THE SURGICAL TREATMENT OF INGROWING TOENAILS

J. D. GREIG, J. H. ANDERSON, A. J. IRELAND, J. R. ANDERSON

From Hairmyres Hospital, East Kilbride and the Royal Infirmary, Glasgow

Two prospective studies of ingrowing toenail management were conducted. In the first, 163 patients (204
ingrowing nail edges) who had not had previous surgery were randomised and treated by total nail avulsion,
nail edge excision, or nail edge excision with phenolisation of the germinal matrix; recurrence rates one year
postoperatively were 73%, 73% and 9% respectively.
In the second study, 63 ingrowing nail edges which had recurred after previous operations underwent
nail edge excision and phenolisation. There was a 5% recurrence rate and a 5% incidence of dystrophy of the
nail one year after operation.

The results of ingrowing toenail treatment are extremely Operative techniques. The distal circulation was checked
variable. The review by Sykes in 1986 of 32 published pre- and postoperatively. The toe was anaesthetised by a
studies quoted recurrence rates which ranged from 0% to digital block with 5 to 10 ml of 0.5% Marcaine.
86%. Most of these studies were retrospective, without Bacteriological swabs were taken pre-operatively from
independent assessment of the results, and the popula- discharging nail beds and excess granulation tissue was
tions studied were inadequately defined. There have been curetted. The following operations were carried out by
few reports of the management of recurrent ingrowing one or other of three surgical trainees.
toenail. Group 1) Total avulsion : the whole nail was removed by
We have assessed three forms of surgical treatment avulsion with a pair of artery forceps.
in patients who had not previously had surgery and also Group 2) Nail edge excision artery . forceps were intro-
reviewed the effectiveness of nail edge excision and duced deep to the nail edge, separating it from the matrix.
germinal matrix phenolisation for those which recurred At least 0.5 cm of the nail was then removed by cutting
after a previous operation. down its longitudinal axis.
Group 3) Nailedge excision andphenolisation a tourniquet
.

was applied and nail edge excision was performed as for

PATIENTS AND METHODS
group 2. The toe was compressed and the gutter dried to
Study! control venous ooze. Paraffinjelly was applied to the skin
We included all patients with ingrowing toenails in around the nail to protect it. Liquified phenol (80%) was
whom conservative treatment had failed, and who were applied in drops from a pipette onto the nail bed and
referred to Hairmyres Hospital and Glasgow Royal along the gutter. It was left for four minutes and then
Infirmary between August 1986 and July 1987. Recurrent removed with swabs. Any remaining phenol was neutral-
ingrowing or onychogryphotic toenails were excluded. ised with methylated spirit.
Patients were randomised to receive one of three Study 2
treatments : group 1) total nail avulsion ; group 2) excision Consecutive patients who presented over the same period
of the ingrowing nail edge ; group 3) nail edge excision with a recurrent ingrowing toenail after one previous
and germinal matrix phenolisation. surgical operation were entered in this study. They were
treated by nail edge excision and phenolisation as
J. D. Greig, FRCS, Registrar
described above.
University Department of Surgery, Royal Infirmary of Edinburgh, 1 In both studies, dressings were changed after three
Laurieston Place, Edinburgh EH3 9YW, Scotland.
days and subsequent postoperative care was provided by
J. H. Anderson, FRCS, Registrar
A. J. Ireland, FRCS, Registrar
the general practitioner. Patients were assessed by the
J. R. Anderson, FRCS, Consultant surgeon two weeks later when bacteriological cultures
University Department ofSurgery, Royal Infirmary, Alexandra Parade,
were taken if appropriate. Infection was defined as
Glasgow G3l 2ER, Scotland.
Correspondence should be sent to Mr J. R. Anderson.
growth of a pathogenic organism from the wound;
antibiotic treatment was guided by reported sensitivities.
1991 British Editorial Society ofBone and Joint Surgery
0301-620X/91/1051 $2.00 Patients were advised on wound care, footwear and
JBoneJointSurg[Br] 1991; 73-B:l3l-3. hygiene.

VOL. 73-B, No. I, JANUARY 1991 131

I 32 J. D. GREIG, J. H. ANDERSON, A. J. IRELAND, J. R. ANDERSON

The patients were reviewed one year later by an Table I. Clinical data of the three treatment
groups in first study (163 patients)
independent assessor who did not know which procedure
had been performed. Recurrence was defined as evidence Sex Mean age
of ingrowth of the nail edge or spicu!e formation; the Procedure in years
(group) Male Female (range)
presence or absence of symptoms was noted.
Total 41 18 26.3
The statistical methods used were the chi-squared
avulsion(1) (12to69)
and the Bonferroni comparison tests.
Nailedge 33 14 28.1
excision (2) (13 to 77)

