Treating onychocryptosis (ingrown toenail) with partial nail avulsion surgery

What is onychocryptosis?

Onychocryptosis is a condition in which the toenail damages the lateral nail fold, this can cause pain, inflammation and can often lead to infection. Partial nail avulsion surgery is indicated when onychocryptosis results in infection, granulation, or hypertrophy of the lateral nail fold where conservative management is unlikely to resolve the condition (Karaca & Dereli, 2012). However, this procedure is contraindicated with allergies to local anesthesia, adverse drug reactions, and certain medical conditions (Scott, 2004). The use of surgical management is also likely to be deferred in nursing and breastfeeding women due to the use of phenol (Zhong et al, 2019). There are many risks that may be a result of partial nail avulsion surgery and needs to be considered by the clinician and patient before a patient gives consent to proceed with surgery. Medico-legal management is also important when considering partial nail avulsion surgery and appropriate history taking, medical records, informed consent, and infection control procedures need to be in place before proceeding (Richert et al., 2011). It is important for a podiatrist to consider these issues before proceeding with surgical management of onychocryptosis of the hallux.

Why is it important to treat onychocryptosis?

Onychocryptosis of the hallux, commonly known as an ingrown toenail, “is a pathologic condition of the nail apparatus in which the toenail damages the nail fold. It is a common condition provoking pain, inflammation, and functional limitation” (Martínez-Nova, Sánchez-Rodríguez & Alonso-Peña, 2007). This condition is often resolved with a surgical procedure conducted by podiatrists. The importance of this surgery is that cellulitis, ulceration, and necrosis may lead to amputation in patients with diabetes or arterial disease and those with no co-morbidities can resolve the pain, inflammation, and infection due to an ingrown toenail (Bailey Jr & Shah, 2009). The surgical procedure commonly used is a partial nail avulsion with phenolisation. This procedure involves preparing the nail with alcohol wipes, injecting a local anesthetic to perform a digital ring block, placing a digit tourniquet, removing the offending nail with a Beaver blade and freeing the nail plate of the nail bed, applying phenol directly to the site of the nail matrix, removing the tourniquet and dressing the toe (RACGP, 2016). There are indications and contraindications for partial nail avulsion surgery. There are also risks of proceeding with surgical management which will be explored. Medico-legal factors also need to be considered when performing partial nail avulsion surgery.

When is it indicated to surgically manage an ingrown toenail?

Surgical management for onychocryptosis is suitable for a patient who presents with a condition that cannot be managed conservatively or is likely to not respond to conservative treatment. This is a long-term solution for patients with recurring ingrown toenails (Pandhi & Verma, 2012). Ingrown toenails can be classified into three stages as by Huang and his team in 2015. Stage I is mild erythema, tenderness, and swelling of the lateral nail fold. Stage I recommended treatment is conservative management such as soaking the foot in the water, topical and oral antibiotics, and correct nail trimming. Stage II is increasing symptoms and infection which can be treated with either conservative or surgical treatment. Stage III has amplified symptoms with granulation tissue, lateral fold hypertrophy, and further infection, this stage requires surgical management (Huang et al., 2015). Podiatrists need to consider if conservative management can resolve the onychocryptosis or whether surgical management in the form of a partial nail avulsion is appropriate.

When is surgical management contraindicated for onychocryptosis?

There are contraindications for surgical management of onychocryptosis of the hallux, this is because the treatment is a mildly invasive procedure that involves the use of local anesthesia and phenol. Contraindications for the use of anesthesia may be due to allergies, the presence of diseases such as cardiovascular disease and asthma. There are also contraindications against the use of local anesthesia with certain medications due to drug interactions such as with Lidocaine and Lorazepam which can increase nervous system side effects such as dizziness and drowsiness (Mayeaux, Carter, & Murphy, 2019). Patients who are pregnant and breastfeeding are also recommended to defer nail surgery where possible due phenolisation (Zhong et al, 2019). It is important to consider these contraindications before proceeding with partial nail avulsion surgery for onychocryptosis.

