The aim of this study was to identify putative aetiological factors of recalcitrant ingrown toenail and then to introduce a new surgical technique for its treatment on the basis of this identification. We found that many of our patients had an upturned morphology on the distal phalanx beneath the recalcitrant ingrown toenail. We thereby designed a new operative technique to treat this problem. From October 1997 to May 2006, 31 patients (38 toes), who were operated on using the new technique, were assigned to the experimental group. Another 38 patients, who were randomly selected from the population without an ingrown toenail, were assigned to the control group. Briefly, the operation is performed as follows: make an elliptical skin incision distal to the hyponychium. Remove the wedge of tissue through incision, together with the periosteum on the lateral side of the distal phalanx. Expose and then transect the distal part of the distal phalanx. Twenty-nine patients (36 toes) were included in the follow up which varied in length from 8 to 29 months. None of them had recurrent symptoms. In conclusion, an upturned abnormality of the distal phalanx may contribute, at least partly, to the formation of recalcitrant ingrown toenail. The partial distal phalanx removal could be considered as an effective technique in recalcitrant ingrown toenail therapy.