RESULTS Nail edge

excision and 39 18 28.3
Study 1 phenolisation (2) (12 to 70)
There were 168 patients in this study. Five were lost to
follow-up, leaving 163 patients in whom the results of
surgery were assessed. The sex distribution and mean
ages of the three groups were similar (Table I). Table II. Incidence of pre- and postoperative
infection in 163 patients treated for ingrowing toe
The incidence of pre- and postoperative infection is nails by number and percentage of group
shown in Table II. In group 2, the one patient who
Infection
developed a postoperative infection had an infected
Procedure
toenail pre-operatively. Patients undergoing nail edge (group) Pre-operative Post-operative
excision and phenolisation had more wound infections Total 13 22 0 0
(seven postoperatively in whom only two had pre- avulsion (1)
n = 59
operative infection) than did those in the other two
groups. All infections settled rapidly on appropriate Nailedge 18 38 1 2
excision (2)
antibiotic therapy. n =47
A total of 204 ingrowing nail edges were treated in
Nailedge 15 26 7 12
the 1 63 patients. The incidence of recurrence was 73%, excision and
73% and 9% respectively for the three groups (Table. III). phenolisation (3)
n = 57
The results were not surgeon-dependent. All recurrences

Table HI. Recurrence rates after three operations for ingrowing toenails (204 procedures)

Number of Rec urrences Sym ptomatic Patient Time to

Procedure ingrowing satisfaction recurrence (months)
(group) nail edges N % N % (%) mean and range

Total 81 59 73 46 57 46 4.4
avulsion(l) (2to 11)

Nailedge 56 41 73 36 64 49 5.4
excision (2) (2 to 12)

Nailedge 67 6 9 6 9 84 4.2
excision and (2 to 10)
phenolisation (3)

in group 3 were symptomatic but not all recurrences in female, with an average age of 22 years (range 1 1 to 63).
groups 1 and 2 produced symptoms. Using the Bonferroni They had 64 recurrent ingrowing toenail edges. Previous
comparison test, there was no significant difference in treatments included : total nail avulsion alone (51); nail
recurrence rates between groups 1 and 2. However, in edge excision with germinal matrix phenolisation (1 1);
the other two comparisons the results were significantly and total nail avulsion with germinal matrix phenolisa-
different: between groups 1 and 3 (p < 0.01) and groups tion (2). At the time of the revision operation 17 edges
2and3(p < 0.01). (27%) were infected.
When asked about their treatment, 27 of 59 (46%) Two weeks postoperatively, four patients had nail
patients in group 1 said that they were satisfied, 23 of bed infections. Three were cured with oral antibiotics
47 (49%) in group 2 and 48 of 57 (84%) in group 3 but one required nail avulsion to eradicate the infection.
(Table III). Two of the infected nails had been infected pre-
Study 2 operatively.
There were 42 patients in this study, 29 male and 13 One year later 63 edges were assessed (one patient

THE JOURNAL OF BONE AND JOINT SURGERY

 THE SURGICAL TREATMENT OF INGROWING TOENAILS 133

was lost to follow-up). There were three recurrent Murray and Bedi (1975) demonstrated that after a second
ingrowing nail edges; all were painful and they had toenail avulsion there was an even higher recurrence rate
recurred three to four months postoperatively. Two (86%). Radical ablative procedures are often disfiguring.
patients (three edges) developed painful dystrophy of the Previous studies of nail edge excision and pheno!isation
nail at the site of phenolisation, eight and 12 months have either failed to state how many patients had
postoperatively. undergone previous operations or failed to exclude them
Of the 42 patients, 37 were satisfied with their from consideration (Cameron 1981 ; Robb and Murray
treatment. The five patients who developed ingrowing or 1982 ; Varma et a! 1983). The importance of adequate
dystrophic nails were dissatisfied. Out of 63 nail edges, primary treatment is emphasised by the high failure rate
57 (90%) were asymptomatic one year after surgery. (47%) reported after total nail bed excision and phenol-
isation for multiple recurrences (Anderson et a! 1990).
In group 2 of our study 1 34% of the recurrences
,
DISCUSSION
happened six months or more after the operation, and in
Sykes 1986 survey of orthopaedic and general surgeons study 2, symptomatic dystrophic nails developed after
found that more than half advocated procedures which eight and 12 months. Follow-up in this type of study
did not ablate the nail bed. The high incidence of should therefore be for at least one year.
recurrence (73%) for simple avulsion in the present study We suggest that nail edge excision with phenolisa-
is similar to that reported by him. Nail edge excision tion is a logical and effective treatment for ingrowing
alone has been advocated because it can be performed toenails in which conservative treatment has failed and
without local anaesthesia and was said by Cameron for those in which recurrence has followed a previous
(1981) to have a lower recurrence rate (39%). However, surgical procedure.
we found it no better than nail avulsion. We recommend
that neither simple avulsion nor nail edge excision alone The authors wish to thank the medical and nursing staff of Hairmyres
should be practised unless phenolisation is contra- Hospital and Glasgow Royal Infirmary for their co-operation in
supporting this study and to Miss E. Anderson for statistical analysis.
indicated. No benefits in any form have been received or will be received
The reported recurrence rates following surgical from a commercial party related directly or indirectly to the subject of
this article.
ablation of the nail bed have varied widely : for Zadiks
operation, 1% to 50% (Fowler 1958 ; Townsend and Scott
1966 ; Andrew and Wallace 1979); for segmental excision
16% to 30%(Wal!ace, Milne and Andrew 1979 ; Morkane,
Robertson and Inglis 1984). These figures should be
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