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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 48  |  Issue : 1  |  Page : 49-52
Protruded and nonprotruded subungual exostosis: Differences in surgical approach


1 Department of Orthopaedics and Traumatology, Sakarya Training and Research Hospital, Sakarya, Turkey
2 Department of Physical Medicine and Rehabilitation, Akyazi State Hospital, Sakarya, Turkey

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Date of Web Publication21-Jan-2014
 

   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

How to cite this article:
Basar H, Inanmaz ME, Basar B, Bal E, Köse KÇ. Protruded and nonprotruded subungual exostosis: Differences in surgical approach. Indian J Orthop 2014;48:49-52

How to cite this URL:
Basar H, Inanmaz ME, Basar B, Bal E, Köse KÇ. Protruded and nonprotruded subungual exostosis: Differences in surgical approach. Indian J Orthop [serial online] 2014 [cited 2019 Aug 25];48:49-52. Available from: http://www.ijoonline.com/text.asp?2014/48/1/49/125496

   Introduction Top


Subungual exostosis is a benign bone tumor. It is most commonly seen in the great toe and is common in the adolescent period. [1] The etiopathogenesis is not clear but it is thought to be associated with micro-trauma and infection. [2],[3] Subungual exostosis presents with pain due to mechanical irritation under the nail bed during physical activity. [4] Radiographs are the main diagnostic tools. An exophytic bone growth at the dorsal surface of the distal phalanx is seen on X-rays. [2] The treatment of subungual exostosis is surgical removal of the tumor. The success of surgical excision is >90%. [5] A 53% recurrence rate is reported with insufficient mass excision. [6] The most common complication after surgery is nail deformity caused by damage to the nail bed. In subungual exostosis surgery, surgical excision of the mass without damaging the nail bed is important. The nail bed should be repaired after the removal of the mass if it has been damaged during surgery.


   Materials and Methods Top


Fifteen patients, with a diagnosis of subungual exostosis, operated between January 2008 and June 2012, were included in the study. Informed consent was obtained from all patients. Excision of the masses was performed by the same surgeon with two different surgical approaches depending on whether the exostoses were protruded or not. In seven patients, there was a history of trauma to the toe.

All patients in the protruded subungual exostosis group complained of: 1) pain under the toe nail which lasted for an average of 16.8 ± 5.2 months, 2) nail deformity which began at an average of 9.3 ± 3.4 months ago, and 3) a mass protruding medially for an average of 4.6 ± 1.5 months [Figure 1]a. There was severe pain over the nail on palpation. Plain radiographs showed a mass lesion on the dorsal aspect of the distal phalanx of the great toe [Figure 1]b. Excision was planned in patients who were diagnosed with subungual exostosis. The nail was removed under local anesthesia as the mass had protruded from the nail bed and had damaged the nail bed. The mass was excised together with the pedicle from the dorsal surface of the distal phalanx [Figure 1]c, d. The nail bed damage was evaluated and repaired with a 6-0 absorbable suture and the removed nail was fixed to its bed [Figure 1]e.

In patients with nonprotruded subungual exostosis, there was pain under the nail that began at an average of 8.3 ± 3.6 months ago and swelling at the toe tip that occurred over time. There were no deformities or any visible mass in this group of patients at the time of diagnosis. Subungual exostosis was often palpable at the nail tip [Figure 2]a. There was severe tenderness over the nail on palpation. There was a mass lesion at the dorsal aspect of the distal phalanx of the toe on plain X-rays [Figure 2]b. Excision was planned in this group as well. As the mass did not protrude from the nail bed, it was excised with a "fish-mouth" type of incision without causing damage to the nail bed [Figure 2]c. Thus iatrogenic damage that may occur during surgery and concurrent nail deformity was prevented [Figure 2]g.
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

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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 1st week followup (e) Clinical photograph at 2nd week control (f) Clinical photograph at 2nd month followup (g) Clinical photograph showing that the nail was seen to grow in a healthy way at 12th month followup

