Post on 27-Nov-2014
Surgical treatments for ingrowing toenails (Review)
Rounding C, Bloomfield S
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4
http://www.thecochranelibrary.com
Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 1 Symptomatic
recurrence at 6 months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Analysis 1.2. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 2 Asymptomatic
recurrence at least 6 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Analysis 1.3. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 3 Recurrence at 6
months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Analysis 1.8. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 8 Post operative
infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Analysis 2.1. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 1 Symptomatic recurrence at 6 months
or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Analysis 2.3. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 3 Recurrence at 6 months or more. 25
Analysis 2.7. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 7 Patient dissatisfied with procedure. 26
Analysis 2.8. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 8 Post operative infection. . . . 27
Analysis 3.3. Comparison 3 PHENOL AND AVULSION vs PHENOL AND SURGERY, Outcome 3 Recurrence at 6
months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Analysis 4.1. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 1 Symptomatic
recurrence at 6 months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Analysis 4.3. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 3 Recurrence at
6 months or more. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Analysis 4.7. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 7 Patient
dissatisfied with procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Analysis 4.8. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 8 Post operative
infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
32APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iSurgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Surgical treatments for ingrowing toenails
Catherine Rounding1 , Sally Bloomfield2
1Institute of Health Sciences, National Perinatal Epidemiological Unit, Oxford, UK. 2Gabatta clinic, Gabalfa, Cardiff, UK
Contact address: Catherine Rounding, Institute of Health Sciences, National Perinatal Epidemiological Unit, Old Road, Headington,
Oxford, OX3 7LG, UK. cath.rounding@perinat.ox.ac.uk.
Editorial group: Cochrane Skin Group.
Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.
Review content assessed as up-to-date: 27 October 2002.
Citation: Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database of Systematic Reviews 2003, Issue
1. Art. No.: CD001541. DOI: 10.1002/14651858.CD001541.pub2.
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Ingrowing toenails are a common condition which, when recurrent and painful, are often treated surgically.
Objectives
To evaluate the effectiveness of methods of the surgical treatment of ingrowing toenails.
Search strategy
Electronic database searching (CENTRAL, MEDLINE, EMBASE, CINAHL) followed by investigation of reference lists of the papers
identified from the initial search.
Selection criteria
Any randomised (or quasi-randomised) controlled trial which compares one form of surgical removal of all or part of a toenail due to
its impact on the soft tissues to another or others. Studies must have a minimum follow period of six months and aim to permanently
remove the troublesome portion of the nail.
Data collection and analysis
Data extraction was carried out independently by the two authors using a pre-derived data extraction form and entered into RevMan.
Categorical outcomes were analysed as odds ratios with 95% confidence intervals.
Main results
Avulsion with phenol versus surgical excision
Phenolisation combined with simple avulsion of a nail is more effective than the use of more invasive excisional surgical procedures to
prevent symptomatic recurrence at six months or more (OR 0.44; 95% CI 0.24 to 0.80).
Avulsion with phenol versus avulsion without phenol
The addition of phenol, when performing a total or partial nail avulsion dramatically reduces the rate of symptomatic recurrence, (OR
0.07; 95% CI 0.04 to 0.12). This is offset by a significant increase in the rate of post-operative infection when phenol is used (OR
5.69; 95% CI 1.93 to 16.77).
1Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors’ conclusions
The evidence suggests that simple nail avulsion combined with the use of phenol, compared to surgical excisional techniques without
the use of phenol, is more effective at preventing symptomatic recurrence of ingrowing toenails.
The addition of phenol when simple nail avulsion is performed dramatically decreases symptomatic recurrence, but at the cost of
increased post-operative infection.
P L A I N L A N G U A G E S U M M A R Y
Surgical interventions for ingrowing toenails
Ingrown toenails occur when the skin at the side of a nail is punctured or traumatised by the growing nail. This causes inflammation
and sometimes infection. After removing part or all of the nail causing the problem, options to prevent recurrence include removing
the nailbed and/or applying phenol (a caustic liquid). The review of trials found that removing the ingrown nail and using phenol
on the nailbed was more effective at preventing recurrence than nailbed removal. However, people whose nailbeds were treated with
phenol were more likely to have infections than those whose nailbeds were untreated after the surgery.
B A C K G R O U N D
Description of the condition
Onychocryptosis or ingrowing toenails is a common condition
with an estimated 10,000 new cases presenting in the UK each
year (Sykes 1986) usually affects the big toe but may also affect the
lesser toes (DeLauro 1995). The condition occurs when the nail
plate punctures or traumatises the skin at the side of the nail, giving
rise to pain, inflammation and sometimes infection. When the
nail punctures the skin, attempts at healing lead to the formation
of highly vascular tissue called granulation tissue. This continues
to be produced until the splinter of nail is removed.
The nail may push laterally or distally against the flesh of the toe
for a variety of reasons but if the footwear is a poor fit it will always
worsen the problem. People born with a nail plate which is very
curved from side to side are predisposed to ingrowing toenails.
Ingrowing toenails are most frequently seen in adolescents and
young adults but it is a common problem in all age groups. In
adolescence the feet perspire more causing the skin and nails to
become soft. The softness of the nails often means they split eas-
ily, so producing nail spicules which can easily pierce the flesh. In
older people, the problem is usually chronic and more a problem
of reduced ability to care for the nails because of reduced mobility
or impaired vision. As part of the natural ageing process the toe-
nails can thicken, so making them more difficult to cut and more
inclined to put pressure on the skin at the sides of the nail.
Description of the intervention
For most cases, conservative treatment in the form of basic foot care
and footwear advice is probably adequate to relieve the symptoms.
When the problem is recurrent, health professionals often view
surgery as the best treatment option to permanently remove either
the whole nail or just the troublesome portion of the nail.
Surgical procedures are carried out routinely under a local anaes-
thetic by general practitioners (GPs), podiatric surgeons, podia-
trists, general surgeons and orthopaedic surgeons. Podiatrists al-
most always carry out nail avulsion with phenolisation. The phe-
nol is applied to nail matrix after the troublesome nail section
has been removed. Its caustic action destroys the nail matrix and
should prevent regrowth. Other professions can choose the more
invasive methods of surgical excision of the nail matrix. Use of cry-
oprobe and use of negative galvanic current are less usual methods
of nail bed ablation which have been used by practitioners
Why it is important to do this review
Despite various trials, there is disagreement on which procedures
produce the most consistent results. Variation in practice (Sykes
2Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1986) and patient satisfaction (Laxton 1995) is still wide. A survey
of current practice of GPs in Oxfordshire, UK (Milwain 1998,
unpublished) further demonstrates this variation in practice. In
this survey, most GPs undertook the surgery themselves rather than
referring to hospital or podiatry departments. The results showed
that three procedures were used almost equally commonly. These
were wedge excision of the nail matrix combined with the chemical
ablation; wedge excision alone and simple avulsion with chemical
ablation. Only one GP mentioned using the less conventional
technique of cryotherapy. In an audit by Laxton, podiatrists using
phenolisation achieved the lowest rates of regrowth (13%) and
the highest rates of patient satisfaction when compared to GPs,
general and orthopaedic surgeons. The rates of regrowth for GPs
were 34% and 50% for general surgeons. Not surprisingly, levels
of patient satisfaction reflected this.
This systematic review will draw together evidence on the different
options for surgical treatment of ingrowing toenails with the aim
of enabling practitioners and consumers to make informed choices
on the most effective way to cure this very common problem.
O B J E C T I V E S
To evaluate the effectiveness of methods of the surgical treatment
of ingrowing toenails. The object of performing surgery on an in-
growing toenail is to prevent its recurrence and so cure the prob-
lem. Therefore the primary outcome measure is the degree of re-
growth.
