Multiple surgical techniques and combinations have been used to treat ingrown toenails. Partial nail avulsion and chemical (phenol) matricectomy is the most common procedure performed for patients in Stages II and III. This procedure is illustrated in Figure 2 and is described below.
Instruments and materials required are:
- alcohol wipes
- lignocaine 1–2% plain
- povidone-iodine ointment (eg Betadine)
- sterile saline
- digit tourniquet (eg Tourni-Cot ring)
- English anvil nail splitter
- Beaver handle with #62 Beaver blade
- eponychium retractor
- straight haemostat or locking forceps
- sterile cotton-tipped applicators
- liquefied phenol BP
- alcohol and chlorhexidine solution for irrigation
- nonstick antiseptic gauze (eg Bactigras paraffin-wax gauze).
Description of procedure:
- Prepare the toe using alcohol skin wipes and inject 3–4 mL of lignocaine 1–2% plain as digital ring block.
- While waiting for the anaesthesia to take effect, the digit can be soaked in an antiseptic bath (povidone-iodine or chlorhexidine). Before beginning the procedure, test for adequacy of anaesthesia by inserting a needle into the digital tip and under the nail.
- Use standard sterile technique after preparing the foot.
- Use a digit tourniquet to exsanguinate the toe.
- Use a nail splitter to split 2–3 mm of the affected side of nail longitudinally (Figure 2A) and complete to the proximal edge with the #62 Beaver blade (Figure 2B).
- With an eponychium retractor, free the nail plate from all skin attachments (including subungal).
- Perform avulsion of the nail by grasping the sectioned nail with a haemostat or locking forceps and using a gentle distraction technique to rotate it towards the midline of the nail plate and ease the nail free of the nail bed (Figure 2C, D).
- Apply liquified phenol BP directly to the site of the germinal nail matrix using small cotton wool applicator tips (Figure 2E). Application of phenol should be carefully confined to the immediate surgical area, avoiding excess phenol contact with surrounding skin as this may result in unnecessary tissue injury. It is important to ensure that the nail sulcus and matrix area are dried immediately before applying phenol as the chemical is quickly neutralised by body fluid.
- Flush the site using alcohol and chlorhexidine solution (Figure 2F).
- Remove the tourniquet and use local pressure to control any bleeding, which is usually minimal or absent.
- Dress the toe with povidone-iodine ointment (eg Betadine), antiseptic gauze (eg Bactigras) and crepe bandage.
Note: When a single irrigation step is performed after phenolisation, alcohol plus chlorhexidine is more effective than alcohol alone for removing residual phenol. When multiple steps are performed, the two solutions are equally effective.
Postoperatively, advise the patient of the following:
- Postoperative analgesics are rarely required.
- Keep the toe dry overnight.
- Monitor for signs of increasing pain/discomfort (infection).
- Return in three days for a check and redress.
- After the redressing at three days, clean the site daily after showering using salt water and redress with Betadine ointment and a simple toe dressing until fully healed (2–3 weeks).
Postoperative treatments such as antibiotics or manuka honey; povidone-iodine with paraffin; hydrogel with paraffin; or paraffin gauze have not been shown to reduce the risk of postoperative infection or postoperative pain, or to improve healing time.
The wound should be reviewed at one week after surgery to evaluate healing, at which time the wound should be debrided of any material inhibiting free drainage of the healing tissue.
Alternative techniques to partial nail avulsion and chemical matricectomy include:
- radical excision of the nail fold (Vandenbos procedure)
- rotational flap technique of the nail fold
- wedge excision, wedge segmental excision, or wedge resection (Winograd procedure)
- combined with chemical matricectomy (phenol or sodium hydroxide)
- total nail avulsion
- combined with total (chemical or surgical) matricectomy (Zadik procedure)
- partial nail avulsion (Ross procedure)
- combined with surgical (partial) matricectomy
- combined with physical (electrofulguration) matricectomy (electrofulguration is a method of electrosurgery used to produce superficial desiccation of tissue).
Evidence for these procedures has not been reviewed.