What are the risks of surgical management for onychocryptosis?

There are risks associated with surgical management of onchocryptosis of the hallux. Risks include delayed healing, commonly caused by phenol burns (Dabakaroff et al., 2018) (Sugden, Levy & Rao, 2001). A vasovagal reaction is another common risk, commonly associated with the anxiety of local anesthesia, needles, and other sharps tools used during a partial nail avulsion (Richert & Dahdah, 2008). Symptomatic and asymptomatic regrowth of the nail spicule may also occur due to the potential inefficacy of the procedure. Infection can also occur as a result of the invasive nature of a partial nail avulsion and microbiomes on the surface of the hallux (Yang & Li, 2002). Bleeding can also commonly occur as the procedure involves the use of sharps equipment. Respiratory and cardiac issues are also a side effect of a partial nail avulsion. Rare complications also include an adverse reaction to local anesthetics such as an allergic reaction and complete lifting of the nail due to irritation to the nail bed. Another risk is ischemia if the tourniquet is not removed after the procedure. Inclusion cysts, pseudonails, and venous thromboembolism are also rare risks for a partial nail avulsion (Park & Singh, 2012). It is vital that podiatrists assess these risks and minimize risk in practice to provide the best outcome for patients with onychocryptosis.

What are the medico-legal implications of podiatric surgical procedures?

There are medico-legal implications of podiatric surgical procedures for onychocryptosis of the hallux. Note-taking, obtaining a medical history, and recording are essential to ensure that there is a record of appointments and what happened during consults so that this can be used in legal proceedings if needed to protect practitioners (Brenneman, 2001). Communication with patients is also important to explain the benefits and risks of a procedure and how it will be conducted so that patients have reasonable expectations. Informed consent, in written form, is also essential, particularly when doing an invasive procedure and surgery (ORR II & Curtis, 2005). It is also important to check those correct calculations are recorded for doses of anesthetic and that the patient is not allergic or has any other contraindications for anesthesia or phenol use (Maher et al., 2008). It is also important to ensure that infection control is used as part of surgical management of onychocryptosis of the hallux. Infection control requires a clean environment with sterile equipment and appropriate personal protective equipment for barrier protection (Humphreys et al., 2014). Therefore it is important to implement effective history taking, patient communication, informed consent, checks on doses and contraindications, and implement infection control in practice when performing a partial nail avulsion.

Take-away

Onychocryptosis of the hallux is a complex condition that may require surgical intervention such as partial nail avulsion. This procedure is indicated for patients with infection of the lateral nail fold and when granulation tissue or hypertrophy is present. Contraindications for partial nail avulsion include allergies, drug reactions, and medical conditions with the use of local anesthetic. The use of phenol is also contraindicated in pregnancy/breastfeeding with phenol. Risks of surgical management include; delayed healing, phenol burns, vasovagal reaction, nail regrowth, infection, bleeding, respiratory problems, cardiac issues, allergies, lifting of the nail, ischemia, inclusion cysts, pseudonails, and venous thromboembolism. Medico-legal management in the surgical management of onchocryptosis involves record-keeping, patient communication, informed consent, and adherence to infection control procedures to reduce the risk of infection. Therefore, there are many factors that impact whether a partial nail avulsion is appropriate for onchocryptosis of the hallux and how the procedure would be performed.

Book an appointment online with our expert podiatrists in Bondi Junction in Sydney to consider the most suitable options for ingrown toenails. We can also perform nail bracing as a conservative management option to improve the shape of nails.

We treat feet from all over Sydney, particularly the Eastern Suburbs. As podiatrists in Bondi Junction, we are happy to treat anyone that comes to our Sydney clinic. Our local area includes Bondi Junction, Bondi, Bondi Beach, North Bondi, Rose Bay, Tamarama, Coogee, Randwick, Bellevue Hill, Dover Heights, Vaucluse, and Edgecliff.

