nail and shrinkage of the graft, Hatoko et al. described the use of a hard-palate mucosal graft to correct severe PND in 2003 [39]. Subsequently nail avulsion, an incision was created along the boom bed, and the nail bed tissue flap was raised at the layer above the digital os. Later on flattening the digital phalanx, the surrounding tissue was bluntly dissected to spread the shrunken blast bed. When the smash bed tissue returned to its original position, the nail bed defect mainly occurred at the distal finish of the bed, and the hard-palate mucosa containing the periosteum was transplanted onto that defect. During the long-term follow-upwards, no deformity appeared on either side of the blast bed, and epithelial formation occurred spontaneously. Therefore, hard-palate mucosal grafts are an constructive option for the treatment of nail bed repair in patients with severe pincer deformities.

five.2.ii. Widening of the Blast Bed

(1) Widening of the Smash Bed with Skin Flap. In 2003, Masaaki and Hiroshi described a procedure that widened the nail bed in the transverse direction with vertical incisions at the distal end [17]. Sutures were then placed in a zigzag pattern, similar to a classic W-plasty subsequently complete release of the hyponychium and paronychium. Additionally, the skin flap was sutured in a zigzag pattern, which prevented postoperative scar contracture and trapdoor deformity. In 2007, Mutaf et al. [twoscore] reported that removing the osteophytes helps in surgical correction of PND. After the removal of osteophytes on the dorsal surface of the distal phalanx to provide a flat surface for the nail bed, the distal role of the nail bed was enlarged in the transverse direction using a modified 5-flap Z-plasty technique. The 5-flap Z-plasty technique was invented by Mustarde [45] to correct epicanthal folds in 1959. This technique has been used extensively, and the first report of its employ to treat PND was described past Mutaf et al. [40].

The to a higher place-mentioned authors reported successful results without recurrence, but Cho et al. considered the 5-flap Z-plasty procedure [40] non effective in flattening the smash bed's distal end [20]. They modified the Z-plasty design to improve its ability to flatten the smash bed's distal end and added a vertical incision to the flap to dissever the nail bed into ii flaps with no vertical skin incision dividing the two Z-designs at the tip of the toes. After flattening the flap (including the raised nail bed), they removed the skin effectually the two flaps parallel to the nail bed. The transposed flap was sutured with nylon sutures to flatten and widen the blast bed in a transverse direction. Their method utilized the successful techniques from both Masaaki and Hiroshi [17] and Mutaf et al. [40].

(2) Widening of the Nail Bed with the Combination of Splint and Nail Bed Cut. In 2005, a splint made from an aspiration tube was used by Ozawa et al. to correct an elevated periosteal flap with intraoperative pinch [21]. They fixed the splint to the proximal nail fold using Schiller'southward method [46] such that pinch of the nail bed onto the distal phalanx and soft tissues was continuous. This technique prevented hematoma formation beneath the periosteal flap, contracture of the nail matrix and nail bed, and direct adhesion of the gauze to the nail bed. Moreover, the smash bed tin be monitored for possible infection and flap necrosis using the transparent aspiration tube.

Ghaffarpour et al. proposed that PND arises from the nail bed [41]. Thus, they combined a splint made of an aspiration tube and nail bed cutting to treat PND. Afterwards removal of the nail plate, the blast bed was elevated by a "U-shaped" incision consisting of 2 incisions nearly the lateral nail and an incision through the distal part of the smash bed and pulp. Next, they created four incisions from the distal part of the lunula to the proximal end of the nail bed parallel to the normal lateral blast grooves. These four incisions concluded within 2-iii mm of the distal flap, which made the nail bed wider and stretchable. The lateral parts of this stretchable nail bed were sutured to the lateral skin of the toe, and the distal office was sutured to the tip of the toe. A prefabricated transparent splint with a suction tube in the shape of a normal blast plate was and then placed under the proximal nail fold on the nail bed and sutured to the outer blast wall, with the transparent aspiration tube assuasive the clinicians to monitor any infection and flap necrosis [21].

