Risk factors for infection following ingrowing toenail surgery: a retrospective cohort study.

BACKGROUND: Ingrowing toenails are a common and painful condition often requiring surgical management. Practitioners who perform surgery on ingrowing toenails include orthopaedic surgeons, general practitioners, podiatrists and podiatric surgeons. There has been limited investigation into the specific surgical approaches used by Australian podiatric surgeons for ingrowing toenails, or the associated infection rates for these procedures. The aim of this study was to assess the frequency and type of ingrowing toenail surgery performed by podiatric surgeons, and identify risk factors for post-operative infection. METHODS: Data was entered into the Australian College Podiatric Surgeons (ACPS) National Audit Tool for all patients who underwent foot and ankle surgery performed by podiatric surgeons in Australia between January 2014 and December 2017. Infection within the first 30 days following surgery was recorded according to the ACPS national audit descriptors. Infection rates, risk ratios (RR) and 95% Confidence Intervals (CI) were calculated to determine postoperative infection risk. RESULTS: Of 7682 records, 1831 reported 2712 diagnoses of ingrowing nails. Patients with a diagnosis of ingrowing toenails were younger, less likely to have systemic disease, and a lower proportion were female compared to those without ingrowing toenails. Furthermore, they were more likely to be diagnosed with a post-operative infection than those without ingrowing toenails (RR = 2.72; CI = 2.00-3.69; P < 0.01). Univariate risk factors for post-operative infection following ingrowing toenail surgery include age greater than 60 years (RR = 3.16; CI = 1.53-6.51; P < 0.01), surgery performed in an office setting (RR = 1.77; CI = 1.05-2.98; P = 0.04), and radical excision of toenail bed procedure (RR = 2.35; CI = 1.08-5.01; P = 0.04). Patients that underwent radical excision or office based procedures were on average older, and more likely to have systemic disease. Further, radical excision procedures were more likely to be performed in office base settings. CONCLUSIONS: Ingrowing toenail surgery carries a greater risk of postoperative infection than other procedures performed by podiatric surgeons. Radical excision of toenail bed was associated with higher postoperative infection rates compared to other ingrowing toenail procedures. Procedures performed in an office setting carry a higher risk of infection. Further research into these associations is recommended.

Modified single pedicle reverse adipofascial flap for fingertip reconstruction.

BACKGROUND: Homodigital adipofascial flap is a well-established method for treating a distal fingertip defect; nonetheless, its use has some limitations. Reconstruction of fingertip injuries, with radial or ulnar tissue loss, may lead to some difficulties in providing an adequate bone coverage. The standard bipedicled technique did not allow the flap to cover the bone exposure without excessive tension. In our series, the reverse adipofascial flap had a single pedicle. The modified technique, because of its improved degree of rotation, granted the flap to reach either radial or ulnar tissue losses. PATIENTS AND METHODS: We treated 15 fingertip amputations distal to the lunula (9 Allen's type II and 6 type III), the mean size of defects was 2.7 cm2 (range, 1.8-3.2 cm2 ), the mean age of patients was 44 years (range, 22-63 years). Quick Disabilities of the Arm, Shoulder, and Hand score and Visual Analogue Scale were evaluated along with a 2-point discrimination test; the aesthetic satisfaction of the patients was estimated subjectively using a 5-point Likert scale. RESULTS: Mean flap size was 3.6 cm2 (range, 2.5-4.2 cm2 ), primary flap survival was observed in 14 out of 15 cases, partial flap necrosis was observed in 1 case, the nail grew in all fingers in about 6 months. Mean proximal and distal interphalangeal joint motion was 89° (range, 80°-100°) and 71° (range, 65°-80°), respectively. No complications were observed at the donor site. The median static 2-point discrimination was 4.5 mm (range, 3-8 mm), the mean quick DASH score was 2.6 (range, 0-9.1). All patients returned to work within a mean of 4.4 weeks (range, 4-5 weeks). The follow-up was 12 months. CONCLUSIONS: Single pedicle reverse adipofascial flap is an effective technique. This modified procedure allows a wider degree of flap rotation; it represents the ultimate arrow in our bow to address some particular defect geometry.

Oral supplementation with specific bioactive collagen peptides improves nail growth and reduces symptoms of brittle nails.

