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Is There a Relationship Between Forefoot Alignment and Ingrown Toenail? A Case-Control Study Ozkan Kose, Mustafa Celiktas, Bulent Kisin, Selahattin Ozyurek and Seyhmus Yigit Foot Ankle Spec 2011 4: 14 originally published online 4 October 2010 DOI: 10.1177/1938640010382293 The online version of this article can be found at: http://fas.sagepub.com/content/4/1/14

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〈 Clinical Research 〉 Is There a Relationship Between Forefoot Alignment and Ingrown Toenail?

Ozkan Kose, MD, Mustafa Celiktas, MD, Bulent Kisin, MD, Selahattin Ozyurek, MD, and Seyhmus Yigit, MD

A Case-Control Study Abstract: Biomechanical imbalance between the hallux and the second toe and external compression of the lateral nail fold are proposed as the main reasons for ingrown toenail. Therefore, any anatomical predisposition facilitating this compression may play a role in the occurrence of ingrown toenail. The purpose of this study is to investigate the relationship between forefoot alignment and ingrown toenail. The authors retrospectively reviewed radiographs of 81 patients with ingrown toenails and compared them with 100 healthy subjects regarding forefoot alignment. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and interphalangeal angle (IPA) were measured, and feet were classified according to digital formula as Egyptian, Greek, and square. The mean HVA was 14.5° ± 5.0° in the case group and 13.2° ± 5.9° in the control group. The mean IMA was 9.1° ± 2.5° in the case group and 8.6° ± 3.1° in the control group. The mean IPA was 11.9° ± 4.1° in the case group and 12.0° ± 5.1° in the control group. There was no statistically significant difference between the groups regarding HVA, IMA, or IPA (P = .123,

P = .198, and P = .925, respectively). The distribution of foot types between groups was also similar (P = .967). This study has failed to demonstrate any abnormality in forefoot alignment in patients with symptomatic ingrowing toenails, and it is suggested that treatment should not be based on the correction of the anatomy if no abnormality exists. Levels of Evidence: Prognostic, Level IV Keywords:  ingrown toenail; oncycryptosis; etiology; nail disorders

I

sweating, bad foot hygeine, trauma, inheritance, certain systemic diseases, medications, and anatomic abnormalities.1,3-7 Biomechanical imbalance between the hallux and the second toe in an ill-fitting shoe is the most commonly cited theory in the etiology, since the lateral margin

Because of these discrepancies in the

literature, it is hard to conclude that a certain foot type is a predisposing factor for ingrown toenail.”

ngrown toenail, or onychocryptosis, is a commonly encountered foot problem in routine orthopaedic practice resulting in pain and disability.1 Although considerable time is spent dealing with conservative and surgical treatment methods of this particular problem, the etiology of the condition is not well understood.2 Several risk factors have been advocated in the pathogenesis, including improper nail trimming, tight-fitting shoes, excessive

of the hallux is more frequently involved. According to this theory, extrinsic compression of the lateral nail fold between the hallux and the second digit initiates a cascade of events starting with irritation and skin breakage and finally results in the typical inflammation, infection, and granulation tissue.8-10 Therefore, any anatomical predisposition facilitating this compression may play a role in the occurrence of ingrown toenail.

DOI: 10.1177/1938640010382293. From the Diyarbakır State Hospital, Orthopaedics and Traumatology Clinic, Diyarbakir, Turkey (OK, MC, BK, SY), and Izmir Military Hospital, Orthopaedics and Traumatology Clinic, Izmir, Turkey (SO). Address correspondence to Ozkan Kose, MD, Diclekent Bulvari, Ataslar Serhat Evleri, D Blok Daire 13, Kayapinar 2100, Diyarbakir, Turkey; e-mail: drozkankose@hotmail.com. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2011 The Author(s)

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Results

The purpose of this study is to investigate the relationship between forefoot alignment and ingrown toenail.

