Evidencing Superior Efficacy. Suture Technique Outperforms Electrocoagulation in Reducing Recurrence in Ingrown Toenail Surgery

Abstract

Background: This study aimed to compare the rates of recurrence, complications, and patient satisfaction among individuals undergoing different variations of the Winograd method (WM) for the treatment of ingrown toenail, including the addition of electrocoagulation (EC) and a novel suture technique. Methods: A retrospective analysis was conducted of 605 patients who underwent surgery for ingrown toenail using the WM at two institutions. Patients were divided into four groups based on the surgical technique used: group 1 (WM + EC + new suture), group 2 (WM + EC + traditional suture), group 3 (WM + non-EC + traditional suture), and group 4 (WM + non-EC + new suture). Recurrence rates, complications, and patient satisfaction levels were assessed. Results: Group 1 demonstrated the lowest recurrence rates, whereas group 3 had the highest. Group 1 exhibited the highest satisfaction rate, whereas group 3 had the lowest. Notably, the suture technique appeared to have a greater impact on reducing recurrence rates than EC. Conclusions: Incorporating germinal matrixectomy with EC and a new suture method with the WM may improve patient satisfaction and reduce recurrence rates in ingrown toenail treatment. The suture technique appears to play a significant role in decreasing recurrence rates compared with EC.

Ingrown toenail is a common and painful clinical condition that accounts for approximately 20% of patients presenting with foot disorders [1,2]. Ingrown toenail is attributed to a multitude of factors, including incorrect nail cutting, shape variation in nails and nail folds, high level of sweating, wearing rigid clothes and shoes, inadequate foot hygiene standards, excessive body weight, genetic predisposition, physical injury, fungal infection, and anatomical susceptibility, either individually or in combination [3].

Nonsurgical techniques such as foot care, antibiotic therapy, and proper nail trimming can effectively treat ingrown toenail [4]. In the initial phases, conservative treatment is usually sufficient. However, if conservative treatments prove ineffective in Heifetz (the categorization system that is often used to assess patients with ingrown toenail) stages 2 and 3, surgical intervention may be required [5]. The Winograd method (WM) is a frequently used and very successful surgical technique for addressing ingrown toenail. A crucial aspect of WM involves partial matrixectomy, which entails the complete removal of the germinal matrix of the nail segment being excised. In order to ensure complete removal of the germinal matrix, various supplementary techniques have been documented, all of which entail the excision or ablation of this particular segment [6]. Electrocoagulation (EC) is something that our group has used extensively for this reason.

In 2014, Uygur [7] introduced a novel suture technique that can be used following completion of the WM. The author stated that the new suture technique resulted in improved operative outcomes, decreased recurrence rates, and higher levels of satisfaction. We hypothesized that incorporating EC into the WM along with the new suture technique could potentially yield improved outcomes. The aim of the current study was to analyze and compare the rates of recurrence, complications, and patient satisfaction for individuals who underwent one of the four procedures: the WM + EC + the new suture technique, the WM + EC + the traditional suture technique, the WM + non-EC + the traditional suture technique, and the WM + non-EC + the new suture technique.

Materials and Methods

We conducted a thorough analysis of 605 patients who had received surgery for a single ingrown toenail using the WM at two different institutions (Elazig Fethi Sekin City Hospital and Fırat University School of Medicine) between August 2018 and January 2022. The surgeries were performed with or without EC and used either the new suture technique or the traditional suture technique. Prior to surgery, all patients were required to provide informed consent, which was obtained in accordance with the approval of the Fırat University Medical Faculty Ethics Committee (approval number 2022/09-12, approval date July 6, 2022).

The current study included only those with Heifetz stage 2 or 3 ingrown toenail who did not show improvement after attempting conservative treatment. We specifically eliminated patients who had Heifetz stage 1 ingrown toenail or traumatic nail deformity, patients treated with methods other than the WM, patients with insufficient follow-up, and patients with dystrophic nails, peripheral vascular disease, or diabetes mellitus. With the exception of the excluded patients, all of our patients were consecutive. The included patients, all of whom had undergone the WM, were then divided into four groups: group 1 (EC + new suture technique), group 2 (EC + traditional suture technique), group 3 (non-EC + traditional suture technique), and group 4 (non-EC + new suture technique).

Surgical Procedure and Follow-up

The operations were conducted via a digital anesthetic block consisting of 1% prilocaine without epinephrine along with a toe tourniquet. Elliptical longitudinal incisions were performed in all patients to execute a wedge resection of the affected medial or lateral margin of the toenail, which accounted for one-fourth of the entire nail. The incisions penetrated the eponychium to a depth of 5 mm. The toenail and germinal matrix were extracted using a clamp positioned under the toenail. A surgical lancet was used to remove hypertrophic granulation tissue. Patients who received the WM with EC (groups 1 and 2) had the germinal matrix ablated using monopolar coagulation set at a medium level. The duration of EC in the germinal matrix ranged from 5 to 6 sec. No curette or chemical was applied. In all patients, the external fold of the toe was subsequently brought close to the nail plate using a 2-0 Prolene suture (Ethicon, Raritan, New Jersey). The new suture technique was implemented in groups 1 and 4, leaving the edge of the nail plate above the skin (Fig. 1A) [7], whereas the traditional suture technique was employed in groups 2 and 3 (Fig. 1B). Gentle dressings that did not apply pressure were used in all instances.