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The patients were followed up at 1 st month, 2 nd month, 3 rd month and 6 th month [Figure 1]f and [Figure 2]d-f. At each followup visit, patient-perceived functional outcome, cosmetic outcome, and level of pain were assessed using three separate 10-point analog scales. [7] On the functional outcome scale, scores ranged from 0, which indicated complete loss of digit function during the activities of daily living activities, to a score of 10, which indicated no functional limitation, with the patient using the digit without difficulty. The cosmetic result was evaluated using the scale published by Zook. [8]

Statistical evaluation

Statistical evaluation of the data was performed using the Chi-square testing for categorical data and unpaired Student's t-tests for the continuous data. Significance was defined as a P < 0.05.


   Results Top


The mean age of the patients in the protruded subungual exostosis group was 17.3 years (range 13-22 years) and consisting of seven female and two male patients. Patients were followed up for a mean of 14.1 ±4.8 months after surgery. The mean age of the patients in nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. Patients were followed up for a mean of 11.6 ± 2.9 months after surgery.

At 1 month, 3 month, 6 month, and final followup controls, no pain or functional impairment was noted in both groups [Figure 1]g and [FIugre 2]g. The cosmetic results of protruted subungual exostosis group at 1 month was fair in three cases and mild in six cases. [8] At 3 months this improved to good in six cases and very good in three cases. At 6 months there was further improvement to very good in two cases and excellent in seven cases. At the last followup, the results were excellent in all cases. The cosmetic results of nonprotruted subungual exostosis group at 1 month was good in two cases and very good in four cases. At 3 months, this improved to very good in four cases and excellent in two cases. The results were excellent in all cases both at 6 months and at the last followup [Figure 1]g and [Figure 2]g.

Comparison of the cosmetic outcome between the two treatment groups was done. Nonprotruted group gave significantly better results than the protruded group at early followup (P < 0.05). But the final outcome between the two treatment groups demonstrated no significant difference (P > 0.05). There was no significant difference in pain, or ability to use the digit in activities of daily living between protruded and nonprotruded patient cohorts at early and final followup (P > 0.05).

Our results improved by changing the surgical approach depending on whether the exostosis is protruded from the nail bed or not. During the followup of patients in both groups after surgery, there were no wound infections, tumor recurrences, or nail deformities [Figure 1]g and [Figure 2]g.


   Discussion Top


Subungual exostosis is a rare osteocartilaginous tumor which is twice more common in females. [3] Subungual exostosis, as in our cases, is often seen in the adolescent age group. [1] The disease, as seen in our patients, is often located at the distal phalanx of the toe. [6] In seven patients, there was a history of toe trauma. In the literature, this condition was found to be associated with trauma and chronic infection. [3] Patients with the diagnosis of subungual exostosis present with complaint of pain over the nail and are diagnosed by radiographic evaluation. In some cases, in addition to pain, there is a mass protruding from under the nail bed. Protrusion was present in seven of our patients.

X-rays are the main diagnostic tools. These reveal an outgrowth with trabeculated pattern of cancellous bone with or without a defined cortex. [9],[10] Other differential diagnoses include ordinary verrucae, mycoses, pyogenic disease, enchondroma, glomus tumour, melanoma and squamous cell carcinoma. [9],[10],[11] The pathological diagnosis verification is important for followup. Complete excision of the subungual exostosis does not need additional treatment.

Many surgical techniques have been described in the literature for subungual exostosis. [2],[6],[12],[13],[14] In these techniques surgical approaches are usually by a direct dorsal surgical incision or fish-mouth-type of incision. After the mass excision, surgical approach varies vis-à-vis repair of the nail bed. Some authors preserve the nail bed as we did. Others excise the nail bed partially or totally (cold-steel matrixectomy, Kaplan's matrixectomy, Zaddick's matrixectomy, Frost's matrixectomy). Total or partial nail bed resection may cause nail deformities, delay in return to daily activities with difficulty in wearing shoes and unacceptable cosmetic outcome. [15] We chose one of the two surgical approaches depending on whether exostosis had protruded or not. Integrity of the nail bed and phalangeal covering was preserved; our patients returned to normal daily activity in a short time with a good cosmetic outcome.

