Did you know that podiatrists can perform minor surgery to remove all or part of a toe nail? We’d usually do this when the nail is painful, affecting your mobility/exercise or when infection is present. A painful toe nail can occur for a number of reasons, all of the examples below might cause pain and/or inflammation, they could also increase the risk of infection if the skin is damaged.
Examples of common toe nail conditions:
Ingrown toe nail: The nail breaks the surrounding skin causing inflammation and/or infection
Involuted toe nails: The nail is curved, putting pressure on the skin/flesh but not piercing the skin
Thickened nails: Often caused by trauma or fungal infection of the nail. The nail is thicker than normal and constantly rubs on the shoe
How can we fix it?
Firstly it is important to see your podiatrist. There are (usually) 10 nails for us to look at on every pair of feet we see, which means most podiatrists have seen a lot of nails, and we’re very good at helping out with them. Sometimes professional nail care and the right advice is enough. Often your podiatrist can cut the nail back, clean it up and check that your footwear isn’t the cause. If this doesn’t work then nail surgery should be considered (providing your medical history makes it safe to do so).
There are two common minor surgical procedures that can help the above complaints; every person is different so the type of procedure will differ depending on your toe nail, which toe is the problem, your medical history and your expectations. Both procedures will involve a local anaesthetic (to numb pain) into the painful toe. Read more about the different procedures below.
1. Partial Nail Avulsion (PNA)
One or both edges of the nail are removed and the root of the nail (matrix) is cauterised using a chemical called phenol. This prevents these painful sections of nail from re-growing. Otherwise, predictably the nail will re-grow in the same way and produce the same problem. The healing time for this procedure is 4-6 weeks (on average).
2. Total Nail Avulsion (TNA)
The entire nail or part of the nail is removed and the root of the nail (matrix) is cauterised using a chemical called phenol. This prevents the nail from re-growing. Otherwise, predictably the nail will re-grow in same way and produce the same problem. The healing time for this procedure is 6-8 weeks (on average).
Which one to choose?
It really depends on the toe/toe nail, and your expectations. If you have a nail that’s beyond saving i.e. it’s thick and unsightly then it’s usually best to have this removed completely (TNA). If you have an otherwise healthy nail that is ingrown then (generally) it’s preferable to save what you can and only remove a section. This way your toe looks pretty much the same as before. The other consideration is the size of the nail. A partial nail avulsion is going to be almost impossible on a 5th (smallest) toe nail, as there wouldn’t be much nail to save after removing a section.
What are the intended benefits?
Correction or resolution of a toe nail related problem
Reduction in long-term pain
Reduction in re-current infections
Improved function (as pain will be improved)
What are the possible complications of nail surgery?
Reaction to local anaesthesia (rare)
Post-operative infection
Re-growth of nail (5% risk)
Loss of sensation locally (temporary)
Phenol burn
Temporary pain
Altered cosmetic appearance
Bruising
Delayed healing
Complications due to poor compliance/aftercare
Temporary loss of nail plate (if having a partial nail avulsion)
Other things to consider
Here's some details of what to expect in the days leading up to, on the day and after the procedure. All of this is relevant to ensure we/you plan appropriately and get that toe healed as quickly as possible.
Preparing for nail surgery
It’s best to avoid alcohol for 24 hours prior to surgery.
Continue to take any medication as normal unless advised otherwise.
Be sure to bring suitable footwear that will fit over a bulky dressing i.e. Flip-flops or open toe sandals.
It’s best to arrange transport home after surgery - you should not walk home or travel by public transport to avoid injury. We recommend arranging a lift home or taking a taxi.
You will need to avoid further local anaesthetic for 24 hours before and after your surgery.
Your employer or school should be informed of the procedure, as you will need to rest the affected foot for at least 24 hours after surgery.
It would be sensible to avoid planning a holiday for up to eight weeks after your surgery, as you may be required to attend clinic appointments during this time.
If you’re under the age of 16 will need to attend with a parent/legal guardian.
If you have diabetes, and have been asked to have a blood test, you MUST go and see you GP, as we will require a copy of your most recent blood glucose levels. (This is not the same as home meter readings).
On the day of surgery
Please take a bath or shower and remove all traces of nail varnish
Eat a normal light meal before the surgery
If you use a GTN spray, inhalers or an Epi-Pen, you must bring these with you on the day of the surgery.
You will be asked for written consent prior to the surgery. Patients under the age of 16 must be accompanied by a parent/legal guardian with you, who can provide the written consent on your behalf.
You will be permitted to bring one adult into the treatment room with you, if you wish. Please note that accompanying children are not allowed into the treatment room.
Bring suitable footwear that will fit over a bulky dressing. i.e. Flip-flops or open toe sandals.
You must not drive for 24 hours after you have had the surgery (Road Traffic Act).
Go straight home after surgery and sit with your foot elevated. We recommend that you rest the affected foot for at least 24 hours.
On the day of surgery your toe will be dressed with a large bandage that you will need to keep on and dry until you return approximately 4-7 days later
You must keep the large bandage dry and in place until your redressing appointment. This is usually within 4-7 days and the appointment will be issued on the day of surgery.
After nail surgery
Your toe(s) may remain numb for 2-3 hours.
You should rest the affected foot for at least 24 hours after surgery.
When the anaesthetic wears off, you may experience some discomfort. You can take over the counter painkillers such as paracetamol or ibuprofen to reduce this.
You must not have any local anaesthetic for 24 hours after your surgery.
Continue to keep the dressing dry and in place. It is normal for some blood/fluid to appear through the dressing. If needed, you can apply some additional gauze on top of the existing dressing. (A pack of gauze will be provided after your surgery.)
If you experience a lot of bleeding which cannot be stopped by raising your foot, you should seek medical advice.
If the dressing comes loose, please apply more tape to secure it. (Some tape will be provided after your surgery). We recommend wearing a loose fitting sock over the affected foot at bedtime to prevent the dressing coming off.
Do not drink alcohol for 24 hours after surgery.
You may need some time off work or school. It is important to avoid any undue pressure or injury to the toe
To help the wound heal and to reduce the risk of infection, it is important to avoid all high impact sports/ gym activities and swimming.
It is very important that you attend your redressing appointment. This will be issued to you after the surgery.
Summary
Overall nail surgery is an effective and safe procedure, if you've ever had an ingrown toe nail you'll know how painful they can be and this offers a permanent solution. It isn't however something to jump at if you haven't tried some good 'traditional' podiatry first. Often painful nails can be solved in one appointment so consider booking with your podiatrist for an assessment and definitely try the more conservative approach first when offered. If that doesn't work though, read through the above carefully and ask about the surgical options.
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