Figure 1. (A) New suture technique. (B) Traditional suture technique.

Figure 1. (A) New suture technique. (B) Traditional suture technique.

For a week following surgery, the patients had to take two pills of diclofenac sodium per day in addition to the surgeon’s choice of oral antibiotic. Moreover, they were instructed to change the dressings every 48 hours and avoid wearing footwear for a duration of 7 days. Following removal of the sutures, the patients were scheduled for weekly appointments during the first month and then shifted to monthly visits.

We gathered data on the recurrence rate and level of satisfaction. Patient satisfaction was assessed with a 10-point visual analog scale. In order to categorize satisfaction levels, we assigned patients a rating of very satisfied if their overall score on the visual analog scale was more than 7, satisfied if their score was 6 or 7, dissatisfied if their score was 4 or 5, and very dissatisfied if their score was less than 4. Antibiotic treatment was used in instances of mild postoperative infection, whereas the presence of a severe infection was regarded as a sign of recurrence. The assessment of patient satisfaction relied primarily on the presence or absence of a recurrence. Unsatisfactory appearance or difficulty wearing shoes, delayed healing of the wound site, and findings of mild infection responding to antibiotic treatment were evaluated as minor events affecting the satisfaction level of the patients.

Statistical Analysis

The SPSS Statistics 22 program (IBM, Armonk, New York) was used for statistical analyses of the findings obtained in the study. The Shapiro-Wilk test was used to determine whether the parameters conformed to a normal distribution. In addition to descriptive statistical methods (mean, SD, and frequency), the Kruskal-Wallis test was used for comparisons of parameters that did not show a normal distribution and the Dunn test was used to determine the group causing the difference. The χ² test was used to compare qualitative data. Significance was evaluated at the P < .05 level.

Results

The study was conducted with a total of 605 patients (347 males [57.4%] and 258 females [42.6%]) aged between 10 and 60 years (mean ± SD, 26.5 ± 12.37 years). The demographics of the study participants are presented in Table 1.

Table 1. Distribution of Study Parameters

Table 1. Distribution of Study Parameters

The χ² test demonstrated a statistically significant difference in recurrence rates across the four groups (P < .001). Post hoc analyses showed that this difference was mainly attributable to comparisons between group 1 (WM + EC + new suture) and group 3 (WM + non-EC + traditional suture) and between group 4 (WM + non-EC + new suture) and group 2 (WM + EC + traditional suture) (P < .05) (Table 2). Group 1, which used EC and a novel suture technique, had the lowest recurrence rates, whereas group 3, which did not use EC and employed the traditional suture technique, had the highest recurrence rates. In group 4, in which the new suture technique was used without EC, recurrence rates were nearly zero. By contrast, in group 2, in which EC was used along with the traditional suture technique, recurrence rates were markedly higher compared with the groups using the new suture technique (groups 1 and 4).

Table 2. Evaluation of Recurrence and Satisfaction Rates Between Groups

Table 2. Evaluation of Recurrence and Satisfaction Rates Between Groups

Similarly, the χ² test revealed that satisfaction rates differed significantly among the four groups (P < .001). Post hoc analyses indicated that the significant differences were primarily between group 1 (WM + EC + new suture) and group 3 (WM + non-EC + traditional suture) and between group 4 (WM + non-EC + new suture) and group 2 (WM + EC + traditional suture) (P < .05). Group 1 (EC + new suture technique) exhibited the highest satisfaction rate, whereas group 3 (non-EC + traditional suture technique) had the lowest satisfaction rate (Table 2). A total of 15 patients in group 2, ten patients in group 3, and one patient in group 4 were identified as dissatisfied in the satisfaction evaluation. These patients did not experience any recurrence; rather, their dissatisfaction was attributed to unsatisfactory appearance, findings of minor infection that were treated with antibiotics, and delayed healing of the wound site.

Group 1, which used the EC + new suture method, included primarily adults, whereas group 4, which used the non-EC + new suture technique, comprised mainly adolescents. Heifetz staging showed that stage 3 occurred much less often in the teen group of group 4 compared with the other groups (Table 3).

Table 3. Evaluation of Study Parameters Between Groups

Table 3. Evaluation of Study Parameters Between Groups

Discussion

The current investigation is unique in the literature for examining four different modifications of the WM—the most commonly used method for treating ingrown toenail—within a single study. Our research findings suggest that incorporating germinal matrixectomy with EC and a novel suture technique alongside the WM can enhance patient satisfaction and reduce recurrence rates. Upon analysis of the four groups, it was determined that the suture technique had a greater impact on reducing recurrence rates compared with the use of EC.

