Toe Nail Surgery

Your specialist has diagnosed that you have a deformity of one or more of your toenails. The most common deformities are an excessively curved or wide nail plate, predisposing it to grow into the skin at the side of the nail, or a thickened toenail. Whilst conservative care can help to prevent pain or infection, this will not cure the problem. In order to correct the deformity you may require an operation, which will be recommended if you have a significant problem or frequent episodes of infection. Answers to common questions are outlined in this information sheet.

Before undertaking surgery you should be certain that conservative (non-surgical) options have been considered and that you understand the implications and complications of the proposed surgery. If you have any concerns please discuss these with your specialist before the operation date.

How will you correct the deformity?

Whilst removing the nail will resolve the current problem, the nail will grow back and it is likely that you will be left with the same problem. In order to prevent the nail growing, the troublesome section of nail is removed and a strong chemical, phenol, is applied to prevent the nail from re-growing. In the vast majority of patients we only need to remove a small section at one or both sides of the nail (partial nail avulsion). This leaves you with a narrower nail but without the troublesome section. In some instances, the whole nail needs removing (total nail avulsion). In this case, there will be no further nail growth.

If an ingrown toenail has been present for some time, there is often a build up of excess tissue that bleeds easily and looks red. This is known as hypergranulation tissue and is an over reaction to the irritation and / or infection. This will be removed during the operation.

What will happen at the operation?

The operation will be performed under local anaesthetic, so you are awake and can eat normally up until the time of your operation. The injection is given at the base of the affected toes and is generally more comfortable than a dental injection. The operation will last for approximately 10-15 minutes per toe but you may be at the hospital / clinic for much longer to allow sufficient preparation and post operative monitoring. A large dressing will be placed on your toes. Whilst we can provide a special shoe, a sandal is usually sufficient. You should avoid wearing tight clothing.

What are the advantages of this operation?

• Less discomfort
• No episodes of infection
• Easier shoe choice
• Easier walking

Whilst it cannot be guaranteed that you will never have another problem with the toe or be completely pain free, it is highly likely that your toe will be much improved.

I have heard it is a very painful operation.

Advances in techniques, local anaesthetics and pain killers now mean that patients have a high level of success with much less pain. Generally speaking, there is very little discomfort the night of the operation or during the healing period, depending on the tightness of the shoes worn. It is rare that the level of pain is not controlled by normal headache tablets (e.g. Paracetamol or Neurofen).

What are the complications?

Every effort is made to minimise the risk of complications and these are rare. However, some specific complications may occur, such as:

• Prolonged weeping (see recovery below)
• Infection. This can occur during recovery although the operation is often performed due to an infected ingrown toenail, thus this is less likely once the nail has been removed
• A reaction to phenol (phenol flare) can occur but this is rare and will be dealt with if necessary (less than 1%)
• Re-growth of the nail. This occurs in approximately 5-8% of patients undergoing partial nail avulsion and 10% of those undergoing total nail avulsion. The re-growth is often less troublesome than the original problem but the procedure can be repeated if necessary.
• In rare cases a small section of nail can re-grow beneath he skin at the base of the nail (less than 0.5%). This can form a small cyst, which requires excision.
• Blood clotting (thrombosis) in the deep veins of the leg (0.5%) can occur with any operation. This condition can result in a small piece of clot dislodging (embolism) and going to the lung (pulmonary embolism). This is extremely rare with this type of operation, as you remain mobile. However, if it does occur, it is a potentially life threatening condition.
• Chronic regional pain syndrome is a very rare complication (less than 0.1%) that can occur following any surgery of the extremities, resulting in severe pain to the area. Specific medical treatment / referral is often necessary to resolve the problem. However, precise diagnosis is difficult and a small number of affected patients are left with disabling long term pain.

Although all these complications are possible they are infrequent. Please be sure to discuss any areas of concern with your podiatrist as well as specific complications related to the procedure you may undergo.

How long will it take me to recover?

First Night

• You should not drive following the operation. We advise you to arrange a lift or get a taxi after the operation.
• We generally advise you to rest the first night and take pain killers as necessary

First week

• The application of the phenol to destroy the nail bed causes a chemical burn, which takes time to heal. However, this can be helped by keeping the operation site draining. You will need to bathe your toe/s in warm salt water for 15 minutes twice daily from the day after the operation.
• It is advisable to keep the toe covered with a sterile dressing to keep it clean.
• You should be able to get about fairly well but may need to take care with your shoe choice and avoid excessive activity.
• You will be seen one week following the operation

Between 2-6 weeks after surgery

• You will need to keep dressing the toe as above until the toe stops weeping. On average, this occurs between 2-6 weeks following the operation. Generally, this is sooner rather than later.
• You should be relatively active during this period.
• You will be seen at 5-6 weeks following the operation.

Please note, if a complication arises, recovery may be delayed.