M E T H O D S
Criteria for considering studies for this review
Types of studies
Any randomised (or quasi-randomised) clinical trial which com-
pares one form of surgery to another or other treatments. The
studies must have a follow-up period of at least six months so that
it is possible to evaluate whether the problem has been cured.
Types of participants
Males and females of any age who require surgical removal of all
or part of a toenail due to its impact on the soft tissues. Those
who have had unsuccessful surgical procedures previously were
included. Those with risk factors such as diabetes and peripheral
vascular disease were to be included, making the assumption that
a patient would only be considered if they have been assessed and
found to be a suitable candidate for surgery.
Types of interventions
Any procedure which aims to permanently remove all or part of a
nail due to its impact on the soft tissues.
Types of outcome measures
Primary outcomes
• Regrowth/relief of symptoms
Secondary outcomes
• Healing time
• Infection
• Post-operative pain - both duration and intensity of pain
• Patient satisfaction
Search methods for identification of studies
Electronic searches
Section 5 of the Cochrane Collaboration Handbook (1997) was
used as a guide to identify the optimum number of relevant RCTs.
An electronic search of CENTRAL was undertaken, followed by
searches of other databases (MEDLINE post 1993, EMBASE,
CINAHL) which have not yet had their RCTs incorporated into
CENTRAL
Electronic searching of Cochrane Skin Group’s specialist register
of trials (please see Appendix 1 for the search terms used).
Searching other resources
Schools of Podiatry were contacted to request dissertation bibli-
ographies and information on unpublished studies.
Reference lists of all papers identified by electronic searching were
searched.
Contact with manufacturers of cryotherapy, radiowave and elec-
trosurgical equipment to identify published or unpublished stud-
ies.
Data collection and analysis
Selection of studies
Selecting trials for inclusion:
3Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Two independent authors selected all randomised controlled trials
which met the inclusion criteria. (Disagreements were resolved
through discussion). Quasi-randomised trials, where the allocation
to procedures was not adequately concealed (eg allocation by date
of birth) were also be included but a sensitivity analysis was carried
out to see if excluding the one trial using this type of allocation
would significantly alter the results.
Data extraction and management
Data extraction was carried out independently by the two authors
using a pre-derived data extraction form. Data was entered into
RevMan.
Assessment of risk of bias in included studies
Assessment of methodological quality
Two authors critically appraised the papers independently to a
pre-defined standard. There was little disagreement, and this was
resolved by discussion. There as no need to pass to a third author, as
originally planned, if the disagreement had persisted. The studies
were assessed on quality of allocation concealment, intention-to-
treat analysis, baseline comparability and completeness of follow-
up.
Assessment of heterogeneity
Heterogeneity between comparable trials was assessed using clini-
cal judgement and tested using the chi-square test available in the
RevMan software. If significant heterogeneity was found statisti-
cally, sensitivity analysis with respect to patient characteristics, for
example, those with diabetes, was to be performed to identify the
source. If the heterogeneity could still not be explained then the
random effects model will be used. Where studies are found to be
suitably homogenous, meta-analysis was performed.
Data synthesis
The categorical outcomes were analysed as odds ratios with 95%
confidence intervals, with continuous outcomes such as pain or
healing time as effect sizes.
R E S U L T S
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of ongoing studies.
Results of the search
Twenty-one studies were identified for possible inclusion in the re-
view. From these, nine fitted the inclusion criteria (Anderson 1990;
Andrew 1979; Greig 1991a; Issa 1988; Leahy 1990; Morkane
1984; Tait 1987; van der Ham 1990; Varma 1983). Two stud-
ies are awaiting further information/data from the authors (Sykes
1988b; Sykes 1988c) and one awaits clarification from the authors
(Zaborszky 1997). Sykes 1988b appears to be a randomised trial
but does not publish data. Sykes 1988c compares different pro-
fessionals (surgeons and chiropodists) performing phenolic abla-
tion and therefore does not fit the inclusion criteria. However, the
authors initially set out to compare phenolisation against surgi-
cal avulsion, but poor results led to the surgical avulsion arm of
the trial being discontinued. If additional data was available from
the authors, this could be an important study. The study awaiting
clarification from authors (Zaborszky 1997) is a Hungarian study
in which the paper did not describe the methodology adequately
enough to be able to make a judgement as to whether the study
was prospective or whether allocation/concealment was adequate.
The study could not be definitely excluded until this can be clari-
fied.
Included studies
The nine included studies compared a variety of procedures in
different combinations. All included the use of phenol and avul-
sion of all or part of the nail in their trial but some combined
phenol with an excisional procedure (involving surgical removal of
the nail matrix) and either compared it against phenolisation with
avulsion alone or excisional surgery alone. Some trialists were spe-
cific in their surgical methods, naming the actual procedure used
eg Winograd, while others were less so, using the broader term of
’wedge excision’. One study (Greig 1991a) compared the use of
partial nail avulsion and phenolisation with simple partial or total
nail avulsion alone. It was debatable whether this study fitted the
inclusion criteria but as its aim was to permanently remove the
problem it was decided that the study should be included.
All the included studies were quite open in their inclusion criteria.
None excluded participants by their age or medical history. Three
studies (Greig 1991a; Morkane 1984; van der Ham 1990) ex-
cluded participants who had had previous toenail surgery and one
study (Anderson 1990) only included participants who had previ-
ously had two or more surgical procedures on their toenail. partici-
pants were generally drawn from referrals from general practition-
ers, accident and emergency departments and referrals to general
surgeons from unspecified sources. All the trials were undertaken
by general surgeons, normally on an outpatient basis.
All trials measured recurrence as an outcome although two did
not specify whether or not the recurrence was symptomatic (Issa
1988; Morkane 1984). Post-operative infection was recorded in
four trials (Anderson 1990; Greig 1991a; Leahy 1990; Tait 1987).
Pain intensity and/or duration was reported in five trials (Issa 1988;
4Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Leahy 1990; Morkane 1984; Tait 1987; van der Ham 1990 but
usable data were not supplied. Similarly healing time was reported
in four trials (Andrew 1979; Tait 1987; van der Ham 1990; Varma
1983) but not with usable data.
Excluded studies
Nine studies were excluded from the review. Four studies had a
follow-up period of less than six months (Beaton 1990; Burssens
1987; Goslin 1992; Holt 1987), two did not compare interven-
tions (Sykes 1988a; Greig 1991b) and one was retrospective (Ful-
ton 1994). One study (Gem 1990) had such a large loss to follow-
up (>30%) that it was decided that it should be excluded. The final
excluded study (Wallace 1979b) did not fit the inclusion criteria in
the sense that one of the interventions did not aim to permanently
remove all or part of a nail.
Risk of bias in included studies
Allocation
All the included trials were described as randomised although three
did not state the method used. Of the remaining trials, three allo-
cated by sealed envelopes (Leahy 1990; van der Ham 1990; Varma
1983), one by random numbers (Issa 1988), one by hospital num-
ber (Andrew 1979) and one by date of birth (Tait 1987).
Blinding
Due to the nature of the interventions it was not possible to blind
the operator to the procedure. Blinding the patient to the pro-
cedure would be difficult but possible, but no study mentioned
any attempt to do this. Two trials (Anderson 1990;Leahy 1990)
used an independent observer to follow-up the procedures at six
months or more. The other trials did not state who they used to
follow-up the procedures.
Incomplete outcome data
Follow-up was very complete with all studies reporting the number
of participants lost to follow-up. Seven of the nine included studies
had a loss to follow up of 3% or less with the remaining two
having loss to follow-up of 13% (Tait 1987) and 6% (Varma 1983)
respectively.