The WM for treating ingrown toenail includes removing a wedge on the side of the toenail along with part of the nail bed and is proven to be an efficient treatment with minimal complications [8]. Nevertheless, in the current study, 37.8% of patients who underwent treatment solely with this method (group 3, WM + non-EC + traditional suture technique) experienced a recurrence. These results are worse than previously published data. Karacan and Ertilav [9] found a 14% recurrence rate among 70 individuals using the WM, whereas Gerristma-Bleeker et al [10] observed a 20.6% recurrence frequency in 34 patients. Kose et al [11] found a 13.2% recurrence incidence among 68 individuals, whereas Camurcu et al [12] found a 7.9% recurrence frequency in 189 toenails.

Upon separate group analysis, the current study revealed the lowest recurrence rate (0%) in the EC + new suture technique group (group 1) (Fig. 2A) followed by the non-EC + new suture technique group (2.2%) (group 4) and the EC + traditional suture technique group (18.6%) (group 2) (Fig. 2B). A study conducted in 2017 by Acar [6] found no recurrence in any patient who employed EC, and a rapid recovery was achieved after the use of EC in recurrent cases. Many have documented the outcomes of using EC in addition to partial matrixectomy, with varying recurrence rates. In a study by Ozan et al [13], there were no recurrences in 57 toenails. Kim et al [14] found three recurrences in 76 toenails, whereas Khan and Kumar [15] reported a 10.34% recurrence rate among 29 patients. In a study by Kim et al [16], a recurrence rate of 13.8% was reported in 29 patients. Gurhan et al [17] found a recurrence rate of 9.6% in 93 patients, whereas Amarin et al [18] observed that 4.2% of 71 participants experienced a recurrence.

Figure 2. Clinical results of (A) the new suture technique and (B) the traditional suture technique.

Figure 2. Clinical results of (A) the new suture technique and (B) the traditional suture technique.

The lack of specificity about EC in studies and the varying recurrence rates indicate the use of a diverse spectrum of EC techniques. The use of EC may entail several methods, such as monopolar or bipolar configurations, various types of electrical current (cutting, coagulation, or mixed), different voltage settings (low, medium, or high), varying application durations (short or long), and different levels of protection for surrounding tissues. In the present study, EC was applied in monopolar coagulation format at medium voltage with a short application time. According to the current research, it is crucial to highlight that EC can reduce recurrence rates. However, the suture technique used plays a more significant role in reducing recurrence rates than EC.

Uygur et al [19] compared the novel suture approach introduced in 2014 by Uygur [7] with the traditional suture technique, finding decreased recurrence rates with the new method. It has been noted that the nail extends into the outer layer of the nail fold, excessively invading the skin. Uygur et al [19] suggested placing the skin of the nail fold under the nail to address this issue. In the authors’ study, curettage was applied without the use of EC or chemicals. In the current study, the EC procedure was conducted along with the new suture technique defined by Uygur et al, and the recurrence rates were then compared. The results of the current study showed that with the newly identified suture technique and the use of EC, recurrence rates were zero. Moreover, upon separate examination of the groups, it was established that the suture technique had a greater impact on reducing recurrence rates than the use of EC.

Satisfaction was assessed on a scale ranging from very high to very low. The use of the new suturing method and EC resulted in higher satisfaction compared with the traditional technique. The lower rate of recurrence likely contributed to increased satisfaction. However, statistical evaluation was not possible owing to the low recurrence rates in groups 1 and 4. In our study, the main factors contributing to dissatisfaction were the recurrence of the issue and the discomfort experienced, which impeded the ability to wear shoes. Several patients needed 2 weeks before they could comfortably wear shoes again. Informing patients before surgery about the potential recovery period could help adjust their expectations and enhance their level of contentment with the procedure.

Our research found that the incidence of Heifetz stage 3 among teenage patients, who made up the majority of group 4, was notably lower compared with the other groups. By contrast, Rota et al [20] found that stage 3 was more prevalent among individuals in the younger age group. One explanation for this difference is that the adolescent patients in group 4 were brought in for treatment early by their parents, before their condition had advanced significantly. In addition, Kayalar et al [21] found no statistically significant correlation between disease stage, recurrence, and infection rate, which aligns with the findings of the present study.

Limitations and Strengths

There were a number of restrictions on this retrospective analysis. Our four groups showed no significant differences in the side of the affected toe (medial or lateral). However, our groups exhibited differences in demographics and severity of ingrown toenail, potentially impacting our findings. Another limitation of the study is the variation in surgical teams and hospitals where the patients were operated on, leading to inconsistencies in follow-up techniques owing to clinician differences. Moreover, we assessed the documents of consecutive individuals for the current study but excluded individuals with insufficient data for an appropriate assessment. Another issue is the absence of a statistical power analysis in the current study. The strength of the present study lies in the fact that it analyzes four different modifications of the WM.

Conclusions

The current study indicates that combining germinal matrixectomy with EC and a new suture method with the WM may improve patient satisfaction and reduce recurrence rates. Moreover, the examination of the four groups revealed that the suture method had a more significant effect on decreasing recurrence rates than the use of EC. It is essential to conduct randomized controlled and prospective studies to compare the WM with alternative methods; assess short-term, medium-term, and long-term outcomes separately; and examine various factors that could impact recurrence rates and patient satisfaction.