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

Abstract

Background When performing nail surgery, clinicians must choose from a multitude of procedures and variations within each procedure. Much has been published to guide this decision making, but there are a lack of up to date robust systematic reviews to assess the totality of this evidence. 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. Two independent reviewers screened records, extracted data, assessed risk of bias and certainty of evidence. Data on co-primary outcomes of symptom relief and symptomatic regrowth were presented in our first paper. This paper presents data for the secondary outcomes and further discussion. Results Of 3,928 records identified, 36 randomised trials were included in the systematic review. Healing time appears to be reduced with shorter application of phenol. A reduced healing time was also apparent was with the addition of curettage, although this may also increase the risk of post-operative bleeding and pain. Post operative bleeding was also reportedly lower in people who received local anaesthetic with epinephrine but no tourniquet. Use of phenol with nail bed excision may decrease the risk of infection. Lower pain scores were reported when using partial matrixectomy and surgical interventions with phenol. Shorter duration of pain was reported with phenolisation and wedge resection. Participant satisfaction was high overall. Conclusion This second paper reports secondary outcomes from a robust systematic review of randomised trials on surgical treatment of ingrown toenails. Despite the large volume of clinical trials conducted on the topic, few clinical conclusions can be drawn due to the poor quality of these studies. Further high-quality clinical trials are needed to answer fundamental questions in the surgical treatment of ingrown toenails.

A survey of the treatment and management of ingrown toenails by UK podiatrists: A cross‐sectional survey

“…It is also notable that a larger proportion of respondents working in the public sector reported typically using two applications when compared to the private sector. Although it is important to clarify that this variation is not precluded within the guidelines, it does perhaps reflect the lack of evidence to inform decision making on key elements of the procedure [5,7,8].…”

“…Similarly, phenol was almost universally used for chemical matrixectomy with 97.2% of respondents using it. With such a large proportion only providing one procedure or one chemical, it is perhaps surprising that a recent systematic review identified that the current evidence base does not demonstrate superiority of one procedure or chemical over others for outcomes of relief of symptoms, symptomatic regrowth, healing time, post‐operative complications, pain or patient satisfaction [ 7 , 8 ]. Similarly, with Royal College of Podiatry guidelines stating that surgical excision may be considered where healing capacity is reduced, and primary intention would be more suitable, it is clear that most podiatrists would need to refer patients to enable this [ 17 ].…”

“…As has been stated in a recent systematic review, there is a lack of research into core aspects of the surgical management of ingrown toenails [ 7 , 8 ]. Building on results from this survey, future research should seek to confirm the safety and effectiveness of reduced patient follow‐up and even patient initiated follow‐up.…”

“…A recent systematic review and meta‐analyses concluded that despite the high number of publications on nail surgery, very few conclusions could be drawn from the evidence due to the poor quality of research [ 7 , 8 ]. Notably when studies were assessed using the Cochrane RoB 2.0 tool, all studies were graded as having an overall bias of either ‘some concerns’ or ‘high risk’.…”