What is the WHO Safer Surgery Checklist and what does it involve?
A checklist developed to reduce errors in surgical practice
It involves taking a ‘surgical pause’ before beginning any procedure and doing the following:
Team member introduction - Ensuring everyone in the team has introduced themselves
Verifying that…
This is the correct patient
This is the correct procedure
This is the correct site to perform said procedure (on the correct side)
Any pre-procedural imaging has been viewed by yourself
The correct instrumentation has been provided
The correct medications/ blood products have been provided
At what point is the surgical pause undertaken in a nail surgery?
Following the swabbing and draping process, before application of a tourniquet
What are some indications for nail surgery?
Onychocryptosis
Chronic or recurrent infections of the nail bed or nail sulcus
Trauma or injury
Nail deformity
Chronic pain related to any nail pathology (e.g onycogryphosis, onychochauxis, involuted nails)
Non-healing ulcers around toenails
Name some nail surgery procedures
Total Nail Avulsion - With or without chemical matricectomy
Partial Nail Avulsion - With or without chemical matricectomy
Incisional procedures such as…
Vandenbos procedure
Zadeks procedure
Winograd procedure
Noel’s procedure
Electocautery ablation of nail matrix
Curettage of nail matrix
Matricectomy with cryotherapy
What are the steps of a total nail avulsion?
Before procedure: Gain consent, perform pre injection swab and administer digital block
- Scrub - Wash hands and forearms and don the usual PPE
- Drape and Swab - Drape surgical site and swab skin with antiseptic (such as Videne) using sterile gauze held by artery forceps
- Surgical Pause - Perform WHO surgical checklist
- Application of Tourniquet - Roll digital tourniquet onto toe starting distally to exsanguinate digit, take note of ‘tourniquet on’ time/ start timer
- Separate Eponychium - Blacks file (pointed face down) is used to separate eponychium from nail plate
- Separate Nail from Nail Bed - Nail elevator is slid under distal aspect of nail to separate it from hyponchium. Elevator is aimed superior to the inferior side of nail to prevent trauma to nail bed, until resistance is met at nail matrix
- Clamp + Rotate Nail Plate - Artery forceps clamp either the medial or lateral aspect of the nail and rotate inwards towards the midline, lifting nail out from the sulcus. Remove forceps and clamp other side of nail, repeating the rotation.
- Lift Nail from Nail Bed - Artery forceps clamp onto now lifted nail and remove it from nail bed
- Check Nail and Nail Bed - Look at the nail: is it complete? Are the edges jagged?, Check nail bed with blacks file for any residual nail hidden in sulci
If performing phenolisation…
10. Apply Phenol (80-89%) - Apply 3 easy swab sticks to nail bed, making sure to reach nail matrix under eponychium, apply each stick for 1 min and take a note of phenol application time. Tissue should turn white
- Flush with IPA - Flush nail bed with syringe filled with IPA
If not performing phenolisation, skip from step 9 to 12
- Remove Tourniquet and Observe Reperfusion - Remove tourniquet gently, observe for colour to return to digit and take note of how long this takes
- Apply Dressing - Apply primary dressing (usually gel based - Atruaman, Bactigras or Jelonet). Apply secondary dressing; sterile gauze wrapped around digit and secured with tubegauze and mepore
In terms of procedure, how does a partial nail avulsion differ from a total nail avulsion?
The steps are different following separation of the eponychium (only from the portion of nail plate to be removed) …
- Elevate One Side of Nail from Nail Bed - A nail elevator (usually McDonald) is slid under the distal aspect of one side of the nail plate to separate the hyponichium from the nail, aiming elevator superior to inferior side of nail to prevent trauma, until meeting resistance at the nail matrix. Only elevating the side to be removed
- Clamp and Rotate - Artery forceps clamp elevated side of nail and rotate inwards, lifting that side of the nail plate out from its sulcus
- Thwaites Cut - Thwaites nail dividers are then used to cut the elevated side of nail, leaving the non elevated side attached to the hyponchium. A beaver blade (SM61) can be used to continue the cut straight under the eponychium, push the blade through the remaining nail until it gives. Artery forceps then clamp the cut piece of nail and remove it
- Inspection of Nail Spicule and Bed - The piece of nail that has been removed is inspected; is it complete? Does it have jagged edges? The nail bed is examined with a blacks file to ensure no residual nail is hidden in the sulcus
If performing phenolisation…
5. Phenol Application - EZ swab phenol application sticks are applied to nail bed and matrix of removed portion of nail, time of application can often be reduced
- Flushing Site w/ IPA - Nail bed is flushed with IPA to dilute phenol
If removing hypergranulation tissue…
7. Elliptical Incision - An elliptical incision is made with a small blade scalpel to remove hypergranulation tissue present on side of nail bed where nail has been removed
- Pack Area - Area is packed with an alginate dressing such as Kaltostat using forceps, steri-strips are then used to hold dressing in place
Tourniquet is then removed, re-perfusion time is noted and dressing applied the same as in a total nail avulsion
What is Zadek’s procedure used for?
