Applied Evidence

A practical guide to the care of ingrown toenails

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How to perform the Vandenbox procedure

The Vandenbos procedure, also known as soft-tissue nail fold excision, was first described in 1958 by Kermit Q. Vandenbos, a surgeon for the US Air Force. He felt that overgrown toe skin was the primary causative factor in onychocryptosis.4

In the procedure, the hypertrophic skin is removed to such a degree that it cannot encroach on the growing nail. After the toe is fully healed, the toe and nail should have a fully normal appearance. Indications and contraindications are the same as for other surgical procedures for the treatment of onychocryptosis. Pain and disability following the procedure is similar to phenolization, and the recovery period takes several weeks for the patient to fully heal.

Equipment needed:

  • alcohol swab
  • tourniquet (optional)
  • 3 mL to 5 mL of local anesthetic (eg, 2% lidocaine)
  • topical antiseptic (eg, iodine or chlorhexidine)
  • number 15 blade scalpel
  • tissue forceps
  • cautery device (electrocautery or thermocautery)
  • dressing supplies (topical ointment, gauze, tape)

The steps15:

  1. Perform a digital nerve block using an alcohol swab and anesthetic. The anesthetic may be used with or without epinephrine.
  2. Place a tourniquet at the base of the toe if the anesthetic does not contain epinephrine. The tourniquet is not required if epinephrine is used during anesthesia.17
  3. Cleanse the toe with iodine, chlorhexidine, or a similar agent.
  4. Make a 5-mm incision proximally while leaving the nail bed intact. Begin approximately 3 mm from the lateral edge of the base of the nail. The incision should extend around the edge of the toe in an elliptical sweep towards the tip of the nail, remaining 3 mm from the edge of the nail. This is best accomplished in a single motion with a #15 blade. An adequate portion of skin must be removed, leaving a defect of approximately 1.5 × 3 cm (approximately the size of a cashew) (FIGURE 1B).
  5. Electrocauterize or thermocauterize along the edges and subcutaneous tissue of the wound. This reduces postoperative bleeding and pain. The matrix should not be damaged.
  6. Dress the wound with ample amounts of petrolatum followed by nonstick gauze. Profuse bleeding can be expected unless pressure is applied, so apply ample amounts of additional gauze to absorb any blood. The foot is elevated and the tourniquet (if used) removed. In order to reduce postoperative bleeding and pain, instruct the patient to lie with the foot elevated as much as possible for the first 24 to 48 hours.
  7. Advise the patient that moderate pain is expected for the first 2 to 3 days. Analgesia may be obtained with an acetaminophen/opiate combination (eg, hydrocodone/acetaminophen 5/325, 1 tablet every 4-6 hours as needed) for the first 2 to 3 days. This may be followed by acetaminophen or nonsteroidal anti-inflammatory drugs thereafter at usual dosing, which can either be prescribed or obtained over the counter.

Postoperative care

After 48 hours, the patient can remove the dressing and gently rinse the wound and reapply a new dressing as before. The dressing should be changed at least once daily and whenever it becomes soiled or wet. After 48 hours, while the dressing remains on the toe, the patient may begin taking brief showers. After showering, the toe should be gently rinsed with clean water and the dressing changed. Blood or crust should not be scrubbed off, as this will impair re-epithelialization, but it may be rinsed off if able. Otherwise, the wound should not be soaked until re-epithelialization has occurred.

Patient follow-up should occur after 1 to 2 weeks (FIGURE 1C). After approximately 6 weeks, the wound should be healed completely with the nail remaining above the skin. (FIGURE 1D shows wound healing after 3 months.)

Advise patients that erythema and drainage are expected, but the erythema should not extend proximally from the metatarsophalangeal joint. Prophylactic antibiotics are not required, although they may be used if infection is suspected. Despite the proximity of the procedure to the distal phalanx, there have been no reported cases of osteomyelitis.15

CORRESPONDENCE
Stephen K. Stacey, DO, Chief Resident, Peak Vista Family Medicine Residency Program, 340 Printers Parkway, Colorado Springs, CO 80910; [email protected].

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