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Nail bed avulsions treated with porcine xenografts
N ail bed avulsions treated with porcine xenografts Robert A. Ersek, M.D., Umesh Gadaria, M.D., F.A.C.S., F.I.C.S., and David R. Denton, Ph.D ., San Antonio and Austin, Texas.
Injuries to the fingernail that also involve damage to the nail bed require careful attention. Regrowth of a normal nail is important not only for cosmetic reasons but for restoration of tactile capabilities as well, and a smooth nailbed is essential for normal nail regrowth and adhesion. I. 2 Frequently, nail bed injuries are treated with simple dressings, an approach almost guaranteed to yield unsatisfactory results because scar tissue resulting from granulation tissue will leave an uneven nail bed and, ultimately, a rough and uneven nail. Both the nail bed and the nail itself are composed of modified epithelium, and, as in other injuries involving epithelial loss, biologic skin is the most effective method of wound coverage. 2
Reprint requests: Robert A. Ersek , M.D ., Park Saint David's, Suite 309, 30th SI. and Red River. Austin, TX 78705.
In treating nail bed injuries, we routinely use silverimpregnated porcine xenograft. Any remaining nail fragments are removed, since we have found these to be prime sites for infection (Fig. 1). Once the nail has been completely removed, nail bed injuries may usually be treated like simple skin abrasions. 3 After lacerations are sutured, a segment of silver-impregnated porcine xenograft is cut to fit the size of the avulsed nail (Fig. 2). This is placed over the nailbed and tucked gently into the nail sulcus (Fig . 3). The fingertip is then dressed with cotton gauze tubing to hold the graft in place until it adheres and to cushion the wound . If the xenograft fails to adhere, it is changed daily until it does adhere. Once adherent, it will remain in place for 2 to 3 weeks and then separate spontaneously from a well-healed nailbed . The nail will then replace itself in approximately 5 months (Fig. 4).4 Porcine xenograft does not become vascularized as does allograft, and it is inherently low in antigenicity . Its effectiveness for temporary coverage of open wounds has been well established :>' 6. 7 When impreg-
Fig. 1. A crush injury of the left ring finger with avulsion of the nail bed .
Fig. 2. The nail bed is replaced in its anatomic position and sutured in place. The prepared porcine xenograft can be observed to the side.
From the University of Texas Health Science Center, San Antonio , Texas. Received for publication Feb. 27, 1984; accepted in revised form May 8, 1984.
152
THE JOURNAL OF HAND SURGERY
Vol. lOA, No.
Nail bed avulsions
January 1985
153
Fig. 3. The porcine xenograft is placed over the repaired nail bed and its absorbable stitches and tucked into the remaining nail sulcus. Silver-impregnation adds a potent antibacterial effect at the wound surface.
nated with silver ions, a potent antibacterial effect is provided that was not previously available in any biologic dressing. The timed release of silver directly at the wound surface reduces the possibility of infection, which is the principal reason for failure of the xenograft to adhere. This is a safe, dependable technique for restoration of a smooth nail bed. Autografting, with its attendant secondary wound, should be considered only where loss of nail bed epithelium is extensive.
Fig. 4. After 10 months this nail demonstrates minimal deformity and good adherence. Though contour and shape may not exactly match uninjured nails, acceptable results are routine.
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NAIL SULCUS
PORCINE XENOGRAFT
REFERENCES I. Zook EG: Injuries of the fingernail. In Green DP, editor: Operative hand surgery. New York, 1982, Churchill Livingstone, vol I, pp 895-914 2. Flatt AE: The care of minor hand injuries, ed 3. SI. Louis, 1972, The CV Mosby Co, pp 109-17 3. Chase RA: Atlas ofhand surgery. Philadelphia, 1973, WB Saunders Co, p 70 4. Weeks PM, Wray RC: Management of acute hand injuries-A biological approach. SI. Louis, 1978, The CV Mosby Co, p 199 5. Bromberg BE, Song IC, Mohn MP: The use of pigskin as a temporary biological dressings. Plast Reconstr Surg 36: 80-90, 1965
REPAIRED NAILIED
Fig. 5.