BACKGROUND: Brittle nail syndrome is a common problem among women and refers to nails that exhibit surface roughness, raggedness, and peeling. AIM: The goal of this study was to investigate whether daily oral supplementation with collagen peptides alleviates the symptoms of brittle nails and improves nail growth rate. METHODS: In this open-label, single-center trial, 25 participants took 2.5 g of specific bioactive collagen peptides (BCP, VERISOL® ) once daily for 24 weeks followed by a 4-week off-therapy period. Nail growth rate and the frequency of cracked and/or chipped nails as well as an evaluation of symptoms and global clinical improvement score of brittle nails were assessed by a physician during treatment and 4 weeks after discontinuation. RESULTS: Bioactive collagen peptides treatment promoted an increase of 12% nail growth rate and a decrease of 42% in the frequency of broken nails. Additionally, 64% of participants achieved a global clinical improvement in brittle nails, and 88% of participants experienced an improvement 4 weeks post-treatment. The majority of participants (80%) agreed that the use of BCP improved their nails' appearance, and were completely satisfied with the performance of the treatment. CONCLUSIONS: This study demonstrated that the daily ingestion of BCP increased nail growth and improved brittle nails in conjunction with a notable decrease in the frequency of broken nails.

Response of Fingernail Growth to Out-of-Field Low-Dose X ray in Cancer Patients Receiving Radiotherapy.

The entire body of a patient with cancer is exposed to low-dose levels of radiation (mGy) during radiation therapy. The safety and biological impact of such exposure to low-dose radiation on the human body are largely unknown. The fingernail is a highly proliferative tissue, and its growth can be monitored during radiation treatment to analyze early effects of low-dose radiation. The fingernails of 30 patients who received external beam radiotherapy (EBRT) were used in this study to investigate the change in nail growth during fractionated radiotherapy. Lead shields were applied to some fingers to create dose variance within individual patients. The absorbed dose was measured, and the relationship between the dose and change in nail growth rate was analyzed. Other factors, including serum albumin, hemoglobin level, body weight index, age, gender and chemotherapy, were also subjected to multivariate analysis. Fingernails from patients received an average of 0.96 mGy per treatment fraction. We observed a surprising decline in fingernail growth rate during radiotherapy, which was more prominent in the nonshielded fingernails with a relatively high-absorbed dose. Such growth delay could be observed as early as one week postirradiation and lasted the entire treatment course. Using fingernail growth as a novel marker for radioresponse, the current study showed that exposure to very low-dose ionizing radiation has previously unrecognized early effects on human tissue.

Combination therapy for onychomycosis using a fractional 2940-nm Er:YAG laser and 5 % amorolfine lacquer.

Onychomycosis remains difficult to cure by traditional methods. The aim of this study was to evaluate the efficacy of combination therapy with a fractional erbium yttrium aluminum garnet (Er:YAG) laser and 5 % amorolfine lacquer on onychomycosis. Nine patients with bilateral nails affected by distal and lateral subungual onychomycosis were included. The bilateral nails of each patient were divided into two groups. The 20 affected nails on one side of each patient as group 1 were treated with a fractional Er:YAG laser once a week and 5 % amorolfine lacquer twice weekly, while the 20 nails on the symmetrical side of each patient as group 2 were treated with amorolfine lacquer only. The laser treatment was conducted at weeks 1, 2, 3, 4, 8, and 12 in group 1. The clinical improvement, onychomycosis severity index (OSI), maximum linear clear nail growth (MLCNG), and mycological cure rate were evaluated. At week 24, 18 of 20 (90 %) nails in group 1 had achieved obvious clinical responses. The mean OSI score showed a significant decrease (5.24) and the average MLCNG was 3.1 mm in group 1. At week 24, 15 of 20 (75 %) nails achieved a negative mycological examination in group 1, compared with four of 20 (20 %) nails in group 2. The treatments were well-tolerated by most patients. This clinical study suggests that combination therapy of a fractional 2940-nm Er:YAG laser and 5 % amorolfine lacquer is an effective, safe, and convenient treatment method for onychomycosis.

Physics of nail conditions: why do ingrown nails always happen in the big toes?

Although surgical treatment of nail conditions can be traced back centuries to the writings of Paul Aegineta (625-690 AC), little is known about the physical laws governing nail growth. Such a poor understanding together with the increasing number of nail salons in the high street should raise legitimate concerns regarding the different procedures applied to nails. An understanding of the physics of nail growth is therefore essential to engage with human medicine and to understand the aetiology of nail conditions. In this context, a theory of nail plate adhesion, including a physical description of nail growth can be used to determine the transverse and longitudinal curvatures of the nail plate that are so important in the physical diagnosis of some nail conditions. As a result physics sheds light on: (a) why/how nails/hooves adhere strongly, yet grow smoothly; (b) why hoof/claw/nail growth rates are similar across species; (c) potential nail damage incurred by poor trimming; (d) the connection between three previously unrelated nail conditions, i.e. spoon-shaped, pincer and ingrown nails and; last but not least, (e) why ingrown nails occur preferentially in the big toes.

