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Subungual Exostosis of the Toes: A Systematic Review

  • Survey (Systematic Review)
  • Published:
Clinical Orthopaedics and Related Research®

A CORR Insights to this article was published on 13 December 2013

Abstract

Background

Subungual exostosis is a relatively common benign bone tumor that occurs in the distal phalanges of the toes and can be a source of pain and nail deformity. There is controversy about the treatment of these lesions and there are few studies that have synthesized what is known and provided meaningful information on treatment.

Questions/purposes

We performed a systematic review to address the following questions: (1) What is the best surgical approach for excising these lesions? (2) What is the age range, sex distribution, and presenting symptoms of subungual exostoses and which toe is most frequently affected? (3) What complications arise from treatment?

Methods

Two authors independently searched multiple databases (Medline, 1950–May 2013; Cochrane EBM database, and EMBASE, 1980–May 2013 provided by OVID; ACP Journal Club, 2003–May 2013; CINAHL by EBSCO, 1937–May 2013; and PubMed by NLM, 1940–May 2013), and key words were chosen to achieve a broad search strategy. We included studies on the management of toe exostoses with > 10 cases and we excluded studies that reported on upper extremity exostoses or osteochondromas. Demographic and treatment data were collected from each article by two independent authors and collated. A total of 124 abstracts were screened, and 116 articles were reviewed in full, of which 13 met the inclusion criteria.

Results

Complete marginal excision through a fish mouth incision protecting the nail led to a recurrence rate of 4% and satisfactory clinical results, defined as no requirement for postoperative intervention and a satisfactory clinical appearance in 73%. Most studies provided incomplete descriptions of specific surgical techniques used. Fifty-five percent of the patients were younger than 18 years of age. A history of toe trauma before diagnosis was present in approximately 30% of the cases. Delayed diagnosis occurred in approximately 10% of the cases and onychodystrophy occurred in more than 10%.

Conclusions

There is weak evidence to guide management of subungual exostosis. Adequate wound management postexcision aiming to minimize disruption to the nail bed and matrix may prevent onychodystrophy, which is a common complication of treatment.

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References

  1. Baran R, Bureau H. Multiple exostoses syndrome. J Am Acad Dermatol. 1991;25:333–335.

    Article  PubMed  CAS  Google Scholar 

  2. Bendl B. Subungual exostosis. Cutis. 1980;26:260.

    PubMed  CAS  Google Scholar 

  3. Bervar M. [Subungual exostosis of the toe and its etiology] [in Serbian]. Vojnosanit Pregl. 1958;15:452–455.

    PubMed  CAS  Google Scholar 

  4. Bostanci S, Ekmekçi P, Ekinci C, Akçaboy B, Gürgey E. Subungual osteochondroma: a case report. Dermatol Surg. 2001;27:591–593.

    Article  PubMed  CAS  Google Scholar 

  5. Cohen HJ, Frank SB, Minkin W, Gibbs RC. Subungual exostoses. Arch Dermatol. 1973;107:431.

    Article  PubMed  CAS  Google Scholar 

  6. DaCambra MP, Gupta SK, Ferri-de-Barros F. A novel management strategy for subungual exostosis. BMJ Case Rep. 2013 Aug 30;2013. pii: bcr2013200396. doi: 10.1136/bcr-2013-200396.

  7. Dal Cin P, Pauwels P, Poldermans LJ, Sciot R, Van den Berghe H. Clonal chromosome abnormalities in a so-called Dupuytren’s subungual exostosis. Genes Chromosomes Cancer. 1999;24:162–164.

    Google Scholar 

  8. Davis D, Cohen P. Subungual exostosis: case report and review of the literature. Pediatr Dermatol. 1996;13:212–218.

    Article  PubMed  CAS  Google Scholar 

  9. De Berker D, Langtry J. Treatment of subungual exostoses by elective day case surgery. Br J Dermatol. 1999;140:915–918.

    Article  PubMed  Google Scholar 

  10. De Palma L, Gigante A, Specchia N. Subungual exostosis of the foot. Foot Ankle Int. 1996;17:758–63.

    Article  Google Scholar 

  11. DiCenso A, Bayley L, Haynes RB. Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evid Based Nurs. 2009;12:99–101.

    Article  PubMed  Google Scholar 

  12. Evison G, Price CH. Subungual exostosis. Br J Radiol. 1966;39:451–455.

    Article  PubMed  CAS  Google Scholar 

  13. Fikry T, Dkhissi M, Harfaoui A, Adil A, Haddoun A, Zryouil B. Subungual exostosis: a retrospective study of 28 cases. Acta Orthop Belg. 1998;64:35–40.

    PubMed  CAS  Google Scholar 

  14. Grisafi PJ, Lombardi CM, Sciarrino AL, Rainer GF, Buffone WF. Three select subungual pathologies: subungual exostosis, subungual osteochondroma, and subungual hematoma. Clin Podiatr Med Surg. 1989;6:355–364.

    PubMed  CAS  Google Scholar 

  15. Guarneri C, Guarneri F, Risitano G, Lentini M, Vaccaro M. Solitary asymptomatic nodule of the great toe. Int J Dermatol. 2005;44:245–247.

    Article  PubMed  Google Scholar 

  16. 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;13:81–87.

    PubMed  CAS  Google Scholar 

  17. Kim S, Park K, Son S. Subungual osteochondroma presenting as verruca vulgaris in a 6-year-old boy. Pediatr Dermatol. 2007;24:584–585.

    Article  PubMed  Google Scholar 

  18. Landon GC, Johnson KA, Dahlin DC. Subungual exostoses. J Bone Joint Surg Am. 1979;61:256–259.

    PubMed  CAS  Google Scholar 

  19. Lee SK, Jung MS, Lee YH, Gong HS, Kim JK, Baek GH. Two distinctive subungual pathologies: subungual exostosis and subungual osteochondroma. Foot Ankle Int. 2007;28:595–601.