5.ii.three. Laser Surgery

Laser treatment is beneficial over surgical excision considering it is like shooting fish in a barrel to utilise, minimalized postoperative intendance, and has rapid treatment time and minimal pain. Light amplification by stimulated emission of radiation handling is cosmetically friendly, as opposed to the inevitable linear scarring from surgery. In 1988, Leshin and Whitaker described the utilise of a carbon dioxide (CO₂) laser for permanent nail ablation via matricectomy to treat PND with a success rate of 100% [42]. Later, Lane et al. advanced this method (Figure 7) [34]. After using a CO₂ laser to ablate the nail plate, they used information technology once again to perform fractional matricectomy to retain medial blast growth and prevent lateral smash regrowth (Effigy 7(d)). Thus, removal of the lateral nail matrix is essential for treatment. The CO₂ laser is beneficial because of its inherent hemostatic properties allowing it to operate on highly vascular anatomical regions like the digits. Additionally, information technology has shallow penetration depth enabling the destruction of desired regions without causing extensive tissue damage to surrounding structures. This results in reduced healing time and desired cosmetic furnishings. Subsequently, Miller and Levitt reported successful outcomes after using a pulsed dye laser to treat PND with multiple periungual pyogenic granulomas [43].

five.2.4. Nail Plate and Bed Reconstruction

In 2018, Shin et al. used nail plate and bed reconstruction to treat PND (Figure 8) [44]. They created a five mm long incision in the proximal area of the nail along the boom fold to approach the nail matrix (Figures viii(a) and eight(b)). The subperiosteal autopsy was performed using an elevator, and the deformed nail plate was removed to prevent injuring the blast bed. Side by side, using a specific musical instrument to curve the nail plate at the maximum curve point, the nail bed was gently detached from the distal phalangeal os using a sharp blade (Figures viii(c) and viii(d)). The surface area of severe hypertrophy was carefully removed with a small rongeur, and the prominent osteophytes were carefully removed with a small burr. The nail curvature was reevaluated, and the smash bed was flattened. For severe PND cases with lateral deformities or unclear margins, one-two mm of the smash was removed from the lateral side of the plate. Subsequently resection, any infected lesions were removed (Figure viii(e)). To preclude recurrence, the proximal nail bed was gently ablated (Figure 8(f)). The nail fold was fixed underneath the lifted nail bed to offering back up and sutured (Figures 8(g) and eight(h)). This procedure removed the bony osteophytes underneath the smash bed and prevented bony devastation, skin necrosis, and ischemia. Consequently, it is beneficial for severe bony deformities and blast deformities.

5.3. Combination Therapy (Table 3)

No. Authors and references Yr Cases Historic period (years) Sex Location Treatment Complication Event Limitations one Kim and Sim [iii] 2003 14 NM NM Left hallux Boom plate and bed separation combined with aluminum splint fixation No Good Insertion of a thick, rigid aluminum strip through the gap betwixt the smash plate and nail bed requires a hard operation [twenty] two Chi et al. [47] 2010 ane 35 Thou Bilateral halluces TCA matricectomy and aluminum splint fixation No Expert NM 3 Chi et al. [47] 2010 1 36 M Bilateral halluces TCA matricectomy and aluminum splint fixation No Good NM iv Chi et al. [47] 2010 ane 25 K Bilateral halluces TCA matricectomy and aluminum splint fixation No Good NM five Chi et al. [47] 2010 ane xi M Bilateral halluces TCA matricectomy and aluminum splint fixation No Adept NM 6 Chi et al. [47] 2010 1 33 F Right hallux TCA matricectomy and aluminum splint fixation No Good NM vii Chi et al. [47] 2010 ane 16 M Left hallux TCA matricectomy and aluminum splint fixation No Proficient NM 8 Chi et al. [47] 2010 1 43 M Bilateral halluces TCA matricectomy and aluminum splint fixation No Proficient NM 9 Markeeva et al. [48] 2015 one 65 Grand Right thumb Failure of twoscore% urea paste, followed past bilateral blast resection, matricectomy with 90% TCA, incision of the median blast, and splinting No Good No 10 Dikmen et al. [49] 2017 14 45.2, average Chiliad/4, F/10 Halluces Surgical matricectomy, thioglycolic acid, and anticonvex sutures Superficial infection (ane/14), recurrence (1/fourteen) Satisfactory Poor cosmetic appearance (15.viii%) 11 Aksakal et al. [l] 2001 10 32-47 M/4, F/6 Bilateral halluces (4/10), unilateral toenail (6/10) Combination of chemical matricectomy with phenol and blast bed repair Wound oozing for a few weeks Good No 12 Plusjé [51] 2001 six NM NM NM Application of phenol to the matrix horns combined with surgical treatment NM Good NM thirteen Sugamata and Inuzuka [52] 2011 9 51, average M/ane, F/8 Halluces (xi) Methylation phenolization combined with surgical treatment Recurrence (ane/11) Practiced Narrow nail

