Subungual exostosis surgery: a guide for patients

What is a subungual exostosis?

A subungual exostosis is an overgrowth of bone or cartilage underneath a toenail.

It is usually caused by injury to the nail area at some point in the past.

The overgrown bone or cartilage presses on the underside of the nail and can produce pain and, frequently, deformity of the nail.

What treatment is available?

Treatment can consist of conservative and surgical options:

Non-surgical treatment

• Alteration of footwear: changing to a wider/deeper fitting shoe can reduce pressure on the toe.
• Protective padding and silicone toe moulds.

Surgical treatment

• Surgery involves removing the offending piece of bone or cartilage, which usually resolves the problem.
• The skin is stitched together and the stitches are removed at two weeks.
• There are different ways to get to the exostosis and sometimes the nail is removed. If this is the case, the nail will regrow but may take up to 12 months to do so.
• If the nail was deformed before surgery, it is likely to remain so afterwards.

About day case surgery under local anaesthetic

Surgery is carried out under a local anaesthetic as a day case. This means that you are awake during the operation, but a screen will prevent you from seeing the operation.

To numb your toe, you will be given some injections around the base of your toe or around your ankle (ankle block).

You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take up to 30 minutes but you should be prepared to be at the hospital longer than this to allow for preparation and recovery. Throughout the operation you will have a tight band (called a tourniquet) placed around your ankle to keep the blood away from your foot. This is sometimes uncomfortable but is released immediately after the operation.

You must have a competent adult at home for the first day and night after surgery.

If you decide on surgical management you will be invited back to attend a pre-surgical assessment clinic. A member of the nursing team will take a medical history and if you are on any medication please bring a list of these with you. This is a good opportunity to ask us any questions or concerns you may have about the procedure.

Recovery after your operation

The first two to three days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only. If you have been given crutches, you must use them in the way shown. You may be able to bear a little weight on the foot.
• You should take the prescribed painkillers. If you experience pain, it is usually worse for the first two days.
• If you are still experiencing pain after three to four days that is not relieved by the pain killers, you should contact the department directly.
• If you have any concerns about your foot you should contact the department directly.
• The department is closed at the weekend. Out-of-hours, you should contact your GP or go to your local accident and emergency department.

Two weeks after surgery

• You must visit the hospital for a wound check and stitch removal.
• You should no longer need a bandage and will be able to wear a normal shoe again. This shoe does need to be roomy, ideally a trainer, because your foot will be quite swollen. If you do not have any, you will need to buy some before surgery.
• At this stage, you can gradually and gently increase your activities. You will still need to rest between activities.
• You can normally start bathing the foot once again a few days following stitch removal.
• Once the stitches have been removed, further wound care may be necessary. If this is the case, the toe will need to be kept dry.
• At this point, you can generally return to work and drive unless you have been instructed otherwise. Please contact your insurance company to check when you can drive.

Between two and six weeks after surgery

• During this time the foot gradually returns to normal and you may be able to vary your footwear.
• There will still be noticeable swelling, especially towards the end of the day. This is quite normal at this stage.
• If the nail has been removed it will now be growing.

Between six and 12 weeks after surgery

• The toe should now be comfortable and returning to normal, but there may still be some slight swelling.

Six months after surgery

• The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

Twelve months after the surgery

• All healing is now complete.

Frequent or serious occurring risks

All operations carry a small risk. Complications following foot surgery are uncommon and most are resolved without permanent disability or pain. Complications specific to this type of surgery include:

• Infection (two in 100)
• Delayed healing of the skin (eight in 100)
• Prolonged swelling post operatively (four in 100)
• Thick or sensitive scar formation (four in 100)
• The exostosis may return
• The nail may grow back thickened causing discomfort from footwear
• Non compliance of patients (four in 100)
• Blood clot Deep Vein Thrombosis (DVT).