Desenvolvimento do sistema tegumentar em bovinos com idades gestacionais estimadas de 20 a 140 dias / Development of the integumentary system in bovine with estimated gestational ages from 20 to 140 days

A pele representa parte importante do sistema tegumentar, pois desempenha funções como a proteção contra desidratação, lesões e infecções, além de apresentar alto poder de renovação. Histologicamente, a pele consiste de duas camadas funcionais, morfologicamente distintas, a epiderme e a derme. As glândulas mamárias, capsula ungueal e cornos também fazem parte deste sistema. Devido à escassez de dados na literatura sobre o desenvolvimento da pele e dos anexos de natureza córnea em bovinos, o objetivo deste trabalho foi descrever as características morfológicas do desenvolvimento do sistema tegumentar durante os períodos embrionário e fetal em bovinos. Os indivíduos foram divididos em três grupos: Grupo I -embriões de 20-26 dias (n=4); Grupo II -embriões 30-47 dias (n=6) e Grupo III -fetos de 74-140 dias (n=6). Durante o desenvolvimento da pele observou-se diferentes padrões morfológicos de acordo com as regiões analisadas, apresentando índice maior de diferenciação no intervalo entre 30-47 dias de gestação. O aparelho ungueal e a glândula mamária se desenvolvem mais tardiamente entre os dias 74-140 da gestação. Em resumo, estes resultados acerca do desenvolvimento do sistema tegumentar em bovinos, poderão auxiliar na interpretação e compreensão da formação dos órgãos que o constituem, assim como para a compreensão de alterações patológicas associadas à organogênese.

The skin is an important part of the integumentary system, which has important functions such as protection against dehydration, injury and infection, as well as present high potential of renewal. Histologically, the skin consists of two functional layers, that are morphologically distinct, the epidermis and dermis. The mammary glands, ungueal capsule and horn are also part of this system. Due the poor data available on literature about the development of skin and other cornea attachments in bovine, the aim of this study was to describe the morphological characteristics of the integumentary system development during the embryonic and fetal periods in bovine. Individuals were allocated in three groups: Group I -embryos from 20 to 26 days (n=4), Group II -embryos from 30 to 47 days (n=6) and Group III -fetuses from 74 to 140 days (n=6). During the development of the skin it was observed different morphological patterns according to the analyzed regions. Especially, a higher level of differentiation was observed during 30-47 days of gestation. The bovine claw and mammary gland develop later between 74 to 140 days of gestation. In summary, these results related to the development of the integumentary system in bovine may help the analysis and understanding of the development of their organs, as well as the pathological disorders associated to the organogenesis.

Nail disorders in infants and children.

PURPOSE OF REVIEW: Nail diseases in infants and children are an uncommon cause of consultation and are often difficult to diagnose and to manage. This review will cover nail diseases that are most commonly seen in clinical practice, including congenital and hereditary disorders and inflammatory, infective, and neoplastic nail diseases. The purpose of the review is to help the reader to recognize nail disorders at an early age and to manage them appropriately. RECENT FINDINGS: Two recent large studies have reported the clinical findings of genetic disorders involving the nails, that is, pachyonychia congenita and epidermolysis bullosa. Only a few articles gave a comprehensive review of a disease, as occurred for onychomycosis, while the majority of the reports published in the recent literature involve single cases. SUMMARY: Nail diseases in children and neonates are not easy to diagnose by nonexperts. Basic knowledge of the anatomy and biology of the nail facilitates their diagnosis as the understanding of their pathophysiology. This review gives hints at the most common nail diseases that affect infants and children.

Update: nail unit dermatopathology.

Nail unit dermatopathology is a growing field filled with many challenges. Many advances in this field have been made in the last 5 years. This review article provides an update on new information and studies published in that period of time. We divided these works into different sections, including clinical and pathologic challenges in diagnosis and treatment of nail disorders, nail unit biopsy and processing techniques, normal nail unit histology, nail plate structural and growth pathology, metabolic disease, inflammatory conditions, onychomycosis, benign growths, malignant growths, and dyschromias. Specific highlights include advances in the marking and orientation of nail unit biopsies for improved histologic interpretation, improved nail plate softening techniques, new methods for histologic evaluation of onychomycosis, descriptions of newly described benign growths unique to the nail unit, and the morphologic and immunohistochemical distinction between benign and malignant pigmented lesions of the nail unit.

The nail plate biopsy may pick up gout crystals and other crystals.

The rewarding use of nail clippings processed histologically for the diagnosis of some nail diseases is well established. A new application of the nail plate biopsies (NPBs) is the detection of crystals in the subungual horn. Besides other subungual crystals, urate crystals are heretofore undescribed. This presentation adds to the advantages of an NPB: the detection of some cases of gout on which urate crystals are extruded subclinically. While searching for fungi, 2 cases of gout were diagnosed histologically, aided by unstained thick sections. A history of gout was then confirmed. No tophi were noted in or near the nail field. Chasing for crystals opens the study of fluids that may exude or transude into nail structures, a kind of "nail window" into hematic or metabolic abnormalities. In sum, the abundance of cytologic and histologic findings in an NPB can expand the armamentarium of physicians to evaluate nail diseases and even systemic diseases in a noninvasive manner.

