Ingrown Toe Nail
Nailed it – should I have nail surgery?
No I’m not asking you to watch my youngest daughter’s favourite US TV show also called “Nailed it” – where wannabe cake creators aim for their moment of glory. Instead I’d like you to take a look at your own toenails and more importantly ask yourself do they cause you repeated problems.
This month we are looking at Nail Surgery
Some of you might be reading this and thinking “well that’s not for me I’m fine” but I would say to you that the majority of the nail problems we see were once problem free. How sure are you that you’re not on the way to a problem later in life
In nearly all cases nail complications happen with the passage of time otherwise called age. It might be from an infection or from trauma. Perhaps a one-off acute event such as dropping something on your foot or wearing unsuitable footwear whilst on a walking holiday.
Sometimes the problem is initiated by cutting your nail badly and either leaving a sharp corner to the nail or damaging the flesh down the side (the sulcus) of the nail.
Gradual trauma is also a very common cause such as a new pair of shoes not fitting properly and pressing on the area or incessant trauma from the way you walk and the forces going through the foot causing the nail to change shape or thicken over the years.
What is nail surgery?
Nail surgery is the name given to a procedure (normally done with the toe having been numbed with local anaesthetic.) whereby the toenail or a portion of it is removed and either allowed to regrow or prevented from regrowing by killing the “root” of the nail.
The aim of it is to create a permanent solution to the person’s nail problem which in most cases prevents reoccurrence.
But what if I have Diabetes – can I have Surgery ?
There is no definitive answer to this, and each person’s case should be assessed individually. Generally speaking, the risks of operating or not should be weighed up and your Podiatrist will probably want to liaise with your consultant or Gp. If you have badly controlled diabetes, then it is always important for you to have good blood sugar control in the weeks running up to any proposed surgery. Obviously, prevention is always best so do all you can to prevent issues with your nails by wearing correct sized appropriate shoes.
Sometimes elective surgery may be considered in the hope that future problems that might come later in life can be prevented.
In recent years I have been repeatedly dealing with my now 22 year old daughter’s involuted nails which curl around at the sides. This is a very common complaint and can lead to repeat episodes of infection. As she has Type 1 diabetes any infection and especially on the feet is best avoided.
During first Lockdown she managed her blood glucose better and we discussed operating to prevent future infections. She was of course most concerned about what they would end up looking like.
I did the operation doing partial nail avulsions with phenolisation to both sides of both big toes. She now has totally healed slightly narrower nails which she is very pleased with.
It is a fine line taking enough away to prevent future problems whilst leaving it looking good and where cosmetic appearance isn’t too important to a person I would normally advise taking a slightly larger section away.
If you would like my opinion on your suitability then please do contact me sending a photo if you like to CONTACT@CIRCLEPODIATRY.CO.UK
Why might you consider Surgery?
Usually, people might consider nail surgery if advised by their Podiatrist and this is normally when other conservative approaches have not been successful. Please see the photos In Figure 1 for some of the types of problems that people present with. I picked some pretty bad looking cases which for most would have been quite painful and I doubt very much if you kick off your shoes and socks now that you would see the likes of these images. However, feet are low on most people’s radar, are often neglected and it is not uncommon for someone to walk or should I say hobble into our clinic and present us with something red, hot and angry when a week or month ago it was only causing minimal discomfort.
My first encouragement to you is to go and get seen as early as you notice a problem. Murphy’s law otherwise known as Sod’s law dictates that your minor problem will be bound to flare up when you least want it to.( half way into a marathon, the week running up to your wedding or perhaps whilst on that holiday of a lifetime.)
When considering treatment for nail problems the saying “a stitch in time save nine” really comes into its own. So, if you have any of the problems in the photos or just occasional twinges of discomfort or even changes in appearance of the nail or surrounding skin then get an early diagnosis from a Podiatrist.
As you read on and I explain more about nail surgery I want to stress not to be frightened because most of the time (in my experience I estimate 95% of the time ) on a first visit we can relieve the problem with certain techniques that cause minimal pain avoiding surgery
It makes my day when I hear people say as they pay the receptionist that they can’t believe it was such a simple procedure and that it feels so much better now.