Effects of interventions
Avulsion with phenol versus avulsion without phenol
The addition of phenol, when performing a total or partial nail
avulsion dramatically reduces the rate of symptomatic recurrence,
with OR = 0.07 (95% CI 0.04 to 0.12; Analysis 4.1). This is offset
by a significant increase in the rate of post-operative infection
when phenol is used (OR = 5.69; 95% CI 1.93 to 16.77). Fewer
participants who had had phenolisation were dissatisfied, despite
the increased incidence of post-operative infection (OR = 0.19;
95% CI 0.11 to 0.34; Analysis 4.7). It is important to bear in
mind that these results are drawn from only one study of 168
participants (Greig 1991a).
Avulsion with phenol versus surgical excision
Phenolisation combined with simple avulsion of a nail is more ef-
fective than the use of more invasive excisional surgical procedures
to prevent symptomatic recurrence at six months or more (OR =
0.44; 0.24 to 0.80; Analysis 1.1). There was no significant hetero-
geneity between studies with a p > 0.1. Although results from five
trials were used (Andrew 1979; Leahy 1990; Tait 1987; van der
Ham 1990; Varma 1983) one trial (van der Ham 1990) had more
than twice the number of participants as any other trial and had a
large influence on the results. When sensitivity analysis was carried
out excluding the trials considered to have inadequate allocation/
concealment (Andrew 1979; Tait 1987) the OR was 0.47 (0.23
to 0.95); the results were still statistically significant.
There were too few data in the comparisons between phenol com-
bined with surgical excision and phenol (used alone), and phe-
nol combined with surgical excision and surgical excision alone to
draw any clear conclusions.
D I S C U S S I O N
Summary of main results
All the studies included in the review were identified on CEN-
TRAL. The Hungarian study (Zaborszky 1997), for which more
information is required before it can be assessed, was found on
MEDLINE. Although schools of Podiatry were contacted, and
their response was good, no studies meeting the inclusion criteria
were identified. Equally, the manufacturers of cryotherapy, radio-
therapy and electrosurgical equipment responded well but no suit-
able studies were identified from this avenue. Two ongoing studies
have been identified (Crawford 2001; Thomson 2001) from the
National Research Register for possible inclusion in the review.
While all included trials measured the primary outcome of the
review, ie recurrence, other outcomes could not be quantified, as
insufficient data were available. No conclusions could be drawn
on the differences in healing times, degree of pain and frequency
of infection between different procedures, except in Greig 1991a
where infection rates were significantly lower in the group which
5Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
had simple avulsion without the addition of phenol. This outcome
was to be expected as although phenol is antiseptic it is also highly
caustic, causing more tissue damage and so more opportunity for
infection. It was interesting to note, however, that in the discussion
section of six of the nine trials the trialists felt that it was generally
preferable to use phenol, two felt it made no difference and one
did not comment.
In the trials where patient satisfaction was recorded, methods of
assessing this were not described and any data should be regarded
with caution. Three trials were excluded because of a follow-up of
less than six months. Although this meant that data were excluded,
it was felt that this was justified, as symptomatic recurrence could
not be measured accurately in a time period of less than six months.
Skill of the operator in performing the procedures is an important
consideration and was not taken into account by any of the trials.
All the trials were undertaken by general surgeons in a hospital
outpatient setting. This does not reflect the large number of pro-
cedures performed by other professionals, particularly those in the
community, for example general practitioners and podiatrists.
No trial attempted to measure cost effectiveness of each procedure.
This could be an important consideration if all other factors are
found to be similar.
All trials were very inclusive in their criteria. Unfortunately we
were unable to analyse subgroups, for example, by age group (the
skin and healing of an adolescent is very different from that of
someone in their seventies) or by medical condition, for example,
diabetes or mild ischaemia
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
From the results of one study, the addition of phenol when sim-
ple nail avulsion is performed decreases symptomatic recurrence,
but at the cost of increased post-operative infection. While use of
phenol will be most appropriate and beneficial for the majority of
people, risks and benefits should be discussed with each patient.
The evidence suggests that simple nail avulsion combined with the
use of phenol, compared to surgical excisional techniques without
the use of phenol, is more effective at preventing symptomatic
recurrence of ingrowing toenails. It should however be borne in
mind that one trial (van der Ham 1990) had a large influence on
the results.
Implications for research
Further well designed trials are needed to confirm that the use of
phenol on the nail matrix is preferable to nail matrix surgical ex-
cision. New trials should also examine short-term outcomes such
as healing time and pain as well as the primary outcome of recur-
rence.
A C K N O W L E D G E M E N T S
Philip Alderson, UK Cochrane Centre
Iain Chalmers, UK Cochrane Centre
Mark Lodge, Cochrane Cancer Network
R E F E R E N C E S
References to studies included in this review
Anderson 1990 {published data only}
Anderson JH, Greig JD, Ireland AJ, Anderson JR. Randomized,
prospective study of nail bed ablation for recurrent ingrowing
toenails. Journal of the Royal College of Surgeons of Edinburgh 1990;
35:240–2.
Andrew 1979 {published data only}
Andrew T, Wallace WA. Nail bed ablation - excise or cauterise?A
controlled study. British Medical Journal 1979;1:1539.
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
chiropodists. Chiropodist 1988;43:224.
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
chiropodists. Chiropodist 1988;43:224.
Greig 1991a {published data only}
Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical
treatment of ingrowing toenails (Study 1). Journal of Bone and Joint
Surgery. British Volume 1991;73:131–3.
Issa 1988 {published data only}
Issa MM, Tanner WA. Approach to ingrowing toenails: the wedge
resection/segmental phenolization combination treatment. British
Journal of Surgery 1988;75:181–3.
Leahy 1990 {published data only}
Leahy AL, Timon CI, Craig A, Stephens RB. Ingrowing toenails:
improving treatment. Surgery 1990;107:566–7.
Morkane 1984 {published data only}
Morkane AJ, Robertson RW, Inglis GS. Segmental phenolization of
ingrowing toenails: a randomized controlled study. British Journal
of Surgery 1984;71:526–7.
Tait 1987 {published data only}
Tait GR, Tuck JS. Surgical or phenol ablation of the nail bed for
ingrowing toenails: a randomised controlled trial [published
erratum appears in J R Coll Surg Edinb 1988 Apr;33(2):109].
Journal of the Royal College of Surgeons of Edinburgh 1987;32:
358–60.
6Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
van der Ham 1990 {published data only}
van der Ham AC, Hackeng CA, Yo TI. The treatment of ingrowing
toenails. A randomised comparison of wedge excision and phenol
cauterisation. Journal of Bone and Joint Surgery. British Volume
1990;72:507–9.
Varma 1983 {published data only}
Varma JS, Kinninmonth AW, Hamer Hodges DW. Surgical wedge
excision versus phenol wedge cauterisation for ingrowing toenail. A
controlled study. Journal of the Royal College of Surgeons of
Edinburgh 1983;28:331–2.
References to studies excluded from this review
Beaton 1990 {published data only}
Beaton DF, Kriss SM, Blacklay PF, Wood RF. Ingrowing toenails: a
patient evaulation of phenolisation versus wedge excision.
Chiropodist 1990;45:62–4.
Burssens 1987 {published data only}
Burssens P, Vereecken L, Van Loon C. [A comparative study of 2
treatment methods for onychocryptosis (ingrown toenail)]. Acta
Chirurgica Belgica 1987;87:294–7.
