Indications
Surgical treatment is indicated in all grade 3 presentations and some of the worst grade 2 presentations. It may also be indicated in other nail conditions which present with discomfort or pain:
- pincer nails, sometimes referred to as involuted nails
- symptomatic onychomycosis which has failed oral antifungal treatment
- onychogryphosis
- onychauxis (Ceilley 1992).
Contraindications
Patients must be assessed to ensure adequate blood supply to ensure wound healing. Physical signs of ischaemia include absent posterior tibial and dorsalis pedis pulses, slow capillary filling time, skin atrophy and absence of skin hair. Patients with an ankle brachial index below 0.5 or toe pressures below 40mm Hg are at risk of non-healing (Giacalone 1997).
Preoperative assessment
In most cases patients do not require laboratory testing prior to nail surgery (Siegle 1992). If a subungual exostosis or bony abnormality is suspected, plain film radiographs are indicated. Radio-isotope studies may be useful if osteomyelitis is suspected, especially in chronic ingrown nails (Cox 1995). Subungual glomus tumours can be detected with magnetic resonance imaging (Holzberg 1992).
Anaesthesia
A local anaesthetic ring block technique is all that is required for routine toenail surgery. Sedation and general anaesthesia is reserved for uncooperative patients or the very young (Dixon 1983, Murray 1989). Lidocaine or bupivicaine is generally used. Bupivicaine has a longer duration of action and therefore provides greater postoperative pain relief. Vasoconstrictors, such as epinephrine, must be avoided in extremities.
A variety of procedures have been advocated. Some procedures require full surgical theatre facilities, where as others can be performed in a clean clinical setting following aseptic techniques.
"Sharp" procedures (requiring theatre)
- Surgical excision of the nail sulcus, plate, bed and matrix - Winograd (1929)
- Surgical excision of the germinal epithelium - Zadik (1950)
- “Terminal Syme’s procedure” as described by Lapidus (1933) – as above with amputation of the distal half of the distal phalanx, named by analogy with the Syme’s amputation of the foot.
In Winograd’s original paper he reported no recurrences of the ingrown nail. Later studies have reported recurrence rates of between 11% and 27% (Keyes E 1934, Murray and Bedi 1975, Issa et al 1988, Van Der Ham et al 1990).
Zadik reported no recurrences but 2 cases of postoperative necrosis. Further studies of this technique have reported recurrence of nail spicules at a rate from 27% to 50% (Townsend and Scott 1966, Murray and Bedi 1975, Palmer and Jones 1979).
The Symes procedure has reported postoperative spicules. Thompson and Terwilliger (1951).
Chemical matrixectomy (requiring clean room)
Two chemical have been described in chemical ablation of the germinal nail matrix; sodium hydroxide and phenol (Travers and Ammon 1980). The use of phenol is most commonly reported. Reports of phenol use occur as early as 1901 with Porter, and Boll introduced this technique formally in 1945. This procedure has lower recurrence rates, reports range from 3.9% to 10% (Morkane et al 1984, Issa and Tanner 1988, Van Der Ham et al 1990, Mori et al 1998, Herold 2001)
Phenol and sodium hydroxide were compared for their postoperative morbidity effects and healing rates (Bostanci, S et al 2007). The first review occurred after two days and sodium hydroxide had a higher incidence of pain, but the two procedures were comparative at subsequent reviews. Healing rates were quicker with sodium hydroxide in comparison (mean 10.8 days vs 18.02 days). Both procedures had a high success rate (95%), comparable with previous studies.
Which procedure?
A number of RCTs have compared surgical techniques. Greig (1991) found a 73% recurrence rate after both total nail avulsion and wedge excision of the nail, but only 9% after phenol matricectomy. Simple avulsion of the whole nail or a wedge should not not be a standard treatment; if surgery is necessary the germinal matrix should be ablated at the first procedure.
Other trials (Issa + Tanner 1988, Herold 2001, Gerritsma-Bleeker 2002) have compared surgical and chemical matricectomy. Recurrence rates were similar, although there was a trend for less revision surgery after chemical ablation. Combined surgical and chemical matricectomy was found by Issa and Tanner to have fewer recurrences than either surgery or chemical ablation alone, and this is the technique we use.
Post-operative complications
Recurrence rates with phenol matricectomy are low, but nail spicules have occurred following this procedure. The main complication can be superficial chemical burns. There is one reported case of amputation of the distal phalanx of a big toe following a chemical burn induced during nail surgery (Sugden and Levy 2001).
In a randomised clinical trial (Bos, AM et al, 2007) studied surgical technique and application of antibiotic local to the surgical wound post operatively. Unsurprisingly, this study found the application of phenol to ablate the germinal matix rather than excision led to reduced recurrence rates. There was no difference in infection rates between the two procedures without the application of antibiotic. In the group who applied antibiotic locally, there was no reduction in infection rate in comparison to the control. There was no effect on recurrence rates between the control group and the group who applied antibiotics.
Conclusion
A Cochrane review in 2005 (Rounding C and Bloomfield S) concluded that the evidence suggests that simple nail avulsion combined with the use of phenol…is more effective at preventing symptomatic recurrence of ingrowing toenails. It was noted that the application of phenol decreased symptomatic recurrence at the cost of increased post operative infection. The paper by Bos clearly contradicts this. The issue of infection may be being clouded by the fact that application of phenol produces a highly inflamed exudative wound which could be mistaken for an infection.
This review has examined the current evidence surrounding the incidence and treatment for ingrown toe nails. Stage 1 and some Stage 2 presentations can be managed with conservative measures. Some Stage 2 and all Stage 3 presentations are best managed surgically. Of all the procedures available for surgical management, phenol matricectomy, possibly combined with surgical matricectomy appears to offer the best results.