ORIGINAL ARTICLES

Postoperative Infection After Excisional Toenail

Matrixectomy
A Retrospective Clinical Audit
Alen Rusmir, MPod*
Angelo Salerno, MPod*

Background: Excisional toenail matrixectomies are performed on the area of the foot
that has been reported to have the highest concentration of resident microorganisms. A
retrospective infection audit was performed to identify whether this unique area of the
foot was more susceptible to postoperative infection.
Methods: A retrospective audit reviewing the postoperative infection rate over a 6-year
period after excisional nail matrixectomy in 111 patients was undertaken.
Results: The postoperative infection rate was found to be high (18.9%) relative to that of
clean orthopedic foot and ankle surgery (0.5%–6.5%).
Conclusions: The unique concentration of resident microbes found in the nail folds
could help explain the high rate of postoperative infections identified in this study. This
may provide some argument to classify excisional nail matrixectomy as clean-
contaminated surgery and, thus, warrant routine antibiotic prophylaxis. Further research
is recommended to confirm the results of this study and to determine whether
appropriately timed oral antibiotic prophylaxis will reduce the infection rate after nail
surgery. (J Am Podiatr Med Assoc 101(4): 316-322, 2011)

Ingrown toenails (onychocryptosis) are common
complaints seen and treated by foot and ankle
specialists.1-5 They cause 3% to 5% of all foot
problems and result in economic loss by restricting
daily routine and work activities.2, 6 Although most
commonly seen on the great toe, ingrown toenails
may occur in any of the toes and even in the fingers.
They may lead to considerable pain and recurrent
infection and subsequently may require surgical
intervention when conservative measures do not
alleviate the condition.1-5 Excisional matrixecto-
mies involve excising nail matrix tissue to perma-
nently eliminate an offending portion of nail.2 These
procedures have been shown to produce satisfac-
tory cosmesis and low recurrence rates, with
patient satisfaction as high as 90%.1-5
Postoperative infection has been defined as a
clinical condition caused by the action of a
pathogenic microorganism in the surgical site. It is
usually characterized by abscess or drainage and
*Podiatry Outpatients, Repatriation General Hospital, Daw
Park, South Australia, Australia.
Corresponding author: Alen Rusmir, MPod, Podiatry
Outpatients, Repatriation General Hospital, Daws Road and
Goodwood Road, Daw Park, South Australia, Australia 5041.
(E-mail: arusmir@gmail.com)
the cardinal signs of inflammation, such as erythe-
ma, heat, pain, and edema.7 Infection can also be
expressed in the following equation: (bacterial dose
3 virulence) 4 host resistance.5 Therefore, it can be
appreciated that reducing the microbial count at the
surgical site will assist in preventing infection.
The foot provides a unique environment for
harboring potential wound pathogens.7-10 Rates of
infection for clean foot and ankle surgery have been
internationally reported to be 0.5% to 6.5%10;
however, it is acknowledged that certain areas of
the foot may be more prone to infection owing to
their unique microbial environment.7-10 The nail
folds seem to be one such area. The reported rates
of infection after excisional nail matrixectomy have
largely varied in the literature, as has the use of
antibiotic prophylaxis for such surgery.3, 11, 12-15
Materials and Methods
Ethics approval for this study was granted by the
Repatriation General Hospital ethics committee.
Preliminary data collection found that 121 patients
had undergone either partial or total excisional
matrixectomy between February 1, 2002, and April

316 July/August 2011  Vol 101  No 4  Journal of the American Podiatric Medical Association
30, 2008. Owing to lack of follow-up, ten subjects
were excluded from the study; therefore, 111
patients were included for data analysis. Relevant
demographic data were collected, as were the
patient’s diabetic status and American Society of
Anesthesiologists (ASA) rating.
Only partial and total excisional nail matrixec-
tomies were included in this study. Chemical nail
matrixectomies were not included in this audit
because these procedures were performed in an
outpatient clinical setting. All of the patients were
referred to Podiatry Outpatients, Repatriation Hos-
pital (Daw Park, South Australia, Australia) by their
podiatric physician or primary care physician. They
were deemed appropriate candidates for surgery
only when their symptoms were not responsive to
conservative measures or if symptoms persisted
after a previously attempted surgical procedure.