Fulton 1994 {published data only}
Fulton GJ, O’Donohoe MK, Reynolds JV, Keane FB, Tanner WA.
Wedge resection alone or combined with segmental phenolization
for the treatment of ingrowing toenail. British Journal of Surgery
1994;81(7):1074–5.
Gem 1990 {published data only}
Gem MA, Sykes PA. Ingrowing toenails: studies of segmental
chemical ablation. British Journal of Clinical Practice 1990;44:
562–3.
Goslin 1992 {published data only}
Goslin RW. A comparison of the dilution and non-dilution of penol
with alcohol following nail avulsions. The Foot 1992;2:225–8.
Greig 1991b {published data only}
Greig JD, Anderson JH, Ireland AJ, Anderson JR. The surgical
treatment of ingrowing toenails [Study 2]. Journal of Bone and Joint
Surgery 1991;73-B:131–3.
Holt 1987 {published data only}
Holt S, Tiwari I, Howell G. Phenolisation as an adjunct to Zadik’s
procedure for ingrowing toenail and onychogryphosis. Journal of
the Royal College of Surgeons of Edinburgh 1987;32:228–9.
Sykes 1988a {published data only}
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
chiropodists. Chiropodist 1988;43:224.
Wallace 1979b {published data only}
Wallace WA, Milne DD, Andrew T. Gutter treatment for ingrowing
toenails (study 2). British Medical Journal 1979;2:168–71.
References to studies awaiting assessment
Sykes 1988b {published data only}
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
chiropodists (study 2). Chiropodist 1988;43:224.
Sykes 1988c {published data only}
Sykes PA, Kerr R. Treatment of ingrowing toenails by surgeons and
chiropodists (study 3). Chiropodist 1988;43:224.
Zaborszky 1997 {published data only}
Zaborszky Z, Fekete L, Tauzin F, Orgovan G. Treatment of
ingrowing toenail with segmental chemical ablation. Acta
Chirurgica Hungarica 1997;36(1-4):398–400.
References to ongoing studies
Crawford 2001 {published and unpublished data}
An evaluation of ingrowing toe nail surgery in primary care.
Ongoing study 01/01/2000.
Thomson 2001 {published and unpublished data}
A clinical and economic evaluation of toe nail surgery performed by
podiatrists in the community and surgeons in the hospital setting: a
RCT. Ongoing study 01/06/99.
Additional references
Bremmer 1976
Bremmer DN, McCormick JC, Price MH, Hunter E. Ingrown
toenail: an evaluation of current treatment methods. Chiropodist
1976;31:330–5.
DeLauro 1995
DeLauro T. Onychocryptosis. Clinics in Podiatric Medicine and
Surgery 1995;12(2):201–13.
Laxton 1995
Laxton C. Clinical audit of forefoot surgery performed by registered
medical practitioners and podiatrists. Journal of Public Health
Medicine 1995;17(3):311–7.
Milwain 1998
Milwain. Ingrowing toenail surgery - a survey of current practice
amongst GPs. 1998.
Sykes 1986
Sykes PA. Ingrowing toenails: Time for critical appraisal?. Journal
of the Royal College of Surgeons of Edinburgh 1986;31(5):300–4.∗ Indicates the major publication for the study
7Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studies [ordered by study ID]
Anderson 1990
Methods Random allocation stated but method not specified
Participants All patients (31) attending general surgery departments of hospital who had undergone at least to previous
surgical procedures. Onychogryphosis was excluded. Age range 15 to 73.
Interventions Zad*k vs phenol and Zad*k
Outcomes Symptomatic recurrence
Total recurrence
Post-operative infection
Patient satisfaction
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Andrew 1979
Methods Allocation by odd/even hospital number
Participants 107 participants with either onchogryphosis or onychocryptosis
Interventions Phenolisation vs Zadik’s
Outcomes Recurrence
Further treatment required for recurrence
Average healing time
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
8Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Greig 1991a
Methods Random allocation stated but method not specified
Participants 204 procedures on 168 participants referred to hospital during one year and for whom conservative
treatment had failed. Recurrent IGTNs were excluded. Participants who had had surgery previously were
excluded.
Interventions Partial nail avulsion vs total nail avulsion vs phenol
Outcomes Symptomatic recurrence
Total recurrence
Post-operative infection
Patient satisfaction
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Issa 1988
Methods Allocation by random numbers
Participants 170 procedures referred from general practitioners and accident and emergency departments. Age range
9 to 54 (mean 21.1). Male female ratio 2.7:1.
Interventions Phenol vs Winograd vs phenol and Winograd
Outcomes Recurrence (symptomatic or asymptomatic)
Pain duration
Pain intensity (linear pain analogue scale)
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Leahy 1990
Methods Allocation by sealed envelopes
Participants All participants (68) with symptoms for more than 1 month who were referred to hospital over a fixed 6
month period. Mean age: 24.
9Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Leahy 1990 (Continued)
Interventions Phenol vs wedge excision
Outcomes Symptomatic recurrence
Asymptomatic recurrence
Post-operative infection
Degree of pain
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Morkane 1984
Methods Random allocation stated but method not specified
Participants 107 procedures on 103 participants referred from general practitioners and accident and emergency
departments who have had symptoms for longer than 2 months. participants who had undergone surgery
previously were excluded.
Mean age: 28.5 for phenol;
Interventions Phenol vs Winograd
Outcomes Recurrence (symptomatic or asymptomatic)
Pain intensity at one week (Wilcoxon Rank Sum Test used)
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Unclear B - Unclear
Tait 1987
Methods Allocation by date of birth
Participants All participants referred to hospital from general practitioners, accident and emergency and surgical clinics
during fixed nine month period. Ninety-five procedures compared (14 lost to follow-up)
Interventions Phenol vs wedge excision
10Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tait 1987 (Continued)
Outcomes Symptomatic recurrence
Asymptomatic recurrence
Post-operative infection
Pain duration
Healing time
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? No C - Inadequate
van der Ham 1990
Methods Randomisation by sealed envelopes
Participants 249 participants referred by general practitioners. participants who had undergone previous surgery were
excluded. Age range 3 to 97.
Interventions Phenol vs Winograd
Outcomes Recurrence
Re-operation required
Healing time
Pain relief required
Time required off work
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
Varma 1983
Methods Consecutive randomised envelopes
Participants 67 participants undergoing IGTN surgery during a fixed 8 months period.
Interventions Standard surgical wedge excision vs phenol wedge cauterisation
11Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Varma 1983 (Continued)
Outcomes Symptomatic recurrence at least six months
Total recurrence
Healing time
Notes
Risk of bias
Item Authors’ judgement Description
Allocation concealment? Yes A - Adequate
IGTN = ingrowing toenail
Characteristics of excluded studies [ordered by study ID]
Beaton 1990 Follow-up only three months
Burssens 1987 Follow-up not necessarily > six months. Although the mean follow-up was 12 months, some participants were
followed up after only 4 months
Fulton 1994 Not prospective
Gem 1990 Very large loss to follow-up (>30%)
Goslin 1992 Follow-up less than six months
Greig 1991b Study 2 - observational study - not comparing interventions
Holt 1987 Follow-up only three months
Sykes 1988a Not a trial - No comparison groups
Wallace 1979b Gutter treatment does not fulfil inclusion criteria as does not remove troublesome portion of the nail.
12Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of ongoing studies [ordered by study ID]
Crawford 2001
Trial name or title An evaluation of ingrowing toe nail surgery in primary care
Methods
Participants
Interventions
Outcomes
Starting date 01/01/2000
Contact information
Notes
Thomson 2001
Trial name or title A clinical and economic evaluation of toe nail surgery performed by podiatrists in the community and surgeons
in the hospital setting: a RCT
Methods
Participants
Interventions
Outcomes
Starting date 01/06/99
Contact information
Notes Complete - awaiting write up and 12 month follow-up
13Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
D A T A A N D A N A L Y S E S
Comparison 1. PHENOL AND AVULSION vs SURGICAL PROCEDURES
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Symptomatic recurrence at 6
months or more
5 585 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.44 [0.24, 0.80]
1.1 Zad*k’s 1 107 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.33 [0.10, 1.11]
1.2 Winograd 1 249 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.25 [0.09, 0.66]
1.3 Wedge/segmental excision 3 229 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.94 [0.35, 2.50]
2 Asymptomatic recurrence at least
6 months
2 166 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.95 [0.45, 2.00]
2.1 Zad*k’s 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.2 Winograd 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.3 Wedge/segmental excision 2 166 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.95 [0.45, 2.00]
3 Recurrence at 6 months or more 6 719 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.54 [0.36, 0.79]
3.1 Zad*k’s 1 107 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.37 [0.16, 0.90]
3.2 Winograd 3 464 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.43 [0.25, 0.73]
3.3 Wedge/segmental excision 2 148 Peto Odds Ratio (Peto, Fixed, 95% CI) 1.05 [0.50, 2.17]
4 Pain duration Other data No numeric data
4.1 Zad*k’s Other data No numeric data
4.2 Winograd Other data No numeric data
4.3 Wedge/segmental excision Other data No numeric data
5 Pain intensity Other data No numeric data
5.1 Zad*k’s Other data No numeric data
5.2 Winograd Other data No numeric data
5.3 Wedge/segmental excision Other data No numeric data
6 Healing time Other data No numeric data
6.1 Zad*k’s Other data No numeric data
6.2 Winograd Other data No numeric data
6.3 Wedge/segmental excision Other data No numeric data
7 Patient dissatisfied with
procedure
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.1 Zad*k’s 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.2 Winograd 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.3 Wedge/segmental excision 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8 Post operative infection 2 147 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.60 [0.24, 1.50]
8.1 Zad*k’s 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8.2 Winograd 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8.3 Wedge/segmental excision 2 147 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.60 [0.24, 1.50]
14Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 2. PHENOL AND SURGERY vs SURGERY
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Symptomatic recurrence at 6
months or more
1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.31 [0.05, 2.05]
1.1 Zad*k’s and phenol vs
zad*k’s
1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.31 [0.05, 2.05]
1.2 Winograd and phenol vs
winograd
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
1.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2 Asymptomatic recurrence at at
least 6 months
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.1 Zad*k’s and phenol vs
zad*k’s
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.2 Winograd and phenol vs
winograd
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
3 Recurrence at 6 months or more 1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.54 [0.13, 2.17]
3.1 Zad*k’s and phenol vs
zad*k’s
1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.54 [0.13, 2.17]
3.2 Winograd and phenol vs
winograd
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
3.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
4 Pain duration Other data No numeric data
4.1 Zad*k’s and phenol vs
zad*k’s
Other data No numeric data
4.2 Winograd and phenol vs
winograd
Other data No numeric data
4.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
Other data No numeric data
5 Pain intensity Other data No numeric data
5.1 Zad*k’s and phenol vs
zad*k’s
Other data No numeric data
5.2 Winograd and phenol vs
winograd
Other data No numeric data
5.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
Other data No numeric data
6 Healing time 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.1 Zad*k’s and phenol vs
zad*k’s
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
15Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
6.2 Winograd and phenol vs
winograd
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
7 Patient dissatisfied with
procedure
1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.16 [0.00, 8.29]
7.1 Zad*k’s and phenol vs
zad*k’s
1 31 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.16 [0.00, 8.29]
7.2 Winograd and phenol vs
winograd
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8 Post operative infection 1 28 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.13 [0.03, 0.66]
8.1 Zad*k’s and phenol vs
zad*k’s
1 28 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.13 [0.03, 0.66]
8.2 Winograd and phenol vs
winograd
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8.3 Wedge/segmental excision
and phenol vs wedge/segmental
excision
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
Comparison 3. PHENOL AND AVULSION vs PHENOL AND SURGERY
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Symptomatic recurrence at 6
months or more
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
1.1 Phenol vs Zad*k’s and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
1.2 Phenol vs Winograd and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
1.3 Phenol vs wedge/
segmental excision and phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2 Asymptomatic recurrence at at
least 6 months
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.1 Phenol vs Zad*k’s and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.2 Phenol vs Winograd and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.3 Phenol vs wedge/
segmental excision and phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
3 Recurrence at 6 months or more 1 115 Peto Odds Ratio (Peto, Fixed, 95% CI) 9.29 [1.27, 68.09]
3.1 Phenol vs Zad*k’s and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
3.2 Phenol vs Winograd and
phenol
1 115 Peto Odds Ratio (Peto, Fixed, 95% CI) 9.29 [1.27, 68.09]
16Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
3.3 Phenol vs wedge/
segmental excision and phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
4 Pain duration Other data No numeric data
4.1 Phenol vs Zad*k’s and
phenol
Other data No numeric data
4.2 Phenol vs Winograd and
phenol
Other data No numeric data
4.3 Phenol vs wedge/
segmental excision and phenol
Other data No numeric data
5 Pain intensity Other data No numeric data
5.1 Phenol vs Zad*k’s and
phenol
Other data No numeric data
5.2 Phenol vs Winograd and
phenol
Other data No numeric data
5.3 Phenol vs wedge/
segmental excision and phenol
Other data No numeric data
6 Healing time 0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.1 Phenol vs Zad*k’s and
phenol
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.2 Phenol vs Winograd and
phenol
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
6.3 Phenol vs wedge/
segmental excision and phenol
