Treatment of subungual exostoses by elective day case surgery

Abstract

Twenty-one patients (11 female, 10 male: mean age 21.3 years) with subungual exostoses were treated with elective surgery under local anaesthetic in a dermatology day case theatre over a period of 8 years. Fifteen (71%) tumours affected the great toe, four (19%) affected other toes and two (10%) affected fingers. All received local excision with great care to remove all tumour residue from the terminal phalanx. Wounds were allowed to heal by secondary intention. Attention was paid to preoperative antiseptic procedure and postoperative analgesia. During follow-up of between 6 and 36 months (mean 17 months), there were two relapses (10%) in the first 12 months, seen in two of the younger subjects aged 9 and 13 years. One required further surgery. One further case suffered long-term dystrophy due to perioperative damage to nail matrix. Conservative and thorough treatment of this pathology can be achieved using the appropriate tools in a dermatology day case theatre.

Subungual Exostosis of the Toes: A Systematic Review

“…This approach seemed to lead to the lowest incidence of recurrence. De Berker and Langtry [9] described the use of a ronguer to adequately resect lesional tissue, whereas Davis and Cohen [8] used a curette to create a ''saucer-like defect'' into normal trabecular bone. Suga and Mukouda [34] introduced the idea that if the nail bed was intact, a fish mouth incision distally with a proximally based flap could be raised lifting the nail bed off of the lesion, thus sparing the nail.…”

“…Lokiec et al [23] showed in his six-patient series that reasonable results in terms of recurrence and cosmesis can be achieved with only partial nail resection using a distally based flap, which is reattached. Recurrence was related to incomplete excision in most described cases; however, overly aggressive dissection was thought to lead to onychodsytrophy and poor cosmesis [8,9,33,34], particularly when the lesion invaded the germinal matrix [9]. In the single podiatric article included in the study, Valinsky et al [37] used local anesthesia, a laterally based incision, and a single application of intralesional corticosteroid and antibiotics.…”

“…Although multiple specific surgical techniques and postoperative wound closure strategies have been reported [6,8,9,23,34,37], as a result of a lack of comparative analyses, no one technique has significant evidence to show its superiority. The principle, however, of a balance between complete lesional excision and delicate separation from underlying nail bed structures is the most important factor in mitigating recurrence and nail problems.…”

“…Although the complication of postsurgical nail deformity is related to the size and location of the lesion at presentation, meticulous surgical technique and wound closure can minimize deformity [9,19,33]. Although the actual rate of defined ''delayed diagnosis'' was found to be only 2%, this number is likely much higher.…”

“…This topic is underrepresented in the orthopaedic literature, because many of the important clinical series have been published in journals from other specialties [4,8,9,12,15,20,21,29,30,33,34,41], reflecting the fact that the condition is treated by many kinds of nonorthopaedic providers. Complete marginal excision of the exostosis appears to mitigate recurrence.…”