Patients who were suspected of having peripheral
vascular disease were referred for ankle-brachial
index measurement and digital plethysmography
studies at the Vascular Laboratory of Repatriation
General Hospital to confirm adequate healing
potential.
All excisional matrixectomies were performed as
day surgery in the hospital’s theater under sedation
with local anesthesia or under local anesthesia
alone. The surgical team was fully gowned in sterile
attire. All of the feet received a preoperative
povidone-iodine solution paint and were covered
with a sterile huck towel before theater transfer. In
the theater, the feet were painted to the ankle with
two passes of povidone-iodine solution and were
draped in a sterile manner with a sterile plastic
drape, two nondisposable drapes, a huck towel, and
two top drapes. Seventeen patients were found to
have been painted with three passes of chlorhexi-
dine gluconate (4%) and isopropyl alcohol (70%) as
an alternative to povidone-iodine either due to
allergy or as a result of new hospital protocol. The
offending nail edges or nail plates were removed in
toto. The exposed nail bed was then swabbed with
povidone-iodine solution before the tissue incision.
A rubber glove digital tourniquet was used for
hemostasis in all cases.
Surgical excision of the nail matrix and hypertro-
phic ungualabia was performed using a Winograd
technique or by total excisional matrixectomy as
described by Chang.2 All of the incisions were
closed with 4–0 nylon monofilament sutures in
simple interrupted and horizontal mattress fashion.
Dressings consisted of a final swab of povidone-
iodine solution, paraffin gauze, dry gauze, and a
crepe dressing.
Journal of the American Podiatric Medical Association  Vol 101  No 4  July/August 2011
Postoperative sandals were also fitted, and all of
the patients were instructed to keep their feet dry
for 2 weeks and to restrict ambulation to no more
than 15 minutes in any given hour for the first week.
Plastic bags with Velcro fastening straps were
supplied to aid with keeping feet dry while
showering. A combination of paracetamol, 500 mg,
and codeine phosphate, 30 mg, was prescribed for
postoperative analgesia in most cases, unless
known allergy or a history of adverse reaction was
reported, in which case an alternative analgesic
agent was prescribed.
A standardized dressing and redressing approach
was used for all of the patients. Seven days after
surgery, patients were reviewed for redressing.
Bandages were removed and wounds were inspect-
ed to assess wound healing. At this point, ca-
dexomer iodine ointment was applied to the
wounds and covered with Inadine (Johnson &
Johnson Medical Ltd, Mount Waverley, Victoria,
Australia) and tube gauze dressing. Fourteen days
after surgery, all of the sutures were removed. All of
the patients were reviewed for the final time 5 to 7
weeks postoperatively unless ongoing infection or
delayed healing was present, in which case ongoing
weekly reviews were continued until wound healing
was complete.
All of the infections were clinically diagnosed
based on the clinical signs of infection, which
included erythema, pain, heat, and, usually, purulent
discharge. Swab samples were not collected be-
cause they were considered to be of limited value in
this setting because many infections had no abscess
formation. All of the infections responded to
empirical antibiotic therapy, which consisted of
500 mg of cephalexin four times a day. For patients
deemed to be at greater risk for infection, oral
cephalexin, 500 mg, three times a day for 7 days,
was prescribed and commenced immediately after
surgery. No allergic reactions were reported by any
of these patients.
