Foot Surgery BOA Blue Book

22. SURGICAL OPTIONS – IN-GROWING TOENAILS (ONYCHOCRYPTOSIS) 22.1 In-growing toenails often cause pain and disability. They occur when the nail plate traumatises the lateral nail fold giving rise to pain, inflammation or infection.

22.2 Inflammation is often caused by a hook of nail being left when the toenail is torn during an inappropriate toenail cutting procedure. The inflammation can often be settled by tepid salt baths, gentle retraction of the inflamed tissue and trimming of the sharp hook of nail.

22.3 Surgical treatment should be considered for patients with recurrent episodes of inflammation or infection.

22.4 Enquiries should be made about the patient’s medical history (e.g. diabetes) and a physical examination for circulation (pulses and capillary profusion) is mandatory.

Physical examination should exclude palpation for subungual exostosis and radiographs should be performed when subungual exostosis are suspected.

22.5 A Cochrane Database Systemic Review (Rounding and Bloomfield 2002) has demonstrated that temporary measures such as simple nail avulsion or wedge excision of the nail without matricectomy have a recurrence rate of over 50%. They are not recommended.

22.6 The same Cochrane database review has shown that chemical matricectomy (such as phenol ablation) have a lower recurrence rate than surgical matricectomy (e.g. Zadik or Winograd). Patients with recurrent problems with in-growing toenails should, therefore, be managed by chemical matricectomy rather than surgical procedures; the added advantage of the chemical procedures is that they can be performed at the time of infection whereas the surgical procedures have to be delayed until infection has settled often, with antibiotic treatment. There is no need to combine surgical and chemical matricectomy as chemical matricectomy works just as well.

22.7 Chemical matricectomy can be carried out in a clean environment (e.g. an outpatient clinic) and does not need to be carried out in a sterile operating theatre environment.

22.8 Surgical procedures, particularly those involving dissection down to bone, are best carried out in a sterile operating theatre environment.

22.9 The surgeon should pay particular attention to the type of tourniquet used and should ensure that the tourniquet is removed at the end of the procedure.

22.10 The ring block should be performed with plain local anaesthetic as ring blocks performed with anaesthetic plus adrenaline can lead to circulatory problems.

22.11 Cases of inadvertent phenol injection into the tissues have been reported and can be avoided with the use of pre-packed phenol swabs.