Lower extremity changes experienced during pregnancy.

The anatomic and physiologic changes occurring with pregnancy result in a variety of symptoms affecting the lower extremity. The purpose of this investigation is to provide a comprehensive look at the lower extremity changes experienced during pregnancy and correlate symptoms with underlying etiology in a literature review. In this retrospective study, 100 postpartum women were interviewed regarding the lower extremity changes experienced in pregnancy. The interview included dermatologic, vascular, neurologic, and musculoskeletal portions. Results demonstrate more than 50% of women reported faster toenail growth, roughened toenail texture, increased dryness of the skin, swelling of the foot, ankle, and leg, unsteady gait, increased foot width, and hip pain. Though a majority of patients did not experience the remaining symptoms represented in the interview, all results are pertinent and deserve understanding to provide better insight and care for the pregnant woman. Therefore, a thorough literature review is presented to correlate the outcomes of the present study with previously published research.

Determination of amphetamine-type stimulants, ketamine and metabolites in fingernails by gas chromatography-mass spectrometry.

A gas chromatography-mass spectrometry (GC-MS) method was developed and validated for the simultaneous qualification and quantification of methamphetamine (MA), amphetamine (AP), 3,4-methylenedioxy-N-methylamphetamine (MDMA), 3,4-methylenedioxy-N-amphetamine (MDA), ketamine (KET) and norketamine (NKT) in fingernails. Fingernail samples (20mg) were washed with distilled water and methanol, digested with 1.0M sodium hydroxide at 95 degrees C for 30 min, and then extracted with ethyl acetate. Extract solutions were evaporated to dryness, derivatized using heptafluorobutyric anhydride (HFBA) at 60 degrees C for 30 min, and analyzed by GC-MS. The linear ranges were 0.1-20.0 ng/mg for AP, MDMA and NKT, 0.2-20.0 ng/mg for MA and MDA, and 0.4-20.0 ng/mg for KET, with the coefficients of determination (r(2)>or=0.9989). The intra- and inter-day precisions were within 7.1% and 10.6%, respectively. The intra- and inter-day accuracies were -10.9% to 0.8% and -4.3% to 4.5%, respectively. The limits of detections (LODs) and the limits of quantifications (LOQs) for each analyte were lower than 0.094 ng/mg and 0.314 ng/mg, respectively. The recoveries were in the range of 72.3-94.9%. The average fingernail growth rates of two subjects for three years and six subjects for two months were 3.12 mm/month and 3.16 mm/month, respectively. The method proved to be suitable also for the simultaneous detection and quantification of MA, MDMA, KET and their metabolites in fingernails.

Fingertip replantations: importance of venous anastomosis and the clinical results.

Overall survival rate for 143 digits with complete amputation of the distal phalanx was 78%. Replanted digits that underwent venous anastomosis showed a very high survival rate of 93%. Loss of the distal interphalangeal joint function in subzone IV was significantly inferior to that in subzones II and III. Protective sensation was achieved in 96% of replanted digits. Sensory recovery in the absence of nerve repair was significantly worse for avulsion injury than for crush injury. Nail deformity tended to be increased for replanted digits in subzone III or with crush-type injury. Successful venous anastomosis appears to offer the best way to promote survival of replanted digits. If venous anastomosis is infeasible, a replanted digit can survive with any methods for venous drainage in subzones II and III, but does not survive in subzone IV. To minimise nail deformity, repair of the germinal matrix is necessary.

Cessation of nail growth following Bajiaolian intoxication.

Bajiaolian (Dysosma pleianthum), a species in the Mayapple family (Podophyllum pelatum), has been widely used as a traditional Chinese herbal medication for the remedies of snake bite, tumor growth, post-partum recovery, and acne. It has also been used in western medicine, especially topically for various skin lesions. Both oral ingestion and dermal application may result in severe toxicity. The clinical presentations reported after Bajiaolian poisoning include nausea, vomiting, diarrhea, abdominal cramps, tachycardia, orthostatic hypotension, paralytic ileus, urinary retention, hepatorenal dysfunction, leukocytosis followed by leukopenia, thrombocytopenia, prolonged areflexia, prolonged paraethesia and sensory ataxia, dizziness, fever, memory impairment, hallucinations, paranoia, convulsion, fainting, and coma. There are no previous reports in the literature about the cessation of nail growth as a clinical presentation following Bajiaolian poisoning. We present a case of nail growth that was halted for more than seven years after a single case of Bajiaolian poisoning.

A method for optimising excision of the nail bed matrix.

This paper describes a useful way of ensuring complete surgical ablation of the germinal matrix of the nail bed by staining the proximal envelope with Bonney's Blue dye.