NM: not mentioned; F: female person; Thou: male person.

5.iii.one. Smash Plate and Bed Separation Combined with Aluminum Splint Fixation

In 2003, Kim and Sim successfully treated 14 patients with severe PND using the nail plate method and bed separation technique combined with aluminum splint fixation (Figure 9) [iii]. They used the focused mode of a CO_ii laser to separate the nail plate by making a longitudinal incision proximally from the lunula edge to the distal edge of the blast plate. A longitudinal incision approximately ane mm in width was created at the center of the curvature to relax the nail plate and straighten it through lifting the edges up. Side by side, an aluminum splint bar was attached to the undersurface of the white free edge of the nail plate. The aluminum splint requires a complimentary edge of approximately two mm. And it was made from aluminum Nigel splints and was cut to the appropriate size in accordance with the nail size, with a typical size of . Finally, cyanoacrylate adhesive was applied between the aluminum splint bar and the boom plate, which were spring by needle holders.

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(b)

v.iii.2. Trichloroacetic Acid (TCA) Matricectomy and Aluminum Splint Fixation

Although Kim and Sim successfully treated PND by installing an aluminum splint below the nail plate surface [iii], Chi et al. considered information technology hard to insert a thick rigid aluminum strip through the gap betwixt the nail plate and the blast bed [47]. They improved the method by fixing an aluminum splint after matricectomy to treat PND. Matricectomy utilizes phenol or sodium hydroxide, although phenol causes systemic side effects, similar intestinal hurting, hemoglobinuria, and purpura. However, the amount used for matricectomy (<two ml) is not harmful. TCA, an alternative to phenol, is widely bachelor and safer at concentrations ranging from 9090% to 100%. Both compounds cause coagulative necrosis, only they are safe when used properly [53].

TCA use in matricectomy was start reported to treat ingrown toenails. Chi et al. applied it to treat PND [47], using 100% TCA for partial bilateral nail avulsion and matricectomy, with a width of the lateral nail avulsion of approximately three-4 mm. A septum lift was then employed to carve up the smash plate from the underlying smash bed. Adjacent, a CO_two laser or nail separator was used to longitudinally split the nail plate throughout the lunula to the distal edge of the nail plate (Figure ten(a)). This longitudinal avulsion reduced the curvature of the distal smash plate. Finally, an aluminum splint bar of advisable size was attached to the nail, and the bar was stock-still to the nail plate using a self-agglutinative wrap (Figure 10(b)). A satisfactory effect was obtained after a long-term follow-upward. In 2015, a successful similar process was used past Evgenia et al. [48].