Rapid recovery and excellent cosmetic appearance are achieved using a fish-mouth approach. But the local recurrence rate (about 30%) is more than dorsal surgical approach after the removal of the nail bed. [16] No local recurrence was diagnosed in patients operated by a fish mouth type of surgical approach in our study.

To conclude, in patients with a protruded subungual exostosis, the mass should be excised by a dorsal approach by the removal of the nail and the impaired the nail bed should be repaired after tumor excision. In patients with a nonprotruded subungual exostosis, the mass can be excised through a "fish-mouth"type incision without causing any iatrogenic damage to the nail bed.

 
   References Top

1.Hoehn JG, Coletta C. Subungual exostosis of the fingers. J Hand Surg Am 1992;17:468-71.  Back to cited text no. 1
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2.De Palma L, Gigante A, Specchia N. Subungual exostosis of the foot. Foot Ankle Int 1996;17:758-63.  Back to cited text no. 2
[PUBMED]    
3.Flores VH, Judit-Cherit JD, Memije ME, Ocariz MS. Subungual Osteochondroma: Clinical and Radiologic Features and Treatment. Dermatol Surg 2004;30:1031-4.  Back to cited text no. 3
    
4.Ilyas W, Geskin L, Joseph KA, Seraly MP. Subungal exostosis of the third toe. J Am Acad Dermatol 2001;45 (6 Suppl):200-1.  Back to cited text no. 4
    
5.Warren KJ, Fairley JA. Stump the experts-case. Dermatol Surg 1998;24:287-9.  Back to cited text no. 5
[PUBMED]    
6.Miller-Breslow A, Dorfman HD Dupuytren›s (subungual) exostosis. Am J Surg Pathol 1988;12:368-78.  Back to cited text no. 6
    
7.Strauss EJ, Weil WM, Jordan C, Paksima N. A prospective, randomized, controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am 2008:33:250-3.  Back to cited text no. 7
    
8.Zook EG. Reconstruction of a functional and aesthetic nail. Hand Clin 2002;18:577-94.  Back to cited text no. 8
[PUBMED]    
9.Webber JM, Miller MV. Subungual exostosis in a young woman. Pathology 1994;26:339-41.  Back to cited text no. 9
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10.Wu KK. Subungual exostosis. J Foot Ankle Surg 1995;34:96-8.  Back to cited text no. 10
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11.Ippolito E, Falez F, Tudisco C, Balus L, Fazio M, Morrone A. Subungual exostosis. Histological and clinical considerations on 30 cases. Ital J Orthop Traumatol 1987;13:81-7.  Back to cited text no. 11
[PUBMED]    
12.Davis DA, Cohen PR. Subungual exostosis: Case report and review of the literature. Pediatr Dermatol 1996;13:212-8.  Back to cited text no. 12
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13.Letts M, Davidson D, Nizalik E. Subungual exostosis: Diagnosis and treatment in children. J Trauma 1998;44:346-9.  Back to cited text no. 13
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14.Cohen HJ, Frank SB, Minkin W, Gibbs RC. Subungual exostoses. Arch Dermatol 1973;107:431-2.  Back to cited text no. 14
[PUBMED]    
15.García Carmona FJ, Pascual Huerta J, Fernández Morato D. A proposed subungual exostosis clinical classification and treatment plan. J Am Podiatr Med Assoc 2009;99:519-24.  Back to cited text no. 15
    
16.Suga H, Mukouda M. Subungualexostosis: A review of 16 cases focusing on postoperative deformity of the nail. Ann Plast Surg 2005;55:272-5.  Back to cited text no. 16
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Correspondence Address:
Hakan Basar
Eski Kazimpasa cad. yolu Arabaci alani mah.Akkent villalari NO: 156/25 Serdivan/Sakarya
Turkey
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Source of Support: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.., Conflict of Interest: None


DOI: 10.4103/0019-5413.125496

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