Results
The data were analyzed with SPSS version 17 (SPSS
Inc, Chicago, Illinois), which evaluated the signifi-
cance between prophylaxed and nonprophylaxed
samples. A two-sample t test was used, and P , .05
was considered statistically significant. Post hoc
power calculations were performed, with infection
rate values given in Table 1. With Fisher’s exact test,
a = 0.05, and a power of 0.80 and defining a 50%
reduction in the rate of infection as clinically
317
Table 1. Infection Rates in Each Group and the Trend in Prophylaxis Use
Patients (No. [%])
Received
Antibiotic
Patient Group Total Prophylaxis
Total sample 111 (100) 22 (19.8)
ASA 1 24 (21.6) 1 (4.2)
ASA 2 45 (40.5) 6 (13.3)
ASA 3 42 (37.8) 14 (33.3)
Diabetic 32 (28.8) 10 (31.2)
Chlorhexidine 17 (15.3) 2 (11.8)
Abbreviation: ASA, American Society of Anesthesiologists.
significant, a sample size of 40 patients was
calculated to be sufficient for respective groups.
The number of patients who were prescribed
antibiotics at 7 days for clinically suspected
infection was 21 (18.9%). Twenty-two of the 111
patients (19.8%) commenced antibiotic therapy
immediately after surgery. These patients were
prescribed antibiotics owing to existing comorbid-
ities or recent infection history. Four of the 22
patients (18.2%) who received antibiotic therapy
immediately postoperatively required a second
course of antibiotics owing to wound infection.
Eighteen of the 89 patients (20.2%) who did not
receive antibiotics developed infection (P = .834).
This finding indicated no statistically significant
difference in infection rates between the group that
received antibiotics and the group that did not.
Twenty-one of 94 patients (22.3%) who were painted
with povidone-iodine were identified as having a
postoperative infection at 1 week. Seventeen
patients (15.3%) received a chlorhexidine gluconate
(4%) and isopropyl alcohol (70%) foot paint. No
postoperative infections were identified in this
group (P = .033), but the small sample size meant
that the statistical significance was underpowered.
There were 32 people (28.8%) with diabetes
mellitus. Ten of these patients (31.2%) received
antibiotics, and, despite this, three developed
infection. Five of the 22 diabetic patients (22.7%)
who did not receive antibiotics also developed an
infection at 1 week. Therefore, there was no
statistically significant reduction in infection when
antibiotic therapy was commenced immediately
after surgery in the two diabetic groups (P = .661).
Forty-five of the 111 patients (40.5%) from the
sample population were deemed to be ASA 2. Ten of
these patients (22.2%) developed a postoperative
infection and required antibiotic therapy; six pa-
tients (13.3%) received antibiotics postoperatively,
318 July/August 2011  Vol 101  No 4  Journal of the American Podiatric Medical Association
Developed Developed Postoperative
Postoperative Infection Despite
Infection Antibiotic Prophylaxis P Value
21 (18.9) 4 (18.2) .834
4 (16.7) 1 (100) Underpowered
10 (22.2) 1 (16.7) .755
8 (19.0) 2 (14.3) .692
5 (15.6) 3 (30.0) .661
0 0 .033 (underpowered)
one of whom (16.7%) developed an infection despite
this (P = .755). Forty-two of the 111 patients (37.8%)
from the sample population were deemed to be ASA
3. Eight of these patients (19.0%) developed an
infection and required antibiotic therapy. Fourteen
patients (33.3%) received antibiotics postoperative-
ly, and two of them (14.3%) developed an infection
despite antibiotic therapy (P = .692). Twenty-four
patients (21.6%) were deemed ASA 1. Four of them
(16.7%) required antibiotic therapy at 1 week,
including 1 patient who was given antibiotics
immediately after surgery. The mean 6 SD age of
the sample population was 65.2 6 14.7 years, and
the mean 6 SD age at infection was 61.2 6 15.2
years. There were 46 males (41.4%) and 65 females
(58.6%).
Discussion
Marcinko7 acknowledged that the skin cannot be
truly sterilized and can only be made surgically
clean. The most that can be hoped for is to reduce
the bacterial load at the surgical site. Several
studies 8, 16-19 have shown that the nail folds
consistently contain microbial pathogens after
surgical skin painting and seem to be the most
difficult area of the foot to decontaminate.