But in some cases it has been left so long or has been a repeated problem on so many occasions that that we really do have to encourage them to book in for nail surgery.
Do I need Antibiotics?
Some Doctors are very aware that in most cases antibiotics are not needed and a quick referral to a Podiatrist is the correct course of action. However, I still do get people coming with obvious ingrown nails where they are on their 3rd or 4th course of antibiotics. I proceed to remove the offending section of nail often without the need for local anaesthetic and it settles down quickly. Sometimes this is all that is needed for a permanent solution but there are of course some that might require either ongoing conservative treatments or surgical intervention. It also goes without saying that there are some occasions when antibiotics might be needed.
Let’s assume you have a problem requiring nail surgery and turn up at my practice.
What actually happens? – Getting ready
I can only speak for my practice of course but it should reflect what you can expect to experience with your Podiatrist
Firstly, I would talk with the person and get a thorough history of the problem and learn about any medical conditions that could affect their suitability for the procedure. For any patient whatever they come for we would have initially done a foot health check in which we would have checked their vascular status and sensory nerve function.
The information gathered so far will then form a basis as to whether to offer surgery as a treatment option. I would then discuss with the patient what their particular procedure will involve both at the time of surgery and the aftercare required both at the clinic and by themselves.
So let us assume you have a nail like one of the toes in the pictures in
You will arrive for your appointment having read the preoperative advice which outlines things such as not expecting to drive home after the operation (not a good idea with a numb toe), not seeing the dentist on the same day (the body can only handle a limited amount of LA.)
You are advised to bring a pair of open sandals or flipflops with you as the dressing will be very bulky and we don’t want a wounded toe squashed into a tight shoe. Also we encourage you to bring some of your favourite music to listen to (as long as it doesn’t make you tap tour feet to the beat). Another tip is to not drink alcohol in the 24 hours prior the surgery as it may affect the effectiveness of the LA.
Having answered any of your concerns I will once again just go over the specific procedure and any associated risks or potential negative outcomes with you before we proceed.
I classify the types of operation into 3 different types of procedure.
- One side of the nail being operated on
- Both sides of the nail being operated on
- Having the whole nail removed
These can each be further split into 2. One where we leave the root intact to regrow and one where we kill the root to leave you with either no nail or a narrower nail
I won’t go into the actual procedure other than to say that the part of the nail (or whole nail) is detached from the nail bed and then either the whole nail is removed or a vertical cut is made up the length of the nail at the point already discussed with you and that part of the nail is then removed.
The nail grows from cells right at the base of the nail under the flesh there (proximal nail fold) and so we have to make sure the nail is cut right back before removing that portion . The skin itself is not normally cut although if there are areas of hypergranulation tissue then this vascular mass may well be trimmed back.
The size of the hidden portion of nail removed from involuted nails can be surprisingly large as shown in the picture.
What is the expected outcome ?
Obviously as the LA wears off the toe will become sore but that can usually be controlled by your normal pain killer.
You will normally be asked to come back within a couple of days for your first dressing where usually we can send you out with a smaller dressing. We do still normally advise wearing an open sandal or very spacious trainer or possibly, an old pair with the toe box cut out.
Dependant on the individual procedure it will be decided when you should come back next and whether you are ready to redress it yourself – instructions of how to do this is provided and explained to you in clinic.
Longer term the outcome will depend to a degree on which procedure was carried out and its aftercare.
With any surgery there is always a risk of infection and the feet of course aren’t easy to keep in a sterile or at least clean environment, so it is really important to follow closely all the aftercare guidance given by your Podiatrist.
Want to know more ?
This advice is for guidance only- each person’s situation and condition is unique and so I would encourage you to contact our clinic for an initial assessment and discussion.
Why not pop along and get your feet checked. If you’re in London or Surrey then please do come along for an initial consultation at Circle Podiatry or go to the website www.circlepodiatry.co.uk