NAIL SURGERY

Nail Surgery of the Foot

What It Is ?

Nail surgery involves partial or total removal of the toenail, sometimes with permanent destruction of the nail matrix to prevent recurrence.

• Most commonly performed for ingrown toenails (onychocryptosis).
• Can be done under local anaesthesia in an outpatient setting.

Indications

1. Ingrown toenail (onychocryptosis)
   • Painful nail edge growing into skin, often infected or recurrent.
2. Recurrent paronychia (nail fold infection).
3. Severe nail deformities (e.g., after trauma).
4. Onychogryphosis (thick, deformed nails).
5. Onychomycosis (fungal nails) — rarely, if very thick or unresponsive to medication.
6. Nail tumors (benign or malignant, e.g., subungual exostosis, melanoma).

 

Types of Nail Surgery

1. Partial Nail Avulsion (PNA)
   • Removal of one side (lateral edge) of the nail plate.
   • Most common for ingrown toenails.
2. Total Nail Avulsion (TNA)
   • Entire nail plate removed; used for severe deformities or infections.
3. Matrixectomy (Permanent Nail Removal)
   • Chemical matrixectomy: Phenol, sodium hydroxide, or trichloroacetic acid destroys nail matrix.
   • Surgical matrixectomy: Excision of nail matrix tissue.
4. Wedge Resection (Winograd Procedure)
   • Removal of lateral nail plate + nail bed + hypertrophic nail fold tissue.
5. Radical Nail Fold Excision (Zadik’s Procedure)
   • Removal of entire nail bed + nail folds; nail doesn’t regrow.

Preoperative Considerations

• Assessment: Identify infection, circulation issues, or systemic conditions (e.g., diabetes).
• Consent: Discuss risks, benefits, recurrence rates, and cosmetic outcomes.
• Anaesthesia: Usually, local digital block with lidocaine ± epinephrine (if no vascular disease).

Procedure Steps (Typical Partial Nail Avulsion with Phenol)

1. Anaesthesia: Digital block for pain control.
2. Tourniquet: Applied at toe base to reduce bleeding.
3. Nail sectioning: Lateral edge cut lengthwise and removed.
4. Chemical matrixectomy: Phenol applied for 1–3 minutes to destroy nail matrix.
5. Irrigation: Saline to neutralize chemical.
6. Dressing : Non-adherent gauze + bandage.

 

Postoperative Care

• Rest and elevation for first 24–48 hours.
• Daily dressing changes with antiseptic.
• Analgesics for discomfort.
• Return to normal shoes in 1–2 weeks (longer for total avulsion).
• Watch for signs of infection: redness, swelling, pus, severe pain.

Healing Times

• Partial nail avulsion : 2–4 weeks.
• Total nail avulsion: 4–6 weeks for regrowth unless matrix destroyed.
• Permanent removal: No regrowth; healing of skin fold 4–6 weeks.

Complications

• Infection (especially if aftercare poor).
• Delayed healing.
• Nail spicule regrowth (if matrix not fully destroyed).
• Cosmetic dissatisfaction.
• Rare: allergic reaction to phenol or anaesthetic.

Success Rates

• Partial nail avulsion + phenol: ~90–95% success for ingrown toenails.
• Lower recurrence compared to avulsion alone.

Alternatives

• Conservative care (soaks, antibiotics, cotton packing) for mild cases.
• Orthonyxia (nail bracing) for early ingrown toenails.
• Laser matrixectomy (less common but used in some centers).

Partial nail avulsion with chemical matrixectomy

 

Modified Winograd method (matrixectomy with partial lateral nail plate excision and germinal matrix resection). It ensures the complete removal of diseased tissue (granulation tissue and germinal matrix) during the surgery. It is simple, effective, and aesthetic solution for the treatment of ingrown toenail.

 

Zadik procedure (total nail removal/destruction). It is surgical method for removing an ingrown toenail, which involves removing the entire toenail and the underlying nail matrix (the tissue from which the nail grows) to prevent regrowth.