Y S Lau , J M C Yeung * Department of General Surgery, Victoria Infirmary, Glasgow; *Department of General Surgery, Kingsmill Hospital, Sutton-in-Ashfield
Correspondence to: Miss Yu Sin Lau, Botnar Research Centre, Nuffield Dept of Orthopaedic Surgery, University of Oxford, Oxford, OX3 7LD Tel: 01865 227982 E-mail: yu.lau@ndos.ox.ac.uk
SMJ 2005 50(1): 22-23
Abstract:
Background: Although the surgical treatment of in-growing toenails is a common procedure, the success of ingrown toenail surgery is extremely variable and recurrences frequently impair the quality of life of those who have this condition. In most hospitals this procedure is commonly performed by junior surgical trainees who may have little experience. Aim: We proposed to find out if the success of this procedure is operator-dependent by comparing the results of standard of toenail surgery performed by basic surgical trainees (BSTs) in our hospitals with already published data. Methods: A retrospective analysis of nail bed ablation surgery performed by BSTs under local anaesthesia over a 15-month period in a district general hospital was conducted. Results: 106 phenol ablations and 46 germinal matrix excisions were performed. Symptomatic recurrence rates 12 months following the procedure were 5.7% for phenol ablation and 4.3% for germinal matrix excisions. Conclusion: Our results are comparable to published data, and we conclude that toenail ablation surgery can be just as successfully performed by junior surgeons after relatively little training in the procedure.
Keywords: In-growing toenail, nail bed ablation, phenol ablation, excision of germinal matrix
Introduction
In-growing toenails are a common affliction among the young adult population. Definitive treatment of symptomatic ingrown toenails is surgical. There are many different treatment options, such as a combination of nail avulsion and nail bed ablation with either phenol or surgical resection of the germinal matrix, or both. However the success of ingrown toenail surgery is extremely variable; although some surgeons report excellent results, these high standards are not universal. Basic Surgical Trainees (BSTs) learn many operative skills and principles through performing minor operations on day case lists. In the course of their training, they would be expected to perform numerous minor procedures, such as ingrown toenail surgery. In spite of this, we were unable to find much published data of the recurrence rates when this procedure is performed by junior surgical trainees.1 We looked at our practice to compare our incidence of symptomatic recurrences with that of published results to determine whether one procedure is superior to the other when performed by a junior surgical trainee, and whether the recurrences rates are acceptable.
Method
A retrospective study was performed in a Scottish district general hospital. All patients attending the Day Surgery Unit over a 15-month period for nail bed ablation under local anaesthesia were recruited. Case notes were examined and the nature of the problem, the type of operation and the grade of surgeon performing the operation were noted. Post-operative complications and symptomatic recurrence within 12 months of the primary operation were also recorded.
Results
One hundred and fifty-two in-growing toenail operations were carried out on 128 patients over the 15-month period under local anaesthetic by eight BSTs without any senior assistance (Table I). All the junior surgical trainees were in their first general surgical placement and had performed an average of five toenail operations prior to operating independently. In total, 106 phenol ablations and 46 germinal matrix excisions were performed. No combination procedures were carried out. All patients recovered well with no significant complications. The recurrence rates were reassuringly low (Table II) in the 12 months following the primary procedure; 5.7% for phenol ablation and 4.3% for germinal matrix excisions.Statistical analysis of the results using the Fisher’s exact test with Yates correction did not show a significant difference between the two procedures.
Discussion
The skills acquired when performing minor operative procedures such as in-growing toenail surgery are valuable for basic surgical training. The volume of patients who present with this common but disabling problem makes it the ideal type of surgery for which a junior surgical trainee can “see one, do one, and teach one”. Although the principle behind the operation is simple, there is no general consensus on the best operative procedure for this condition, with some literature even suggesting that it may be somewhat operator-dependent. Our study shows that the BSTs are capable of performing this procedure well, with results comparable to published data.2- 5 It also raises the question of whether germinal matrix excision is necessary in view of the comparable recurrence rates for both procedures in our study. We feel that our results are representative, even though it became clear from the beginning that the incidence of minor recurrences such as spicule formation would not be documented. However, if these recurrences were sufficiently symptomatic, they would be detected during follow-up in outpatient clinic. Nevertheless we stress that this study is simply a benchmark assessment of the complication rates of this surgery in the hands of junior surgical trainees. A prospective randomised trial should provide more detailed information.
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