Protruded and nonprotruded subungual exostosis: Differences in surgical approach

Abstract

Background: In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis.

Materials and methods: Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a"fish-mouth" type of incision.

Results: The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence.

Conclusions: In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a "fish-mouth" type incision at the toe tip without an iatrogenic damage.

Keywords: Nail bed surgery; subungual exostosis; surgical exposure.

Figure 1

Clinical photograph showing (a) protruded subungual exostosis (arrow) (b) X-ray anteroposterior and oblique views of fore part of great and 2nd toe showing mass at dorsomedial aspect of the distal phalanx of the great toe. (c) Clinical photograph showing damage caused by subungual exostosis at dorsomedial aspect of the nail bed. (d) Subungual exostosis excised with pedicle (e) Clinical photograph showing the nail bed repaired with 6-0 absorbable suture and fixation of removed nail (f) Clinical photographs at 1st, 3rd, 6th,12th months followup showing normal appearance. (g) X-ray anteroposterior and oblique views of fore part of great and 2nd toe at 12 months followup showing no mars over distal phalanx of great toe

Figure 2

(a) Clinical photographs shown nonprotruded subungual exostosis. (b) X-ray anteroposterior and oblique views of fore part of great and 2nd toe showing mass in the dorsal aspect of the distal phalanx of the toe (c) Clinical photograph showing exposure with a transverse incision at fingertip excised mass damaged caused by subungual exostosis (d) Clinical photograph at 1^st week followup (e) Clinical photograph at 2^nd week control (f) Clinical photograph at 2^nd month followup (g) Clinical photograph showing that the nail was seen to grow in a healthy way at 12^th month followup