Materials and Methods We retrospectively reviewed all patients who underwent surgery for symptomatic ingrown toenails in our clinic between May 2008 and May 2010. Patients with medial or bilateral ingrowing nail edge, with subungal exositosis, or lacking preoperative foot radiographs were excluded from the study. A total of 81 patients   with lateral border ingrown toenail were eligible and included in the analysis (Figure 1). Foot radiographs of the control group were obtained from patients presenting to our emergency department with blunt foot trauma, in the same age range. They were randomly selected from the Picture Archiving and Communication Systems and institutional clinical database. Patients with a history of ingrown toenail and patients having fractures, old united fractures, and congenital deformity or malformation were excluded from the control group. All of the measurements were carried out by one author, who was blinded to the clinical information of the patients. AP foot x-rays were used to measure the hallux valgus angle (HVA), first and second intermetatarsal angle (IMA), and interphalangeal angle (IPA) of the great toe (Figure 2). The feet were classified according to predefined criteria. Three types of feet were identified by the digital formula: the Greek foot, in which   the first toe is shorter than the second toe; the Egyptian foot, in which the first toe is longer than the second toe; and the squared foot, in which the first toe is the same length as the second toe (Figure 3). Continuous variables were calculated and are reported as means ± standard deviations and were compared using the Student t test for independent samples. Categorical variables were described using frequency distributions and compared using the c2 test. All tests were considered significant at an a level of P < .05.

The mean age was 23.3 ± 9.8 years in patients with ingrown toenails and 25.2 ± 10.4 years in the control group. There were 34 female and 47 male patients in the case group and 31 female and 69 male patients in the control group. No significant difference in age or gender was found between the 2 groups (P = .203 and P = .126, respectively). The mean HVA was 14.5° ± 5.0° in the case group and 13.2° ± 5.9° in the control group. The mean IMA was 9.1° ± 2.5° in the case group and 8.6° ± 3.1° in the control group. The mean IPA was 11.9° ± 4.1° in the case group and 12.0° ± 5.1° in the control group. There was no statistically significant difference between groups regarding HVA, IMA, or IPA (P = .123, P = .198, and P = .925, respectively). The distribution of foot types between groups was also similar (P = .967). A summary of the data is presented in Table 1.

Discussion Various anatomical characteristics of nail structure have been investigated as potential risk factors for ingrown toenail. Langford et al11 stated that 3 critical anatomical predispositions (increased nail fold width, decreased nail thickness, and medial rotation of the toe) exist in most patients with ingrown toenail. Other extrinsic factors act only as triggers in patients with these anatomic precursors.11 Li et al12 reported a series of anatomical abnormalities on the distal part of the great toe in patients with ingrown nail: an upturned pulp deformity, nail fold hypertrophy together with a deeper nail groove, incurvatum of the nail plate, and upturned abnormality of the distal part of the distal phalanx. Parrinello et al13 found a high and significant correlation between the shape of the proximal aspect of the nail plate and that of the phalangeal base. On the other hand, Pearson et al14 showed that there was no difference in either curvature or axis between subjects with and without ingrown toenail.

Figure 1. Lateral margin ingrown toenail. Black arrow shows the typical hypertrophied nail fold and granulation tissue.

Figure 2. Method of measurements. Hallux valgus angle (HVA), the angle between the longitudinal axis of first metatarsal and proximal phalanx of the great toe. Intermetatarsal angle (IMA), the angle between the longitudinal axis of the first and second metatarsal. Interphalangeal angle of the great toe (IPA), the angle between the longitudinal axis of the proximal and distal phalanges of the great toe.

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Figure 3. Types of feet according to digital formula. (a) Egyptian foot. (b) Greek foot. (c) Square foot.

Table 1. Summary of the Data Ingrown Toenail Group (n D 81)

Control Group (n D 100)

Significance, P Value

Age, y, mean ± SD

23.3 ± 9.8

25.2 ± 10.4

.203

Sex, male/female, n

47/34

69/31

.126

HVA, °, mean ± SD

14.5 ± 5.0

13.2 ± 5.9

.123

IMA, °, mean ± SD

  9.1 ± 2.5

  8.6 ± 3.1

.198

IPA, °, mean ± SD

11.9 ± 4.1

12.0 ± 5.1

.925

Foot type, n

.967

Square

35

45

Egyptian

33

39

Greek

13

16

Abbreviations: HVA, hallux valgus angle; IMA, first-second intermetatarsal angle; IPA, interphalangeal angle of the great toe.

Some investigators showed a relation between certain foot type and ingrown toenail. Viladot15 reported that Egyptian foot is a risk factor for ingrown toenail. However, Günal et al16 showed that the incidence of ingrown toenail is higher in Greek and square foot. They speculated that counterpressure of the second toe on the lateral nail fold is greater in these foot

types.16 Similarly, Ogawa and Hyakusoku17 found a high percentage of Greek and square foot in patients with ingrown nail. On the contrary, we have found no relation between foot type and ingrown toenail. Because of these discrepancies in the literature, it is hard to conclude that a certain foot type is a predisposing factor for ingrown toenail.

