WHAT IS NAIL SURGERY?
Nail surgery is a common procedure carried out by a podiatrist to remove part, or all of a problem toenail. If the whole nail is removed it is called a Total Nail Avulsion, often abbreviated to TNA. If only part of the nail is removed, which is the most common operation, then it is termed a Partial Nail Avulsion (PNA). Problem nails include infected, ingrowing toenails or damaged, distorted thick nails that are causing pain and have not responded to conservative treatment. Phenol is applied to the underlying
nail matrix to help stop regrowth of the nail. This procedure is known as Phenol Matricectomy and has a success rate of around 95% in preventing re-growth.
WHAT ARE THE BENEFITS OF HAVING NAIL SURGERY?
Nail surgery is carried out to provide permanent pain relief and/or preventing recurrent infections in problem toes. Occasionally, it is carried out for cosmetic reasons.
WHAT HAPPENS AT THE ASSESSMENT APPOINTMENT?
It is usual for you to be assessed first, and an appointment made for surgery at a later date. During the assessment the podiatrist will explain the procedure and answer any questions you may have.
They will carry out a careful examination of your toe(s) and will also assess your general health to ensure you are suitable for surgery. If you are taking any medication, please inform the podiatrist. You will need to sign a consent form for the surgical procedure to go ahead; however, you can withdraw your consent at any time.
Please inform the podiatrist if –
· There is a possibility you may be pregnant
· You are taking Warfarin
· You have a blood disorder such as sickle cell anaemia or haemophilia
· You have a needle or blood phobia
If your doctor is prescribing you tablets, injections or other medication then they may, in consultation with the podiatrist, advise that you temporarily alter or suspend the medication – if you are on Warfarin, for example. Do not take any additional medication unless advised to do so and please bring your most recent prescription with you on the day of the surgery. If you suffer from asthma, breathlessness, epilepsy, or angina it is essential that you bring your medication with you.
WHAT WILL HAPPEN WHEN I HAVE NAIL SURGERY?
You will be fully awake during the procedure, but it is recommended you do not watch in case it makes you feel uncomfortable. A local anaesthetic is injected in the toe to stop you feeling any pain. A tight rubber band, called a tourniquet, is put around the toe to reduce bleeding. The nail, or piece of nail, is then removed.
A chemical called phenol is applied to the nail bed to stop the nail from growing back (however, in rare cases re-growth can occur). The tourniquet is removed and an antiseptic dressing is applied, along with another special dressing that will help stop any post-operative bleeding.
These dressings are then covered with sterile gauze which helps pad and protect the wound. You will be asked to return in a few days for the wound to be inspected and re-dressed. After that you’ll be given advice about how to look after your toe and to continue any re-dressings yourself.
WHAT DOES IT FEEL LIKE TO HAVE NAIL SURGERY?
There is some discomfort when injecting the anaesthetic, but this only lasts a couple of minutes. Once the toe has been anaesthetised (numbed), you will be able to move the toe but will not feel any pain.
The local anaesthetic usually wears off in 2-4 hours, so it is important to exercise caution during this period and avoid any unnecessary activity.
WHAT WILL MY TOE LOOK LIKE AFTER SURGERY?
The result of your surgery will depend on your particular toenail problem and the exact procedure used.
In the days following surgery it is usual for there to be a temporary discharge from the wound, and bruising around the injection sites.
Phenol may cause some inflammation at the base of the nail and the area can be a little red and tender for a few weeks. These should all settle in time. If you have a total nail avulsion with phenolisation your toe, after healing, will have skin covering where the nail once was. If you’ve had just a small section of nail removed then the result will be a narrower nail plate as the fold(s) of skin at the side(s) closes up.
WILL NAIL SURGERY AFFECT WORK OR SCHOOL?
If you have an active job, you may need to take a few days off work to rest the affected toe(s). We recommend that you wear open toe shoes until the first redressing appointment. Please be aware that these may not comply with any Health & Safety requirements at your place of employment so it may be wise to ask for time off or request a temporary change in role. For children we recommend they do not return to school until after the follow-up appointment when the toe is re-dressed (typically after about 3 days). If necessary the surgery can be arranged to avoid clashes with other commitments, for example, exam time or holidays.
IS THERE AN ALTERNATIVE TO NAIL SURGERY?
There may be instances when the patient’s general health indicates that surgery is not recommended. In these cases careful, regular nail cutting from a podiatrist may help, and they may apply padding to the inner edges of the nails to provide relief. Sometimes, just wearing footwear with adequate toe space may be sufficient in keeping the problem manageable. Your podiatrist will advise you of the options open to you. Rarely, a local anaesthetic cannot be used for a particular patient, in which case a referral can be arranged for the procedure to be carried out under general anaesthetic in a hospital setting.