Ostrander et al8 reported that the hallux nail folds
had the greatest concentration of skin flora after
foot painting with povidone-iodine. Swab samples
collected in this area were cultured and grew
pathogenic microbes in 84% of the sample popula-
tion of 25; this percentage was significantly higher
than the 22% cultured from the anterior ankle
control group. They felt that the foot was a unique
environment and that the resident skin flora may
play a role in the higher infection rates associated
with surgery of the foot and ankle. They recom-
mended the use of foot scrubs with bristle brushes
preoperatively to remove nail debris in an attempt
to reduce the high microbial concentration in the
nail folds.8
More recently, Becerro de Bengoa Vallejo et al16
compared four methods of surgical skin preparation
in terms of their efficacy in eliminating bacteria
from the hallux nail fold and first web space in 28
patients. All of the nail folds were scrubbed with a
bristled brush to help dislodge microbe-carrying
debris. What they found was that incorporating
alcohol with povidone-iodine reduced the bacterial
load in the nail fold most effectively. Despite this,
the nail folds remained contaminated after all of the
skin preparation methods tested. They concluded
by stating that ‘‘every effort should be made to
lower the risk of contamination from the
nail.’’16(p990)
A randomized controlled study by Bibbo et al17
showed that the application of chlorhexidine and
alcohol was superior to traditional painting with
povidone-iodine in decontamination of skin flora for
foot and ankle surgery. Despite halving the number
of positive cultures compared with povidone-iodine,
23 of the 60 patients painted with chlorhexidine and
alcohol had positive cultures, and 21 of these
cultures were from the toes and nail folds.
Keblish et al18 acknowledged that eliminating
bacteria from the skin and nails before foot and
ankle surgery is a challenge. They compared the
effectiveness of four methods of skin preparation.
They found that scrubbing the nails with a bristle
brush was superior in decontaminating the nail
folds compared with the same skin preparation
without the use of a bristle brush. They concluded
that an alcohol solution in conjunction with
scrubbing the nails with a bristle brush was superior
to povidone-iodine and a bristled brush.
All of the patients in this study received a
preoperative paint with povidone-iodine before
theater admission. Foot scrubbing with bristle
brushes was not performed because this was not
part of the hospital’s preoperative protocol. The
lack of preoperative scrubbing of the nail folds and
the use of povidone-iodine to paint the skin rather
than an alcohol-based product may have been
contributing factors in the higher-than-expected
rate of postoperative infection.
Antibiotic Prophylaxis Indications
Therefore, given the unique bacterial load present in
the nail folds after surgical skin preparation, we
consider the indications for antibiotic prophylaxis.
Surgical antibiotic prophylaxis is defined as the use
Journal of the American Podiatric Medical Association  Vol 101  No 4  July/August 2011
of antibiotics to prevent infection at the surgical
site.20, 21 The effectiveness of antibiotic prophylaxis
in reducing postoperative infection was shown over
40 years by Burke.7, 9, 20, 21
More recently, several authors5, 7, 9, 10, 20, 22 have
made recommendations regarding indications for
antibiotic prophylaxis in orthopedic and podiatric
surgery. Indications in foot and ankle surgery
include 1) implantation of a foreign material, ie, a
prosthesis or external/internal fixation; 2) systemic
diseases that interfere with host defenses, ie,
diabetes mellitus, rheumatic heart disease, malnu-
trition, long-term corticosteroid use, chemotherapy,
peripheral vascular disease, etc; 3) acute trauma;
and 4) other indications, ie, age older than 70 years
or prolonged surgical time longer than 2 hours.7
Therefore, it seems that these indications exclude
prophylaxis for excisional nail matrixectomies in
young healthy individuals. As previously discussed,
recent studies17-19 have shown that the nail folds are
consistently contaminated with pathogenic mi-
crobes after surgical skin painting, probably owing
to the macroscopic debris located in the periungul
labia. Subsequently, when one reviews the current
surgical classification scheme, nail surgery may
require special consideration and possibly different
classification.
