A wedge resection or Zadek procedure is one of the more radical methods of curing an ingrown toenail, but will result in a permanent cure of the problem in most cases, although there may be a recurrence in about 10% of patients. It is only performed if the nail is significantly ingrown, or previous procedures have been unsuccessful. The aim of a total or formal Zadek procedure is to remove the nail and nail bed completely so that the nail never regrows. The more common procedure is a partial Zadek procedure, which is an operation is to permanently narrow the nail by one quarter to one third of its width. A partial Zadek procedure is described.
After cleaning the toe with an antiseptic solution, the patient will be given an anaesthetic injection into either side of the base of the toe. There is then a five to ten minute wait for the anaesthetic to be effective. Sometimes a third injection is given into the end of the toe after this time.
A tourniquet (often a broad rubber band) is then placed around the base of the toe, it is again cleaned with antiseptic, and draped with a sterile dressing. The operation is then performed. The patient may feel pulling and tugging, but no pain should be felt. If pain is experienced, tell the doctor, and more anaesthetic will be given.
During the procedure a cut is made from the flesh behind the base of the nail, through the entire length of the nail. A second cut is made around the outside edge of the nail to curve around and meet the first cut at both ends. These cuts are deepened to meet in the flesh beneath the nail, and a wedge of nail and flesh is removed. Part of the nail bed behind the base of the nail is also removed in the wedge.
In most cases, the defect in the nail is then sewn up with stitches through both the flesh and the nail, the tourniquet is removed, and a firm dressing is applied. It is necessary to return to have a lighter dressing applied after one day, and to have the stitches removed after ten days.
When the anaesthetic wears off after about 90 minutes there will be considerable discomfort in the toe due to the depth of the incision and the pressure from the bandage. The doctor will give the patient pain killing tablets to take as necessary for the next 24 hours. After the dressing is changed the next day, much of the pain will ease, and paracetamol is all that is normally needed for the next couple of days.
Bleeding from the wound into the dressing is common in the first few hours. Additional bandaging may be added to the original dressing if necessary. Keeping the foot elevated will prevent both bleeding and pain. The patient should not walk any more than is absolutely necessary for the first day, and shoes should not be worn until after the stitches are removed. Sandals, thongs and open toed shoes that do not put pressure on the wound are appropriate.
The wound should be kept clean, dry, covered and elevated as much as possible until the sutures are removed. The patient may shower briefly, remove the dressing after showering, pat the toe completely dry, then apply a clean dry dressing. The patient must not swim or take a bath unless the toe is kept out of the water. A soggy wound is more likely to get infected and heal poorly.
An immediate complication may be excessive bleeding from the wound, and this may require further suturing or dressing. Infection is an uncommon possibility that may occur one or more days after the procedure. If there is foul ooze, smell, increasing pain or redness in the toe, the patient should return to the doctor for antibiotic treatment.
A long-term complication may be the growth of a spicule of nail from the damaged nail bed. This can grow out parallel to the existing nail, or may grow into the flesh at an angle to cause pain and infection. If this occurs, a further operation may be necessary.
In some cases the remaining nail may be distorted without growing into the flesh again, and may not be as cosmetically attractive as the patient may desire, although still pain free.