Nail Surgery

General

Troublesome nails can be due to being abnormally shaped; poor self care; trauma or underlying bony growth. Symptoms include a painful swollen toe or soreness between the nail and skin which, occasionally, can become infected and require antibiotics.

Diagnosis

This is a clinical diagnosis made by the examining the toe, occasionally X-rays are required to exclude the underlying bony growth.

Nails with varying degrees of inflammation with a low grade infection

Treatment options

Conservative care

• Routine care
• Antibiotics

Surgical Management

• Removing the in-growing section of nail or in some situations, the whole nail.
• Removing the underlying bony growth from under the nail and in some situations, a 
portion or the entire nail will be removed too.

Incisional nail surgery

 

The operation


1) In-growing toe nail(s)

Your toe nail(s) will be removed by one of two methods:

• Partial Nail Excision

The Hockey stick (L shaped) incision is made on the top of your toe through the nail plate and into the soft tissue, in order to expose the base of the nail plate.

• Total Nail Avulsion

The nail plate will be removed completely without a skin incision and dependent on the desired outcome, phenol (a caustic) will be applied to the entire nail bed to stop any new nail growth. Alternatively, no caustic is applied in order to allow a new nail plate to grow.

2) Bony growth (under the nail)

The Bony Prominence will be removed by one of two approaches depending on the size and location of the exostosis.

• Through the nail plate

The incision will pass centrally through the toenail creating two flaps which allow exposure of the underlying bone. This approach may result in unavoidable nail plate damage with unequal growth.

• Through an incision in the end of the toe.

A simple incision in the apex (end) of the toe below the nail plate allows exposure of the exostosis. This approach may result in a haematoma (blood) formation, under the nail, which may result in temporary loss of the nail plate.

Recovery

You must rest with the leg elevated for the first 48hrs (essential walking only). It is important that you do not interfere with the dressings and keep them dry. You can buy a purpose made waterproof cover to keep the leg dry, from your chemist. You will be seen for a dressing change 3-6 days post surgery, most patients can then return to walking to pain tolerance around the house.

Nail excision & Sub-Ungual exostectomy. After 10-days the dressings and stitches will be removed, and you are advised to return to a comfortable shoe. At this stage you can wash your foot and gradually increase your activities.

Total nail avulsion with Phenol. The wound will require daily dressing changes after your shower.

This type of surgery aims to reduce recurrence from the in-growing toe nail, allowing you to wear a greater range of footwear without discomfort.

Possible Complications

Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital.  Most patients have an uneventful recovery.  Outlined below are the common problems or those rare complications with serious outcomes.  In cases where we do not have accurate audit, we have used published results from the podiatric literature.  An asterisk accompanies these *

• Reoccurrence of part of the nail – 1-2%
• Thick and or sensitive scar – no audit data is available.
• Adverse reaction to the post-operative painkillers.  1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue.  The incidence is 1 in every 83 operations*
• Infection of bone occurred in 3 out of 916 patients.
• Delayed healing of the soft tissue.  No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10-year period.
• Deep vein thrombosis, which can result in a clot in the lung and is potentially a life threatening condition.  Deep vein thrombosis incidence is 1 in every 900 cases.
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident.  This normally requires management by specialists in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.

Pre operative screening of your health allows us to determine whether you are fit for surgery.  It is important that you disclose your full medical history.  If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. The surgeon and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post-operative instructions, which include resting and elevating the operated leg.  Keeping the wound clean and dry until advised otherwise is essential.  Please ask the nurse or Professor Tagoe if you are not sure what to do.
• Having a healthy diet is important. This provides the nutrition required for healing.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.