The three categories of surgical contamination
are clean, clean-contaminated, and contaminat-
ed.20, 21 Clean surgery is defined as surgery under
sterile conditions where healthy skin is incised, and
it may include implantation of a prosthetic or
artificial device. Examples include hip replacement
surgery, mastectomy, and cosmetic surgery, and
antibiotic prophylaxis is not recommended gener-
ally; however, where a prosthesis is implanted,
antibiotic prophylaxis is recommended.20, 21 Elec-
tive foot and ankle surgery falls under this category.
Clean-contaminated surgery is defined as penetra-
tion of the genitourinary, alimentary, or respiratory
tract under controlled sterile conditions without
unusual contamination. Examples include laryngec-
tomy, cholecystectomy, uncomplicated appendec-
tomy, and transurethral resection of the prostate
gland. In these cases, antibiotic prophylaxis is
recommended.20, 21 Contaminated surgery is defined
as the macroscopic soiling of the operative field.
Examples include large bowel resection, biliary or
genitourinary tract surgery with infected urine.
Again, antibiotic prophylaxis is strongly recom-
mended.20, 21
Munckhof20 acknowledged that there are excep-
tions to the normal indications for antibiotic
prophylaxis, including procedures on patients with
319
impaired host defenses and surgical procedures
longer than 1 hour. Antibiotic prophylaxis is also
indicated for neurosurgery and cardiac surgery
owing to infection at the surgical site being
potentially disastrous.
Thus it seems that excisional nail matrixectomies
are performed under controlled sterile conditions
rather than under clean sterile conditions owing to
the unique microbial environment in the nail folds.
Therefore, it may be more appropriate to classify
such procedures as clean-contaminated rather than
as clean.
Antibiotic Timing and Administration
The results of this audit indicate that the postoper-
ative use of antibiotics did not provide prophylaxis.
This seems to be due to incorrect timing. Munck-
hof20 recommended that intravenous administration
was the preferred choice over oral administration
for antibiotic prophylaxis. However, where oral
administration was required, it was advised that
prophylaxis be commenced at least 2 hours preop-
eratively to allow for adequate gastrointestinal
absorption. The correct timing of antibiotic prophy-
laxis is essential to ensure adequate tissue concen-
tration at the surgical site at the time of sur-
gery.9, 20, 21 The importance of sufficient antibiotic
tissue concentration at the time of surgical incision
has been well recognized.7, 9, 20, 21 The emergence of
antimicrobial-resistant microbes is now well estab-
lished; therefore, judicious use of antibiotics is
more imperative than ever.7, 9, 20, 21 The wide use of
cephalosporins has been linked to the increasing
prevalence of infections due to methicillin-resistant
Staphylococcus aureus and vancomycin-resistant
enterococci.7, 10, 20 Therefore, appropriate use of
such agents, particularly in a prophylactic setting, is
essential to slow this trend. Polk and Griffiths (cited
by Marcinko7) confirmed the effectiveness of
intravenous antibiotic prophylaxis when adminis-
tered at the correct time. The correct time was
suggested to be 30 to 60 min before incision because
it allowed for the minimal inhibitory concentration
in the tissues to be reached and provided coverage
of 100 min against S aureus infection. This is
referred to as the ‘‘effective’’ or ‘‘definitive’’ period.7
However, owing to delayed gastrointestinal absorp-
tion, it is recommended that oral administration be
given earlier than intravenous administration to
account for the delay in therapeutic tissue concen-
tration.20 Repeated doses for procedures less than 4
hours in duration is unwarranted unless the
antimicrobial agent has a short half life, which will
320 July/August 2011  Vol 101  No 4  Journal of the American Podiatric Medical Association
result in low tissue concentrations at the time of
surgery.20 The extended use of prophylactic antibi-
otics past the period of surgery does not improve
the efficacy and only adds to toxicity and cost.9, 20
The postoperative administration of oral cephalexin
and the continued use for up to 7 days does not
comply with current evidence in the literature and
therapeutic guidelines for surgical prophylax-
is.7, 9, 20, 21 Furthermore, in many instances where
nail matrixectomies are performed under local
anesthesia without intravenous cannulation, pa-
tients receive a prescription for oral antibiotics
and do not administer their medication for up to
another hour. Thus if one considers this delay in
conjunction with gut absorption, the surgery would
take place outside of the ‘‘effective period’’; thus,
prophylaxis would not occur. If tissue concentra-
tions become therapeutic in 1 to 2 hours, significant
microbial proliferation may have taken place,
which, in conjunction with surgical insult, suture
material, and a unique concentration of skin flora in
the periungual region, results in greater potential for
infection. This seems to explain the high rate of
postoperative infections in patients who received
antibiotics postoperatively.