References

Bailey Jr, B. L., & Shah, V. (2009). Ingrown toenail (onychocryptosis). eMedRef (MU).

Brenneman, L. (2001). Guidelines for writing SOAP notes and history and physicals. Glen Gardner, NJ: NPCEU Inc, 26.

Dabakaroff, L., Mayorga, T., Singha, J., & Markinson, B. (2018). Surgical treatment of Onychocryptosis. In Scher and Daniel’s Nails (pp. 419-430). Springer, Cham.

Huang, J., Zhang, Y., Ma, X., Wang, X., Zhang, C., & Chen, L. (2015). Comparison of Wedge Resection (Winograd Procedure) and Wedge Resection Plus Complete Nail Plate Avulsion in the Treatment of Ingrown Toenails. The Journal Of Foot And Ankle Surgery, 54(3), 395-398. doi: 10.1053/j.jfas.2014.08.022

Humphreys, P. N., Davies, C. S., & Rout, S. (2014). An evaluation of the infection control potential of a UV clinical podiatry unit. Journal of foot and ankle research, 7(1), 17.

Karaca, N., & Dereli, T. (2012). Treatment of Ingrown Toenail With Proximolateral Matrix Partial Excision and Matrix Phenolization. The Annals Of Family Medicine, 10(6), 556-559. doi: 10.1370/afm.1406

Maher, A. J., Metcalfe, S. A., & Parr, S. (2008). Local anaesthetic toxicity. The Foot, 18(4), 192-197.

Martínez-Nova, A., Sánchez-Rodríguez, R., & Alonso-Peña, D. (2007). A New Onychocryptosis Classification and Treatment Plan. Journal Of The American Podiatric Medical Association, 97(5), 389-393. doi: 10.7547/0970389

Mayeaux Jr, E. J., Carter, C., & Murphy, T. E. (2019). Ingrown toenail management. American family physician, 100(3), 158-164.

ORR II, D. L., & Curtis, W. J. (2005). Obtaining written informed consent for the administration of local anesthetic in dentistry. The Journal of the American Dental Association, 136(11), 1568-1571.

Pandhi, D., & Verma, P. (2012). Nail avulsion: indications and methods (surgical nail avulsion). Indian Journal of Dermatology, Venereology, and Leprology, 78(3), 299.

Park, D. H., & Singh, D. (2012). The management of ingrowing toenails. Bmj, 344, e2089.

Richert, B., & Dahdah, M. (2008). Complications of nail surgery. Complications in dermatologic surgery. Philadelphia: Mosby, 137-58.

Richert, B., Haneke, E., & Di Chiacchio, N. (2011). Surgery of the nail bed. In Nail Surgery (pp. 67-96). CRC Press.

Royal Australian College of General Practictioners. (2016). Partial nail avulsion and chemical matricectomy: Ingrown toenails [Ebook]. Retrieved from https://www.racgp.org.au/getattachment/e2428ba7-3b87-4c1a-a27a-99a2488dbee6/Partial-nail-avulsion-and-matricectomy-for-ingrown.aspx

Scott, P. M. (2004). Partial and total toenail excision. JAAPA-Journal of the American Academy of Physicians Assistants, 17(1), 53-55.

Sugden, P., Levy, M., & Rao, G. (2001). Onychocryptosis — phenol burn fiasco. Burns, 27(3), 289-292. doi: 10.1016/s0305-4179(00)00115-7

Yang, K. C., & Li, Y. T. (2002). Treatment of recurrent ingrown great toenail associated with granulation tissue by partial nail avulsion followed by matricectomy with sharpulse carbon dioxide laser. Dermatologic surgery, 28(5), 419-421.

Zhong, Q., Peng, M., He, J., Yang, W., & Huang, F. (2019). Association of prenatal exposure to phenols and parabens with birth size: A systematic review and meta-analysis. Science of The Total Environment, 134720.