6. Elliott RA Jr, Hoehn JG: Use of commercial porcine skin for wound dressings. Plast Reconstr Surg 52:401-5,1973 7. Ersek RA, Denton DR: Silver-impregnated porcine xenograft for damaged or missing skin. Cont Surg 23:83-93, 1983
Injuries to the fingernail that also involve damage to the nail bed require careful attention. Regrowth of a normal nail is important not only for cosmetic reasons but for restoration of tactile capabilities as well, and a smooth nailbed is essential for normal nail regrowth and adhesion. I. 2 Frequently, nail bed injuries are treated with simple dressings, an approach almost guaranteed to yield unsatisfactory results because scar tissue resulting from granulation tissue will leave an uneven nail bed and, ultimately, a rough and uneven nail. Both the nail bed and the nail itself are composed of modified epithelium, and, as in other injuries involving epithelial loss, biologic skin is the most effective method of wound coverage. 2
Reprint requests: Robert A. Ersek , M.D ., Park Saint David's, Suite 309, 30th SI. and Red River. Austin, TX 78705.
In treating nail bed injuries, we routinely use silverimpregnated porcine xenograft. Any remaining nail fragments are removed, since we have found these to be prime sites for infection (Fig. 1). Once the nail has been completely removed, nail bed injuries may usually be treated like simple skin abrasions. 3 After lacerations are sutured, a segment of silver-impregnated porcine xenograft is cut to fit the size of the avulsed nail (Fig. 2). This is placed over the nailbed and tucked gently into the nail sulcus (Fig . 3). The fingertip is then dressed with cotton gauze tubing to hold the graft in place until it adheres and to cushion the wound . If the xenograft fails to adhere, it is changed daily until it does adhere. Once adherent, it will remain in place for 2 to 3 weeks and then separate spontaneously from a well-healed nailbed . The nail will then replace itself in approximately 5 months (Fig. 4).4 Porcine xenograft does not become vascularized as does allograft, and it is inherently low in antigenicity . Its effectiveness for temporary coverage of open wounds has been well established :>' 6. 7 When impreg-
Fig. 1. A crush injury of the left ring finger with avulsion of the nail bed .
Fig. 2. The nail bed is replaced in its anatomic position and sutured in place. The prepared porcine xenograft can be observed to the side.
From the University of Texas Health Science Center, San Antonio , Texas. Received for publication Feb. 27, 1984; accepted in revised form May 8, 1984.
152
THE JOURNAL OF HAND SURGERY
Vol. lOA, No.
Nail bed avulsions
January 1985
153
Fig. 3. The porcine xenograft is placed over the repaired nail bed and its absorbable stitches and tucked into the remaining nail sulcus. Silver-impregnation adds a potent antibacterial effect at the wound surface.
nated with silver ions, a potent antibacterial effect is provided that was not previously available in any biologic dressing. The timed release of silver directly at the wound surface reduces the possibility of infection, which is the principal reason for failure of the xenograft to adhere. This is a safe, dependable technique for restoration of a smooth nail bed. Autografting, with its attendant secondary wound, should be considered only where loss of nail bed epithelium is extensive.
Fig. 4. After 10 months this nail demonstrates minimal deformity and good adherence. Though contour and shape may not exactly match uninjured nails, acceptable results are routine.
-----
NAIL SULCUS
PORCINE XENOGRAFT
REFERENCES I. Zook EG: Injuries of the fingernail. In Green DP, editor: Operative hand surgery. New York, 1982, Churchill Livingstone, vol I, pp 895-914 2. Flatt AE: The care of minor hand injuries, ed 3. SI. Louis, 1972, The CV Mosby Co, pp 109-17 3. Chase RA: Atlas ofhand surgery. Philadelphia, 1973, WB Saunders Co, p 70 4. Weeks PM, Wray RC: Management of acute hand injuries-A biological approach. SI. Louis, 1978, The CV Mosby Co, p 199 5. Bromberg BE, Song IC, Mohn MP: The use of pigskin as a temporary biological dressings. Plast Reconstr Surg 36: 80-90, 1965
REPAIRED NAILIED
Fig. 5.
6. Elliott RA Jr, Hoehn JG: Use of commercial porcine skin for wound dressings. Plast Reconstr Surg 52:401-5,1973 7. Ersek RA, Denton DR: Silver-impregnated porcine xenograft for damaged or missing skin. Cont Surg 23:83-93, 1983