Limitations
We note several limitations of this study. First, the
retrospective design meant that patients were not
blinded and not randomized to antibiotic prophy-
laxis groups. Another major limitation that became
apparent was incorrect timing of antibiotic prophy-
laxis. This would have meant that true prophylaxis
did not occur and is likely to account for the fact
that there was no statistically significant reduction
in postoperative infection compared with the rest of
the sample population.
Diagnosis of infection was made clinically, and
infection was reflected in the data wherever
patients were prescribed antibiotic therapy 1 or 2
weeks after surgery. Subsequently, many of the
recorded wound infections may not have necessar-
ily been infected and may have resolved without
antibiotic therapy. However, owing to the large
number of patients with comorbidities, it was
deemed appropriate to prescribe antibiotics rather
than risk the onset of infection and patient
morbidity. Therefore, many infections picked up
by the data collection may not necessarily have
been true infections but rather moist wounds or
suture abscesses in an ASA 3 patient or diabetic
patient who was prescribed oral antibiotics as a
precautionary measure to prevent more serious
complications. Wound swab samples were not
collected, but this may have been of little value
because all infections responded to empirical
treatment, and contamination of collected speci-
mens may lead to inappropriate antibiotic treat-
ment.7
Although the use of chlorhexidine and alcohol
skin painting seemed to reduce the rate of surgical
site infections compared with povidone-iodine in
this audit, the validity was limited by the under-
powered sample of patients and the lack of
randomization and blinding. Thus, conclusions
cannot be drawn between these skin preparation
agents in the prevention of infection after excisional
nail matrixectomies.
Randomization of patients was not possible
because patients who were deemed to be ‘‘at risk’’
for infection were given antibiotics postoperatively
because this was the standard of care in the
department. Patient safety would have been com-
promised if antibiotics were withheld in immuno-
compromised individuals. A prospective blinded
study with ASA 1 patients randomly assigned to
antibiotic prophylaxis and placebo control groups
would have been a superior design to assess the
effectiveness of oral antibiotic prophylaxis, but the
limitation is that most patients treated have
comorbidities as evidenced by the sample popula-
tion of ASA 2 and ASA 3 comprising 78.4%. The high
percentage of comorbid patients may also be
another reason for the high rate of postoperative
infections identified in this study.
No regrowth or recurrence of symptoms after
excisional matrixectomy was encountered during
the duration of this study, but patients were
discharged 5 to 7 weeks after surgery and were
advised to return if symptoms recurred. However,
longer patient follow-up and patient satisfaction
questionnaires are required to validate the long-
term effectiveness, which was not the aim of this
study.
Conclusions
A high postoperative infection rate (18.9%) was
identified after nail matrixectomies in our depart-
ment. The unique concentration of resident mi-
crobes found in the nail folds after surgical skin
preparation has been shown in several recent
studies. This may help explain the higher rate of
postoperative infections identified by this audit
compared with other clean foot and ankle surgery.
Thus we believe that this uniquely colonized
surgical site could be more prone to infection than
Journal of the American Podiatric Medical Association  Vol 101  No 4  July/August 2011
the remainder of the foot and ankle. This seems to
provide some argument to classify excisional nail
matrixectomy as clean-contaminated surgery and
may provide an indication for routine antibiotic
prophylaxis. Owing to several limitations in the
methods, further research is recommended to
confirm the results of this study and to determine
whether appropriately timed oral antibiotic prophy-
laxis will reduce the infection rate after nail surgery.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
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