A systematic review and meta‐analysis of randomised controlled trials on surgical treatments for ingrown toenails part I: recurrence and relief of symptoms

Abstract

Background Ingrown toenails are a common nail pathology. When conservative treatments are ineffective, a surgical approach is often utilised. Despite recent narrative reviews, there is a need for an up-to-date and rigorous systematic review of surgical methods for treating ingrown toenails. Methods Five databases (MEDLINE, Embase, CINAHL, Web of Science and CENTRAL) and two registers (Clinicaltrials.gov and ISRCTN) were searched to January 2022 for randomised trials evaluating the effects of a surgical intervention(s) for ingrown toenails with a follow-up of at least 1 month. Two independent reviewers screened records, extracted data, assessed risk of bias and certainty of evidence. Results Of 3,928 records identified, 36 (3,756 participants; 62.7% males) surgical interventions were included in the systematic review and 31 studies in the meta-analysis. There was very low quality evidence that using phenol with nail avulsion vs nail avulsion without phenol reduces the risk of recurrence (risk ratio [RR] 0.13 [95% CI 0.06 to 0.27], p < 0.001). No favourable effect was observed between chemical or surgical vs conservative management (0.55 [0.19 to 1.61], p = 0.280; 0.72 [0.33 to 1.56], p = 0.410), chemical or surgical vs other (e.g., CO2 laser, electrocautery) (1.61 [0.88 to 2.95], p = 0.120; 0.58 [0.25 to 1.37], p = 0.220), chemical vs surgical (0.75 [0.46 to 1.21], p = 0.230), surgical vs surgical (0.42 [0.21 to 0.85]), chemical vs chemical (0.19 [0.01 to 3.80], p = 0.280), surgical vs surgical + chemical (3.68 [0.20 to 67.35], p = 0.380), chemical vs surgical + chemical (1.92 [0.06 to 62.30], p = 0.710), local anaesthetic vs local anaesthetic + adrenaline (1.03 [0.22 to 4.86], p = 0.970), chemical timings 30 s vs 60 s (2.00 [0.19 to 21.41]) or antibiotics vs no antibiotics (0.54 [0.12 to 2.52], p = 0.430). Central toenail resection was the only procedure to significantly relieve symptoms (p = 0.001) but data were only available up to 8 weeks post-surgery. Conclusion Despite the high number of publications, the quality of research was poor and the conclusions that can be inferred from existing trials is limited. Phenolisation of the nail matrix appears to reduce the risk of recurrence following nail ablation, and with less certainty 1 min appears to be the optimum time for application. Despite this being a widely performed procedure there remains a lack of good quality evidence to guide practice.

A systematic review and meta‐analysis of randomised controlled trials of surgical treatments for ingrown toenails part II: healing time, post‐operative complications, pain, and participant satisfaction

“…Findings from this paper should be interpreted in line with the assessments of risk of bias and certainty of evidence reported in the first paper [15]. All studies included in the review were assessed as having either high risk or having some concerns about bias when assessed with the Cochrane ROB 2.0 tool.…”

“…Studies were restricted to English, pertaining to human participants, and must have reported one of the pre‐defined outcomes for inclusion. Our co‐primary outcomes were relief of symptoms, and symptomatic regrowth (nail spicules/nail spikes), which are reported elsewhere [15]. Secondary outcomes: healing time, post‐operative complications (e.g., infection and haemorrhage), pain of operation, post‐operative pain (duration and intensity) and participant satisfaction are reported herein.…”

“…Alvarez‐Jimenez et al reported that using a Martini bone curette following partial nail avulsion and destruction of the nail matrix with phenol reduced healing time by a third (7.5 ± 1.8 days compared to 12.4 ± 3 days, p = 0.001) [32]. They also found that it reduced rates of post operative infection, but increased post operative bleeding and as reported previously had no effect on recurrence[15]. However, with only 51 patients, and that this has not been tested in multiple trials, care must be taken not to overinterpret these findings.…”

“…All studies included in the review were assessed as having either high risk or having some concerns about bias when assessed with the Cochrane ROB 2.0 tool. Similarly, none of the comparisons were considered to have high certainty when assessed with the GRADE system in the first paper [15]. These issues could have been averted at the protocol development stage of each trial and there is a large body of literature to guide the development and conduct of such trials [62][63][64][65][66].…”

“…Shorter application of phenol during the chemical matrixectomy was linked to shorter time to healing in two studies, but application duration appeared to have little effect on post operative complications [26, 28]. Although this may suggest that clinicians should use a shorter duration of phenol, this must be balanced against the meta‐analysis in the first paper which indicate higher rates of regrowth are associated with shorter application times[15]. The optimal balance of effectiveness and sequalae is yet to be determined and clinicians may opt to vary application times to meet the needs of individual patients.…”