0 0 Mean Difference (IV, Fixed, 95% CI) Not estimable
7 Patient dissatisfied with
procedure
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.1 Phenol vs Zad*k’s and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.2 Phenol vs Winograd and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
7.3 Phenol vs wedge/
segmental excision and phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8 Post operative infection 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8.1 Phenol vs Zad*k’s and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8.2 Phenol vs Winograd and
phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
8.3 Phenol vs wedge/
segmental excision and phenol
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
Comparison 4. PHENOLISATION AND AVULSION vs SIMPLE AVULSION
Outcome or subgroup titleNo. of
studies
No. of
participants Statistical method Effect size
1 Symptomatic recurrence at 6
months or more
1 209 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.07 [0.04, 0.12]
1.1 Total nail avulsion 1 116 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.07 [0.03, 0.14]
1.2 Partial nail avulsion 1 93 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.08 [0.04, 0.18]
17Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2 Asymptomatic recurrence at at
least 6 months
0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.1 Total nail avulsion 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
2.2 Partial nail avulsion 0 0 Peto Odds Ratio (Peto, Fixed, 95% CI) Not estimable
3 Recurrence at 6 months or more 1 220 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.04 [0.02, 0.06]
3.1 Total nail avulsion 1 116 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.03 [0.01, 0.06]
3.2 Partial nail avulsion 1 104 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.05 [0.02, 0.10]
4 Pain duration Other data No numeric data
4.1 Total nail avulsion Other data No numeric data
4.2 Partial nail avulsion Other data No numeric data
5 Pain intensity Other data No numeric data
5.1 Total nail avulsion Other data No numeric data
5.2 Partial nail avulsion Other data No numeric data
6 Healing time Other data No numeric data
6.1 Total nail avulsion Other data No numeric data
6.2 Partial nail avulsion Other data No numeric data
7 Patient dissatisfied with
procedure
1 220 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.19 [0.11, 0.34]
7.1 Total nail avulsion 1 116 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.19 [0.09, 0.40]
7.2 Partial nail avulsion 1 104 Peto Odds Ratio (Peto, Fixed, 95% CI) 0.20 [0.09, 0.46]
8 Post operative infection 1 220 Peto Odds Ratio (Peto, Fixed, 95% CI) 5.69 [1.93, 16.77]
8.1 Total nail avulsion 1 116 Peto Odds Ratio (Peto, Fixed, 95% CI) 8.56 [1.87, 39.22]
8.2 Partial nail avulsion 1 104 Peto Odds Ratio (Peto, Fixed, 95% CI) 3.76 [0.81, 17.44]
18Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.1. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 1
Symptomatic recurrence at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES
Outcome: 1 Symptomatic recurrence at 6 months or more
Study or subgroup phenol surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s
Andrew 1979 3/53 9/54 25.2 % 0.33 [ 0.10, 1.11 ]
Subtotal (95% CI) 53 54 25.2 % 0.33 [ 0.10, 1.11 ]
Total events: 3 (phenol), 9 (surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 1.80 (P = 0.073)
2 Winograd
van der Ham 1990 3/125 14/124 37.3 % 0.25 [ 0.09, 0.66 ]
Subtotal (95% CI) 125 124 37.3 % 0.25 [ 0.09, 0.66 ]
Total events: 3 (phenol), 14 (surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 2.78 (P = 0.0055)
3 Wedge/segmental excision
Leahy 1990 4/39 2/46 13.1 % 2.44 [ 0.46, 12.75 ]
Tait 1987 1/43 1/38 4.6 % 0.88 [ 0.05, 14.43 ]
Varma 1983 3/28 7/35 19.8 % 0.50 [ 0.13, 1.94 ]
Subtotal (95% CI) 110 119 37.5 % 0.94 [ 0.35, 2.50 ]
Total events: 8 (phenol), 10 (surgery)
Heterogeneity: Chi2 = 2.09, df = 2 (P = 0.35); I2 =4%
Test for overall effect: Z = 0.13 (P = 0.90)
Total (95% CI) 288 297 100.0 % 0.44 [ 0.24, 0.80 ]
Total events: 14 (phenol), 33 (surgery)
Heterogeneity: Chi2 = 5.88, df = 4 (P = 0.21); I2 =32%
Test for overall effect: Z = 2.68 (P = 0.0075)
Test for subgroup differences: Chi2 = 3.79, df = 2 (P = 0.15), I2 =47%
0.05 0.2 1 5 20
Favours phenol Favours surgery
19Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 2
Asymptomatic recurrence at least 6 months.
Review: Surgical treatments for ingrowing toenails
Comparison: 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES
Outcome: 2 Asymptomatic recurrence at least 6 months
Study or subgroup Phenol Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Wedge/segmental excision
Leahy 1990 7/39 10/46 49.2 % 0.79 [ 0.27, 2.28 ]
Tait 1987 10/43 8/38 50.8 % 1.13 [ 0.40, 3.22 ]
Subtotal (95% CI) 82 84 100.0 % 0.95 [ 0.45, 2.00 ]
Total events: 17 (Phenol), 18 (Surgery)
Heterogeneity: Chi2 = 0.23, df = 1 (P = 0.64); I2 =0.0%
Test for overall effect: Z = 0.13 (P = 0.89)
Total (95% CI) 82 84 100.0 % 0.95 [ 0.45, 2.00 ]
Total events: 17 (Phenol), 18 (Surgery)
Heterogeneity: Chi2 = 0.23, df = 1 (P = 0.64); I2 =0.0%
Test for overall effect: Z = 0.13 (P = 0.89)
0.1 0.2 0.5 1 2 5 10
Favours phenol FavFavours surgery
20Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.3. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 3
Recurrence at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES
Outcome: 3 Recurrence at 6 months or more
Study or subgroup Phenol Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s
Andrew 1979 8/53 18/54 19.3 % 0.37 [ 0.16, 0.90 ]
Subtotal (95% CI) 53 54 19.3 % 0.37 [ 0.16, 0.90 ]
Total events: 8 (Phenol), 18 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 2.19 (P = 0.029)
2 Winograd
Issa 1988 4/53 7/55 9.7 % 0.57 [ 0.16, 1.97 ]
Morkane 1984 4/54 16/53 15.9 % 0.23 [ 0.09, 0.60 ]
van der Ham 1990 12/125 20/124 27.2 % 0.56 [ 0.27, 1.17 ]
Subtotal (95% CI) 232 232 52.8 % 0.43 [ 0.25, 0.73 ]
Total events: 20 (Phenol), 43 (Surgery)
Heterogeneity: Chi2 = 2.37, df = 2 (P = 0.31); I2 =16%
Test for overall effect: Z = 3.13 (P = 0.0017)
3 Wedge/segmental excision
Leahy 1990 11/39 12/46 16.4 % 1.11 [ 0.43, 2.89 ]
Varma 1983 7/28 9/35 11.6 % 0.96 [ 0.31, 2.99 ]
Subtotal (95% CI) 67 81 28.0 % 1.05 [ 0.50, 2.17 ]
Total events: 18 (Phenol), 21 (Surgery)
Heterogeneity: Chi2 = 0.04, df = 1 (P = 0.85); I2 =0.0%
Test for overall effect: Z = 0.13 (P = 0.90)
Total (95% CI) 352 367 100.0 % 0.54 [ 0.36, 0.79 ]
Total events: 46 (Phenol), 82 (Surgery)
Heterogeneity: Chi2 = 6.98, df = 5 (P = 0.22); I2 =28%
Test for overall effect: Z = 3.17 (P = 0.0015)
Test for subgroup differences: Chi2 = 4.57, df = 2 (P = 0.10), I2 =56%
0.1 0.2 0.5 1 2 5 10
Favours phenol Favours surgery
Analysis 1.4. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 4 Pain
duration.
Pain duration
Winograd
21Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pain duration (Continued)
van der Ham 1990 Phenol: Mean 0.4 days
Winograd: Mean 1.1days
Wedge/segmental excision
Tait 1987 Phenol: 2.25 days
Excision: 2.3 days
Analysis 1.5. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 5 Pain
intensity.
Pain intensity
Wedge/segmental excision
Leahy 1990 1 (out of 32) patient found phenol treatment unacceptably painful. 2 (out of 34) patients found the
surgical excision unacceptably painful
Analysis 1.6. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 6 Healing
time.
Healing time
Zad*k’s
Andrew 1979 Phenol: average 3 weeks for cryptosis, 2 weeks for gryphosis
Zadik’s: average 4 weeks for cryptosis, 2 weeks for gryphosis
Winograd
van der Ham 1990 Phenol: Mean 2.2 weeks
Winograd: Mean 2.5 weeks
Wedge/segmental excision
Tait 1987 Phenol: 28.3 days
Excision: 21.8 days
22Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.8. Comparison 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES, Outcome 8 Post
operative infection.