Venkatachalam18 presented a case with recurrent ingrown toenail after  first metatarsophalangeal joint fusion with excessive medial rotation. This case supports the biomechanical imbalance and excessive pressure between the first and second toe. Furthermore, Darwish et al19 demonstrated that abnormal internal deviation of the  hallux—in other words, increased HVA and IPA—was associated with ingrown toenail. However, in this current study, there was no significant difference in angles that represent the forefoot alignment in subjects with or without ingrown toenail. Our conclusion can be supported by 2 other observations. First, not all people with hallux valgus have recurrent ingrown toenail. Second, even simple nail avulsion can be curative for ingrown toenail without changing any anatomical axis of the forefoot. In this current study, we measured the forefoot alignment with HVA, IMA, IPA, and foot type. We included only patients with lateral nail fold involvement, because the theory proposing biomechanical imbalance between first and second finger theory explains the causation of lateral nail fold ingrown toenail. We found no association between forefoot alignment and ingrown toenail. The angles that represent the alignment of the forefoot were similar, and the foot types were equally distributed in both groups. This study has failed to demonstrate any abnormality in forefoot alignment in patients with symptomatic ingrowing toenails, and we suggest that treatment should not be based on the correction of the anatomy if no abnormality exists.

References 1. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;15:79(4):303-308. 2. Ikard RW. Onychocryptosis. J Am Coll Surg. 1998;187(1):96-102. 3. Cohen JL, Scher RK, Pappert AS. Congenital malalignment of the great toenails. Pediatr Dermatol. 1991;8(1):40-42. 4. Alam M, Scher RK. Indinavir-related recurrent paronychia and ingrown toenails. Cutis. 1999;64(4):277-278.

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Operative Orthopaedics. Philadelphia, PA: Mosby; 2003:4171-4172.

5. Jaffray D, el Masri W. Ingrowing toenails and tetraplegia. Paraplegia. 1985;23(3):176-181. 6. Cölog˘lu H, Koçer U, Sungur N, Uysal A, Kankaya Y, Oruç M. A new anatomical repair method for the treatment of ingrown nail: prospective comparison of wedge resection of the matrix and partial matricectomy followed by lateral fold advancement flap. Ann Plast Surg. 2005;54(3): 306-312. 7. Thommasen HV, Johnston CS, Thommasen A. The occasional removal of an ingrowing toenail. Can J Rural Med. 2005;10(3):173-180. 8. Dockery GL. Nails. In: Banks AS, Downey MS,  Martin DE, Miller SJ, ed. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2001: 211-213. 9. Richardson EG, Hendrix CL. Disorders of nails and skin. In: Canale ST, ed. Campbell’s

10. Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. 2005;18(2):CD001541. 11. Langford DT, Burke C, Robertson K. Risk factors in onychocryptosis. Br J Surg. 1989;76(1):45-48. 12. Li J, Chen J, Hong G, Chen Z, Weng Y, Wang F. Clinical study of treatment for recalcitrant ingrown toenail by partial distal phalanx removal. J Plast Reconstr Aesthet Surg. 2009;62(10):1327-1330.

15. Viladot A. Metatarsalgia due to biomechanical alterations of the forefoot. Orthop Clin North Am. 1973;4:165. 16. Günal I, Kos¸ ay C, Vezirog˘lu A, Balkan Y, Ilhan F. Relationship between onychocryptosis and foot type and treatment with toe spacer: a preliminary investigation. J Am Podiatr Med Assoc. 2003;93(1):33-36. 17. Ogawa R, Hyakusoku H. Does Egyptian foot present an increased risk of ingrown   toenail? Plast Reconstr Surg. 2006;117(6): 2111-2112.

13. Parrinello JF, Japour CJ, Dykyj D. Incurvated nail: does the phalanx determine nail plate shape? J Am Podiatr Med Assoc. 1995;85(11):696-698.

18. Venkatachalam S. Ingrowing great toenail following metatarsophalangeal joint fusion for hallux valgus: a case report and proposed mechanism of aetiology. J Foot Ankle Surg. 2001;7:113-115.

14. Pearson HJ, Bury RN, Wapples J, Watkin DF. Ingrowing toenails: is there a nail abnormality? A prospective study. J Bone Joint Surg Br. 1987;69(5):840-842.

19. Darwish FM, Haddad W, Ammari F, Aoudat Z. Association of abnormal foot angles and onychocryptosis. Foot (Edinb). 2008;18(4):198-201.

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Is There a Relationship Between Forefoot Alignment and Ingrown Toenail  

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