WHAT ARE THE RISKS OF NOT HAVING THE PROCEDURE?
If the nail has caused a previous bacterial infection then it is likely to recur even with repeated courses of antibiotics. As a result, there is a chance you will suffer from repeated episodes of pain and discomfort.
WHAT ARE THE POSSIBLE COMPLICATIONS/RISKS IN HAVING SURGERY?
Like all medical procedures there are risks in undergoing nail surgery. These are rare, but can include:
· Bruising from the injection or tourniquet
· An allergic reaction to the local anaesthetic
· Pain (this will often subside within a few days)
· Periostitis – inflammation/infection of the outer covering of the bone
· Nail re-growth – it may also grow back deformed
· Persistent wound drainage
· Persistent numbness
· Long healing time of between 6-12 weeks
· Cosmetic changes – skin will eventually cover the removed nail.
WHERE IS NAIL SURGERY CARRIED OUT?
Nail Surgery is carried out in the clinical room of your selected clinic. Please ensure you arrive early for your appointment. If you are late there may insufficient time to carry out procedure and the appointment will have to be re-booked for a later date.
WHAT TO WEAR
Wear an open toe sandal or similar shoe on the day of your procedure. This will allow room for the large dressing that will be applied. Wear loose, comfortable clothing that can be rolled back to the knee.
Please remove all nail varnish from toenails before attending the clinic.
We would advise you not to use public transport or walk home after the procedure, as this may prolong any bleeding or increase the likelihood of accidental damage to the toe while it is still numb. Please arrange for someone to take you home in a car, or make arrangements for a taxi. Important note:
Driving when your toe is anaesthetised may make you unfit to drive and/or invalidate your insurance.
CAN I BRING SOMEONE?
You may bring a relative / friend / carer with you for support, but this is not essential unless you are under 16 years old. Anybody attending with the patient should be not be prone to fainting or feeling unwell at the sight of needles or blood – we would politely request that the person does not attend if this is a possibility. Accompanying persons may be asked to leave if the procedure is inhibited by their presence. We only allow for a maximum of one accompanying person, due to restricted clinic space.
HOW LONG WILL IT TAKE?
The time you need to allow will depend on the exact nature of the procedure you are undergoing and how quickly the local anaesthetic takes affect. Whilst the actual operation usually only takes around 20 minutes, please allow 1 hour for your appointment.
Your podiatrist will ask you to remain seated for a few minutes following the procedure to ensure you are OK and that it is safe for you to leave.
WHAT HAPPENS WHEN I ARRIVE TO HAVE MY PROCEDURE?
You will be called into the clinic room where your details will be confirmed and your medical information double-checked. The procedure will be explained again and confirmation of your consent will be verified. If you have any further questions at this stage your podiatrist will be happy to answer them.
The podiatrist will need to check to see if there have been any changes since the original assessment, such as the possibility that you may be pregnant. If this is so, the procedure should not go ahead as the anaesthetic used may affect the unborn baby, particularly in the first trimester.
A local anaesthetic will be distributed into the affected toe via two injections, one on each side at the base of the digit. After a short while the area will begin to feel strange and numb. Your podiatrist will thoroughly test the area to confirm that the anaesthetic has taken full effect. Only when both yourself and the podiatrist are completely happy will the procedure start.
AFTER THE PROCEDURE
If you feel any discomfort in the hours following surgery we advise you to take a mild painkiller that you would normally take for a headache (but avoid aspirin as this encourages bleeding). Resting, with the foot raised, for 24 hours following surgery often helps to ease discomfort. It is important that you make appropriate arrangements to allow yourself to recuperate. You will be given general aftercare advice and how to contact us if there are any problems.
Slight discharge from the wound may continue for up to six weeks. If you are concerned, however,
please return for the wound to be examined and redressed.
Keep the dressing clean and dry until your first appointment when you will have the wound assessed and a new dressing applied. If blood is visible through the dressing do NOT remove it but simply apply additional ones over the top. Some extra dressings are given at the time of your nail surgery for you to apply at home, but please note we are unable to t supply all the dressings whilst your toe heals. Sterile gauze affixed with tape are cheap to buy and suitable to apply at home, and your podiatrist will show you how to do this. The redressing appointments will typically be at the location of the procedure.
Following the procedure if you experience:
· Persistent throbbing pain in the toe
· Excessive bleeding which saturates your dressing
Call the clinic to book an urgent appointment
This has been written to help you understand more about the nail problems. This information is not a substitute for professional medical advice and should be used only as guidance for the procedure.