Local anesthesia, usually using regional ring blockade, or general anesthesia may be used. The aim is to excise the lateral edge of the ingrowing toenail including the underlying nail bed by removing a tissue wedge. The excision must include the germinal matrix proximal to the nail fold.

The nail excessively folds around the lateral edge of the nail bed and ingrows into the lateral pulp of the toe. The nail bed extends proximally below the skin at the nail fold and excision must include all of the nail, nail bed and the germinal matrix more proximal still to the nail to prevent regrowth of the nail. The excised tissue should extend almost to the distal interphalangeal metatarsal joint, but not breach the joint capsule. The germinal matrix is often adherent to the distal phalanx and requires curettage to adequately remove the germinal tissue from which the nail can regrow. The length of the distal phalanx itself and the proximity of the germinal matrix to the distal interphalangeal joint can vary between individuals. Note that anatomically, the hallux has only one interphalangeal joint (Table 5.1).

Surgery for excision of ingrowing toenail is usually very straightforward and complications are few and minor; however, serious complications can be debilitating and necessitate further surgery. Patients should be aware of the small chance of these serious complications. The decision for surgery must be balanced by the non-operative alternative of antibiotic therapy and conservative management. Recurrent infection may be debilitating and in some patients, such as diabetics or immunosuppressed individuals can lead to gait disturbances, lower limb cellulitis, systemic infections, or very rarely osteomyelitis and toe necrosis. The ingrowing toenail may be subject to recurrent infections and it is prudent to avoid surgery in the acute infected state. Surgery should be postponed during active infection and treated with antibiotics until further clinical review prior to undertaking surgery. Recurrence of the ingrowing toenail can occur at the same site or involve the other side of the toenail. Should the toenail ingrown on both borders, Zadik’s procedure should be considered because bilateral wedge resections may lead to a narrow nail with obvious cosmetic issues. Bilateral ingrowing toenails are most commonly seen in teenage boys.

Bleeding may be severe and rarely leads to the need for surgical drainage. Infection especially in diabetics or immunosuppressed individuals may be systemic and occasionally even life-threatening. Bone or joint infections are very rare, but are potentially very serious complications that are chronic and debilitating, necessitating prolonged antibiotic therapy and sometimes further surgery. Recurrence of the ingrowing toenail is not uncommon depending on the technique. The nail remnant is often quite troublesome for the patient as it can protrude from the nail bed at an odd angle, catching on socks. This will often necessitate revision surgery. Numbness is rarely an issue. Gait difficulties are a consequence of infection or joint stiffness/fusion, but may arise without surgery. Cosmesis can be poor; however, the preoperative ingrowing toenail can also be unsightly in appearance. It is useful to advise the patient about the potential for deformity of the remaining nail.

Local anesthesia, usually using regional ring blockade or general anesthesia may be used. The aim is to excise the entire nail and proximal part of the nail bed including the ingrowing toenail to prevent regrowth and recurrence. The excision must include the germinal matrix proximal to the nail fold.

The nail folds around the lateral edge of the nail bed and ingrows into the lateral pulp of the toe. The nail bed extends below the skin proximally at the nail fold and excision must include all of the nail, proximal nail bed and the germinal matrix more proximal still to the nail to prevent regrowth of the nail. The excised tissue should extend almost to the distal metatarsal joint, but not breach the joint capsule. The germinal matrix is often adherent to the distal phalanx and requires curettage to adequately remove the germinal tissue from which the nail can regrow. The length of the distal phalanx itself and the proximity of the germinal matrix to the distal interphalangeal joint varies between individuals (Table 5.2).