    Article  PubMed  Google Scholar 

  20. Letts M, Davidson D, Nizalik E. Subungual exostosis: diagnosis and treatment in children. J Trauma Acute Care Surg. 1998;44:346–349.

    Article  CAS  Google Scholar 

  21. Li Y, Yue T, Han Y. Subungual exostosis. 1991;6:169–171.

    Google Scholar 

  22. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700–b2700.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Lokiec F, Ezra E, Krasin E, Keret D, Wientroub S. A simple and efficient surgical technique for subungual exostosis. J Pediatr Orthop. 2001;21:76.

    Article  PubMed  CAS  Google Scholar 

  24. Mavrogenis A, Papagelopoulos P, Soucacos P. Skeletal osteochondromas revisited. Orthopedics. 2008;31:1018–1028.

    Article  Google Scholar 

  25. Mertens F, Möller E, Mandahl N, Picci P, Perez-Atayde AR, Samson I, Sciot R, Debiec-Rychter M. The t(X;6) in subungual exostosis results in transcriptional deregulation of the gene for insulin receptor substrate 4. Int J Cancer. 2011;128:487–491.

    Article  PubMed  CAS  Google Scholar 

  26. Miller-Breslow A, Dorfman H. Dupuytren’s (subungual) exostosis. Am J Surg Pathol. 1988;12:368.

    Article  PubMed  CAS  Google Scholar 

  27. Multhopp-Stephens H, Walling A. Subungual (Dupuytren’s) exostosis. J Pediatr Orthop. 1995;15:582.

    Article  PubMed  CAS  Google Scholar 

  28. Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. Radiographics. 2000;20:1407–1434.

    Article  PubMed  CAS  Google Scholar 

  29. Oliveira AS, Picoto AS, Verde SF, Martins O. Subungual exostosis: treatment as an office procedure. J Dermatol Surg Oncol. 1980;6:555–558.

    Google Scholar 

  30. Ortega ORM, Sanchez HG. 23 observations of subungual exostosis. Med Cut ILA. 1988;16:11–14.

    Google Scholar 

  31. Smith LC, Funkhouser WK, Campion ER, Morrell DS. A firm nodule on the great toe of a 13-year-old boy. Pediatr Dermatol. 2009;26:747–748.

    Article  PubMed  Google Scholar 

  32. Stark JD, Adler NN, Robinson WH. Hereditary multiple exostoses. Radiology. 1952;59:212–215.

    PubMed  CAS  Google Scholar 

  33. Storlazzi C, Wozniak A, Panagopoulos I, Sciot R, Mandahl N, Mertens F, Debiec-Rychter M. Rearrangement of the COL12A1 and COL4A5 genes in subungual exostosis: molecular cytogenetic delineation of the tumor-specific translocationt (X; 6)(q13-14; q22). Int J Cancer. 2006;118:1972–1976.

    Article  PubMed  CAS  Google Scholar 

  34. Suga H, Mukouda M. Subungual exostosis. Ann Plast Surg. 2005;55:272–275.

    Article  PubMed  CAS  Google Scholar 

  35. Toyoda M, Morohashi M. An ultrastructural study of subungual exostosis, with specila reference to intranuclear inclusions. Medical Electron Microscopy. 1998;31:142–146.

    Article  Google Scholar 

  36. Tuzuner T, Kavak A, Ustundag N, Parlak A. A painful subungual nodule: subungual exostosis. Acta Orthop Traumatol Turc. 2004;38:71.

    PubMed  Google Scholar 

  37. Valinsky MS, Hettinger DF, Gennet PM. Subungual exostosis removal utilizing a minimal incision technique. Curr Podiatr Med. 1991;40:10–15.

    Google Scholar 

  38. Webber J, Miller M. Subungual exostosis in a young woman. Pathology. 1994;26:339–341.

    Article  PubMed  CAS  Google Scholar 

  39. Wright JG, Kocher MS, Sanders JO. Evidence-based pediatric orthopaedics: an introduction, Part I. J Pediatr Orthop. 2012;32:S83–S90.

    Article  PubMed  Google Scholar 

  40. Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85:1–3.

    Article  PubMed  Google Scholar 

  41. Zambrano E, Nosé V, Perez-Atayde A, Gebhardt M, Hresko MT, Kleinman P, Richkind KE, Kozakewich HP. Distinct chromosomal rearrangements in subungual (Dupuytren) exostosis and bizarre parosteal osteochondromatous proliferation (Nora lesion). Am J Surg Pathol. 2004;28:1033.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of British Columbia, 3-11 Royal Avenue East, New Westminster, BC, Canada

    Mark P. DaCambra MD, MSc

  2. Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA

    Sumit K. Gupta MD

  3. Department of Surgery, University of Calgary, Calgary, AB, Canada

    Fabio Ferri-de-Barros MD, MSc

  4. Division of Pediatric Orthopaedic Surgery, Alberta Children’s Hospital, Calgary, AB, Canada

    Fabio Ferri-de-Barros MD, MSc

Authors
  1. Mark P. DaCambra MD, MSc
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  2. Sumit K. Gupta MD
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  3. Fabio Ferri-de-Barros MD, MSc
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Corresponding author

Correspondence to Mark P. DaCambra MD, MSc.

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Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

This work was performed at the Alberta Children’s Hospital, Calgary, Alberta, Canada.

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DaCambra, M.P., Gupta, S.K. & Ferri-de-Barros, F. Subungual Exostosis of the Toes: A Systematic Review. Clin Orthop Relat Res 472, 1251–1259 (2014). https://doi.org/10.1007/s11999-013-3345-4

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