A partial or total nail avulsion with incisional matricectomy
What is a Winograd procedure used for?
Partial nail avulsion with partial incisional matricectomy
What instrumentation is required for a Zadek’s or Winograd procedure?
Non-stick Antiseptic Gauze (e.g Bactigras paraffin wax gauze)
4.0 Non-absorbable Suture and Suture Forceps
No.15 Scalpel
Thwaites Nail Splitter
Small Curette
Halstead Mosquito Forceps (straight)
Sterile Saline
Digital Tourniquet
Following scrubbing, draping, a surgical pause and application of the tourniquet, what are the steps to a Zadek’s procedure?
- Removal of Nail Plate - No.15 scalpel is used to make the 1st incision, beneath the nail plate. Artery forceps then clamp the nail plate and remove it
- Exposure of Nail Matrix - Two to three further incisions are made into the skin proximal to the eponychium to expose the germinal nail matrix. The skin is then retracted and the geminal nail matrix is removed with a curette
- Excision of Nail Bed and Matrix - The nail bed and nail matrix are excised with the No.15 scalpel, and then any remaining matrix tissue is removed using the small curette
- Inspect the Nail Bed and Matrix - The area is then inspected with the small curette to ensure all matrix tissue has been excised
- Flush and Suture - Flush surgical site with saline and close the wound with simple interrupted sutures
Tourniquet is then removed, with re-perfusion time noted and wound dressed the same as in total nail avulsion
Following scrubbing, draping, a surgical pause and application of the tourniquet, what are the steps to a Winograd procedure?
- Splitting of Nail Plate - Thwaites nail splitters are used to split 2-3mm of the ingrown side of the nail longitudinally
- 1st Incision - Scalpel is used to make the 1st incision deeply through the split nail and nail bed, extending proximally to include the dorsal skin over the nail matrix
- 2nd Incision - A second incision is made, connecting the distal and proximal ends of the 1st incision to excise the medial or lateral sulcus (making a half-moon shape)
- Excision of Nail Bed and Matrix - Excise the nail section, bed and matrix with scalpel and then gently curette to remove any remaining tissue
- Flush + Suture - Flush surgical site with saline and close the wound with simple interrupted sutures (only on one side of nail)
Tourniquet is then removed, re-perfusion time noted and dressing applied same as in a total nail avulsion
What are the main risks of nail surgery and what factors can be identified and considered prior to surgery to prevent them?
Infection - Identifying immunosuppressed patients (with conditions associated with immunosuppression or on immunosuppressive medication)
Ulceration + Impaired Healing - Identifying risk factors for impaired healing such as: PAD, Peripheral Neuropathy, Diabetes, RA and other vasculitis associated autoimmune disorders
Prolonged Bleeding - Identifying conditions and medications associated with poor coagulation such as: Haemophilia, Thrombocytopenia, Disseminated Intravascular Coagulation, Hepatic Disease, Oral Anti-Coagulants (rivaroxaban, dabigatran), Oral Anti-Platelets (Aspirin, Clopidogrel)
Development of Thrombus in Small Vessels - Identifying conditions and medications associated with increased coagulation such as: Factor V Leiden, Sickle Cell Anaemia, Antithrombin deficiency, Prothrombin gene mutations, hormonal birth control medications
What conditions and medications cause suppression of the immune system, and should be considered with caution prior to nail surgery?
Conventional and Biological DMARDs - E.G Methotrexate, Sulfalazine, Adalimumab, Infliximab, Ritumixmab, Abatacept
Oral Retinoids - E.G Acitretin, Tretinoin, Adapalene
Chemotherapy Treatment
Some Anti-Convulsants
Diabetes
RA, SLE
Downs Syndrome
HIV, AIDS, Epstein-Barr Virus
Renal Insufficiency
Hepatic Insufficiency
Sickle Cell Anemia
Aplastic Anemia
Cancer
Malnourishment
Alcohol Abuse
What are the indications for a nail avulsion surgery without phenolisation?
Patients who wish for their nail to grow back/ when there is no underlying deformity causing ingrowth i.e involuted nails, so in theory nail plate could grow back normally without recurrence of onychocryptosis
Onychocryptosis in paediatric or young patients where aetiology is related to: Onychotillomania, poor footwear or acute trauma
Patients where risks of phenolisation are too high (Impaired healing or infection) due to:
Severe PAD and/or uncontrolled diabetes mellitus
Systemic conditions causing immunosuppression
Medications causing immunosuppression
What are the indications for nail avulsion with phenolisation performed without a tourniquet?
Patients with very poor skin quality due to:
Advanced age
Medications - E.G oral steroid or retinoids
Systemic illness
Arterial disease
Patients at risk of vasculo-occlusive crisis if tourniquet is applied due to:
Sickle cell anaemia
What is the expected healing time for a partial or total nail avulsion without phenolisation?
2-4 weeks
What is the expected healing time for a partial nail removal with phenolisation?
4-8 weeks
What is the expected healing time for a total nail avulsion with phenolisation?
8-12 weeks