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(b)

five.iii.iii. Surgical Matricectomy, Thioglycolic Acrid (TGA), and Anticonvex Sutures

In 2017, Dikmen et al. used surgical matricectomy combined with TGA and anticonvex sutures in a report of nineteen cases of PND in 14 patients [49]. They thickly applied a five% TGA solution, embedded in gauze, straight to the affected toenail surface while the patients were in the preoperative waiting room. The nail was then covered with a minimal dressing to ensure contact betwixt the TGA and boom surface to soften the boom plate. Thirty minutes afterwards application, two minor oblique incisions were created on the skin of the lateral aspects of the eponychial fold (Figure 11(a)). The smash plate was cut longitudinally as a nail strip using a straight pair of scissors to an approximate iii/4 mm width. Subsequently, the nail plate's ingrown segment was removed. After raising the eponychial flap outward with a hook, the nail matrix down to the periosteum was exposed and excised (Figure 11(b)). Next, afterward the one-0 polypropylene suture, two correcting anticonvex sutures were placed in the proximal and distal parts of the softened nail plate to straighten the plate (Figures eleven(c) and 11(d)). The anticonvex sutures were removed 3 months later on. Using this process, in that location was a cosmetic blast shape and less pain and trauma to surrounding tissues, when compared with those achieved with flap techniques [38, forty].

five.3.4. Nail Methylation Phenolization (NMP) Combined with Surgical Treatment

The NMP has the advantages of an like shooting fish in a barrel surgical process without specialized equipment, a minimal surgery time combined with minimal postoperative hurting and bed rest, and low recurrence rates. Additionally, considering phenol is antiseptic, the NMP technique tin be used to treat PND complicated with infection. In early on years, this method was extremely effective to treat ingrown nails. Up until 2001, Aksakal et al. used the combination of chemic matricectomy with nail bed repair to right PND [fifty]. In 2001, Plusjé also used phenol combined with surgery to correct PND [51]. They applied phenol to the matrix horns before operating on the distal phalanx, contrasting Sugamata and Inuzuka's method [52].

In 2011, Sugamata and Inuzuka incised the nail plate longitudinally from the top to the root with fine-tipped scissors [52]. The excised boom'southward width was approximately 4-5 mm from the lateral edge of the nail plate. The incurved distal third of the nail plate was then excised transversely (Figure 12(a)). A fine cotton-tipped applicator was immersed in phenol solution at a concentration greater than 88% . The posterior nail fold, nail matrix, nail bed, and lateral boom fold were cauterized completely with 5-six cotton-tipped applicators that had been immersed in phenol for approximately 5 minutes (Figures 12(b) and 12(c)). The site of cauterization was done with a sufficient corporeality of saline to inactivate the residual phenol. As a outcome, the nails returned to their normal lengths in two-4 months (Figure 12(d)). All patients reported an appreciable improvement in their PND and the disappearance of hurting from the halluces. Additionally, there were no serious complications, such as necrosis or phenol intoxication. The only disadvantage of this approach was the narrowness of the smash.

6. Conclusions

The pincer nail is a common nail deformity with a complicated pathogenesis and etiology. Many effective methods for the treatment of PND accept been reported, including bourgeois treatment, surgical treatment, and combination therapy. However, no consensus has been reached regarding the suitable method for correcting PND, necessitating further inquiry. Although many treatments described in the literature have demonstrated practiced results, these findings may be subject field to publication bias and influenced by patient choice. Satisfactorily treating PND is not piece of cake, and an appropriate clinical treatment method should be selected according to the patient'south request and the clinical manifestations of PND to maximize patient satisfaction.

Conflicts of Interest

The authors declare that there is no disharmonize of interest regarding the publication of this paper.

All authors substantially contributed to the manuscript. Chao Huang and Wenlai Guo designed the study, performed the literature review, extracted the data, and analyzed the pooled data. Rui Huang, Min Yu, and Ying Zhao drew the figures and organized the tables. Rui Li and Zhe Zhu reviewed and edited the manuscript. All authors read and canonical the concluding manuscript. Chao Huang and Rui Huang contributed equally to this study and share co-get-go authorship.

Copyright

Copyright © 2020 Chao Huang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original piece of work is properly cited.

Source: https://www.hindawi.com/journals/bmri/2020/2939850/

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