From the Research
Surgical excision with preservation of the nail bed is the recommended treatment for subungual exostosis, as it allows for a good balance between radical excision of the exostosis and preservation of the natural protection granted by the native nail, yielding good functional results and patient satisfaction. This approach is supported by a retrospective study published in the Journal of Pediatric Orthopedics, Part B, in 2020 1, which reported good functional results and high patient satisfaction in 13 patients who underwent surgical excision with nail bed preservation. The study found that the median American Orthopedic Foot & Ankle Society score was 100, and the median personal satisfaction score was 9, with a median follow-up of 30 months.
The procedure typically involves elevating the nail or partially removing it to access the bony growth, followed by careful excision of the exostosis down to normal bone using a small rongeur or bone cutter. After removal, the nail bed is repaired and the nail may be replaced as a biological dressing. Post-operative care includes keeping the area clean, applying antibiotic ointment, and taking oral analgesics for pain management. Patients should avoid strenuous activity involving the affected digit for 2-3 weeks and wear comfortable, non-constrictive footwear. Complete healing typically occurs within 4-6 weeks.
Surgery is necessary because subungual exostosis is a benign bone tumor that grows under the nail, causing pain, nail deformity, and sometimes infection, and will not resolve without intervention. Recurrence rates are low (approximately 5-10%) when the lesion is completely excised, as reported in a study published in the Singapore Medical Journal in 2016 2. Other studies, such as those published in BMJ Case Reports in 2013 3, Cutis in 2016 4, and The Journal of Foot and Ankle Surgery in 1995 5, also support the use of surgical excision for the treatment of subungual exostosis. However, the 2020 study published in the Journal of Pediatric Orthopedics, Part B, is the most recent and highest-quality study, and its findings should be prioritized when making treatment decisions.
Some key points to consider when treating subungual exostosis include:
- The importance of preserving the nail bed to maintain natural protection and promote healing
- The need for careful excision of the exostosis to prevent recurrence
- The use of post-operative care measures, such as antibiotic ointment and oral analgesics, to promote healing and prevent infection
- The importance of avoiding strenuous activity and wearing comfortable footwear to promote healing and prevent complications.