Review: Surgical treatments for ingrowing toenails
Comparison: 1 PHENOL AND AVULSION vs SURGICAL PROCEDURES
Outcome: 8 Post operative infection
Study or subgroup Phenol Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Wedge/segmental excision
Leahy 1990 4/32 3/34 34.0 % 1.47 [ 0.31, 6.94 ]
Tait 1987 5/43 10/38 66.0 % 0.38 [ 0.13, 1.17 ]
Subtotal (95% CI) 75 72 100.0 % 0.60 [ 0.24, 1.50 ]
Total events: 9 (Phenol), 13 (Surgery)
Heterogeneity: Chi2 = 1.89, df = 1 (P = 0.17); I2 =47%
Test for overall effect: Z = 1.09 (P = 0.28)
Total (95% CI) 75 72 100.0 % 0.60 [ 0.24, 1.50 ]
Total events: 9 (Phenol), 13 (Surgery)
Heterogeneity: Chi2 = 1.89, df = 1 (P = 0.17); I2 =47%
Test for overall effect: Z = 1.09 (P = 0.28)
0.1 0.2 0.5 1 2 5 10
Favours phenol Favours surgery
23Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.1. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 1 Symptomatic recurrence
at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 2 PHENOL AND SURGERY vs SURGERY
Outcome: 1 Symptomatic recurrence at 6 months or more
Study or subgroup Phenol and surgery Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s and phenol vs zad*k’s
Anderson 1990 1/14 4/17 100.0 % 0.31 [ 0.05, 2.05 ]
Subtotal (95% CI) 14 17 100.0 % 0.31 [ 0.05, 2.05 ]
Total events: 1 (Phenol and surgery), 4 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.22)
2 Winograd and phenol vs winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Wedge/segmental excision and phenol vs wedge/segmental excision
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 14 17 100.0 % 0.31 [ 0.05, 2.05 ]
Total events: 1 (Phenol and surgery), 4 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.22)
0.05 0.2 1 5 20
Favours phenol % su Favours surgery
24Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.3. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 3 Recurrence at 6 months or
more.
Review: Surgical treatments for ingrowing toenails
Comparison: 2 PHENOL AND SURGERY vs SURGERY
Outcome: 3 Recurrence at 6 months or more
Study or subgroup Phenol and surgery Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s and phenol vs zad*k’s
Anderson 1990 6/14 10/17 100.0 % 0.54 [ 0.13, 2.17 ]
Subtotal (95% CI) 14 17 100.0 % 0.54 [ 0.13, 2.17 ]
Total events: 6 (Phenol and surgery), 10 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 0.87 (P = 0.38)
2 Winograd and phenol vs winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Wedge/segmental excision and phenol vs wedge/segmental excision
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 14 17 100.0 % 0.54 [ 0.13, 2.17 ]
Total events: 6 (Phenol and surgery), 10 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 0.87 (P = 0.38)
0.1 0.2 0.5 1 2 5 10
Favours phenol and s Favours surgery
25Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.7. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 7 Patient dissatisfied with
procedure.
Review: Surgical treatments for ingrowing toenails
Comparison: 2 PHENOL AND SURGERY vs SURGERY
Outcome: 7 Patient dissatisfied with procedure
Study or subgroup Phenol and surgery Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s and phenol vs zad*k’s
Anderson 1990 0/14 1/17 100.0 % 0.16 [ 0.00, 8.29 ]
Subtotal (95% CI) 14 17 100.0 % 0.16 [ 0.00, 8.29 ]
Total events: 0 (Phenol and surgery), 1 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 0.91 (P = 0.36)
2 Winograd and phenol vs winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Wedge/segmental excision and phenol vs wedge/segmental excision
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 14 17 100.0 % 0.16 [ 0.00, 8.29 ]
Total events: 0 (Phenol and surgery), 1 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 0.91 (P = 0.36)
0.005 0.1 1 10 200
Favours phenol % su Favours surgery
26Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.8. Comparison 2 PHENOL AND SURGERY vs SURGERY, Outcome 8 Post operative infection.
Review: Surgical treatments for ingrowing toenails
Comparison: 2 PHENOL AND SURGERY vs SURGERY
Outcome: 8 Post operative infection
Study or subgroup Phenol and surgery Surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Zad*k’s and phenol vs zad*k’s
Anderson 1990 1/14 7/14 100.0 % 0.13 [ 0.03, 0.66 ]
Subtotal (95% CI) 14 14 100.0 % 0.13 [ 0.03, 0.66 ]
Total events: 1 (Phenol and surgery), 7 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 2.46 (P = 0.014)
2 Winograd and phenol vs winograd
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
3 Wedge/segmental excision and phenol vs wedge/segmental excision
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol and surgery), 0 (Surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 14 14 100.0 % 0.13 [ 0.03, 0.66 ]
Total events: 1 (Phenol and surgery), 7 (Surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 2.46 (P = 0.014)
0.02 0.1 1 10 50
Favours phenol % su Favours surgery
27Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.3. Comparison 3 PHENOL AND AVULSION vs PHENOL AND SURGERY, Outcome 3
Recurrence at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 3 PHENOL AND AVULSION vs PHENOL AND SURGERY
Outcome: 3 Recurrence at 6 months or more
Study or subgroup Phenol Phenol and surgery Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Phenol vs Zad*k’s and phenol
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Phenol and surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
2 Phenol vs Winograd and phenol
Issa 1988 4/53 0/62 100.0 % 9.29 [ 1.27, 68.09 ]
Subtotal (95% CI) 53 62 100.0 % 9.29 [ 1.27, 68.09 ]
Total events: 4 (Phenol), 0 (Phenol and surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 2.19 (P = 0.028)
3 Phenol vs wedge/segmental excision and phenol
Subtotal (95% CI) 0 0 0.0 % 0.0 [ 0.0, 0.0 ]
Total events: 0 (Phenol), 0 (Phenol and surgery)
Heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 53 62 100.0 % 9.29 [ 1.27, 68.09 ]
Total events: 4 (Phenol), 0 (Phenol and surgery)
Heterogeneity: not applicable
Test for overall effect: Z = 2.19 (P = 0.028)
0.01 0.1 1 10 100
Favours phenol Favours phenol % sur
28Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.1. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 1
Symptomatic recurrence at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION
Outcome: 1 Symptomatic recurrence at 6 months or more
Study or subgroup Phenol Simple avulsion Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Total nail avulsion
Greig 1991a 6/57 46/59 55.4 % 0.07 [ 0.03, 0.14 ]
Subtotal (95% CI) 57 59 55.4 % 0.07 [ 0.03, 0.14 ]
Total events: 6 (Phenol), 46 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 7.27 (P < 0.00001)
2 Partial nail avulsion
Greig 1991a 6/46 36/47 44.6 % 0.08 [ 0.04, 0.18 ]
Subtotal (95% CI) 46 47 44.6 % 0.08 [ 0.04, 0.18 ]
Total events: 6 (Phenol), 36 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 6.12 (P < 0.00001)
Total (95% CI) 103 106 100.0 % 0.07 [ 0.04, 0.12 ]
Total events: 12 (Phenol), 82 (Simple avulsion)
Heterogeneity: Chi2 = 0.09, df = 1 (P = 0.77); I2 =0.0%
Test for overall effect: Z = 9.50 (P < 0.00001)
Test for subgroup differences: Chi2 = 0.09, df = 1 (P = 0.77), I2 =0.0%
0.02 0.1 1 10 50
Favours phenol Favours avulsion
29Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.3. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 3
Recurrence at 6 months or more.
Review: Surgical treatments for ingrowing toenails
Comparison: 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION
Outcome: 3 Recurrence at 6 months or more
Study or subgroup Phenol Simple avulsion Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Total nail avulsion
Greig 1991a 6/57 59/59 52.8 % 0.03 [ 0.01, 0.06 ]
Subtotal (95% CI) 57 59 52.8 % 0.03 [ 0.01, 0.06 ]
Total events: 6 (Phenol), 59 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 9.66 (P < 0.00001)
2 Partial nail avulsion
Greig 1991a 6/57 41/47 47.2 % 0.05 [ 0.02, 0.10 ]
Subtotal (95% CI) 57 47 47.2 % 0.05 [ 0.02, 0.10 ]
Total events: 6 (Phenol), 41 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 7.78 (P < 0.00001)
Total (95% CI) 114 106 100.0 % 0.04 [ 0.02, 0.06 ]
Total events: 12 (Phenol), 100 (Simple avulsion)
Heterogeneity: Chi2 = 0.97, df = 1 (P = 0.33); I2 =0.0%
Test for overall effect: Z = 12.37 (P < 0.00001)
Test for subgroup differences: Chi2 = 0.97, df = 1 (P = 0.33), I2 =0.0%
0.1 0.2 0.5 1 2 5 10
Favours phenol Favours avulsion
30Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.7. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 7
Patient dissatisfied with procedure.
Review: Surgical treatments for ingrowing toenails
Comparison: 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION
Outcome: 7 Patient dissatisfied with procedure
Study or subgroup Phenol Simple avulsion Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Total nail avulsion
Greig 1991a 9/57 32/59 54.3 % 0.19 [ 0.09, 0.40 ]
Subtotal (95% CI) 57 59 54.3 % 0.19 [ 0.09, 0.40 ]
Total events: 9 (Phenol), 32 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 4.31 (P = 0.000016)
2 Partial nail avulsion
Greig 1991a 9/57 24/47 45.7 % 0.20 [ 0.09, 0.46 ]
Subtotal (95% CI) 57 47 45.7 % 0.20 [ 0.09, 0.46 ]
Total events: 9 (Phenol), 24 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 3.83 (P = 0.00013)
Total (95% CI) 114 106 100.0 % 0.19 [ 0.11, 0.34 ]
Total events: 18 (Phenol), 56 (Simple avulsion)
Heterogeneity: Chi2 = 0.01, df = 1 (P = 0.92); I2 =0.0%
Test for overall effect: Z = 5.77 (P < 0.00001)
Test for subgroup differences: Chi2 = 0.01, df = 1 (P = 0.92), I2 =0.0%
0.1 0.2 0.5 1 2 5 10
Favours phenol Favours avulsion
31Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.8. Comparison 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION, Outcome 8 Post
operative infection.
Review: Surgical treatments for ingrowing toenails
Comparison: 4 PHENOLISATION AND AVULSION vs SIMPLE AVULSION
Outcome: 8 Post operative infection
Study or subgroup Phenol Simple avulsion Peto Odds Ratio Weight Peto Odds Ratio
n/N n/N Peto,Fixed,95% CI Peto,Fixed,95% CI
1 Total nail avulsion
Greig 1991a 7/57 0/59 50.4 % 8.56 [ 1.87, 39.22 ]
Subtotal (95% CI) 57 59 50.4 % 8.56 [ 1.87, 39.22 ]
Total events: 7 (Phenol), 0 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 2.76 (P = 0.0057)
2 Partial nail avulsion
Greig 1991a 6/57 1/47 49.6 % 3.76 [ 0.81, 17.44 ]
Subtotal (95% CI) 57 47 49.6 % 3.76 [ 0.81, 17.44 ]
Total events: 6 (Phenol), 1 (Simple avulsion)
Heterogeneity: not applicable
Test for overall effect: Z = 1.69 (P = 0.090)
Total (95% CI) 114 106 100.0 % 5.69 [ 1.93, 16.77 ]
Total events: 13 (Phenol), 1 (Simple avulsion)
Heterogeneity: Chi2 = 0.56, df = 1 (P = 0.46); I2 =0.0%
Test for overall effect: Z = 3.16 (P = 0.0016)
Test for subgroup differences: Chi2 = 0.56, df = 1 (P = 0.46), I2 =0.0%
0.02 0.1 1 10 50
Favours phenol Favours avulsion
A P P E N D I C E S
Appendix 1. Electronic search terms
Keywords:
INGROWING TOENAIL*
ONYCHOGRYPHOSIS
ONYCHOCRYPTOSIS
CHEMICAL ABLATION
PHENOL*
ZADEK*
ZADIK*
ZADECK*
WINOGRAD*
WEDGE RESECTION
WEDGE EXCISION
NAIL BED ABLATION
32Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
NAIL BED EXCISION
NAIL MATRIX
CRYO*
INVOLUTED TOENAIL*
HYDROGEN PEROXIDE
NITROUS OXIDE
SALICYLIC ACID
F E E D B A C K
Comment received 9 December 1999
Summary
Comment 1
This is an interesting and useful review, but I think the inclusion criteria
should be modified so that in the next revision any trial comparing a
surgical treatment with another treatment, whether surgical or not, is
included. In practice the doctor and patient have to choose between all the
treatments on offer, not just between different surgical treatments. There
is no a priori reason why a treatment should aim to remove part or all of a
nail. The trial by Wallace et al which was excluded, compares the much
simpler and easier gutter treatment with surgery, and was worthwhile even
though it was effective in a lower proportion of cases.
Comment 2
In the authors’ view, what other reviews are needed? It would be good to
have a comment on this in the conclusion under ’Implications for research.
Comment 3
The paragraph on ’Implications for research’ should be expanded to include
estimation of the cost-effectiveness of the different treatments, and of
their effects on various aspects of disability (eg time off work, ability to
walk normally, need for follow-up visits).
Comment 4
Did any consumers or participants with experience of ingrowing toenail comment
on the review? Did any chiropodist do so? If so, this should be said; if
not, such comments should be solicited and used to strengthen the review.
33Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Reply
Comment 1
Conservative treatment is successful for most cases for ingrowing toenails.
Surgery is generally chosen as a 2nd line of treatment after more
conservative treatments have already been tried and failed. I wouldn’t
expect to find trials comparing a surgical treatment to a more conservative
treatment because ethically, where possible, a conservative treatment should
be tried, before involving the patient in invasive surgery.
While there is scope to evaluate conservative treatments, I think this
should be done as a separate review.
Comment 2
On the theme of surgery for ingrowing toenails I have a couple of ideas for
useful reviews:
1. comparison of operators eg general surgeon versus podiatrist on
recurrence, cost and complication rates.
2. post-operative care of wounds (particularly after phenolisation).
On foot care generally there are a huge number of reviews which would be
useful, although those done recently on diabetic foot health are very
important. If choosing one area to review, I think the impact of the free
availability of podiatry services on the well-being of elderly people would
be particularly useful to funders.
Comment 3
Yes, fair comment. I had mentioned these factors in the discussion and on
reflection, do think I can justify adding them to ’Implications for research.
Comment 4
C. Rounding is an ex-chiropodist and S. Bloomfield is a practising
chiropodist. L. Gliddon, who had an ingrowing toenail, commented on the
review for readability and relevance. A practising chiropodist acted as a
content referee for the protocol and final review.
Contributors
Comment sent by:
Andrew Herxheimer
Reply from:
Catherine Rounding (lead reviewer)
Processed by:
Urbà González, Cochrane Skin Group Criticisms Editor
Tina Leonard, Review Group Co-ordinator for the Cochrane Skin Group
34Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
W H A T ’ S N E W
Last assessed as up-to-date: 27 October 2002.
12 June 2008 Amended Converted to new review format.
H I S T O R Y
Protocol first published: Issue 2, 1999
Review first published: Issue 3, 1999
18 November 2002 Amended Minor update
29 October 2002 Feedback has been incorporated Response to feedback added
29 October 2002 Feedback has been incorporated Feedback added
28 October 2002 New citation required and conclusions have changed Substantive amendment
28 October 2002 New search has been performed New studies sought but not found
28 November 2000 New search has been performed New studies found and included or excluded
20 November 2000 New search has been performed New studies found but not yet included or excluded
30 September 1999 Amended Reformatted
D E C L A R A T I O N S O F I N T E R E S T
None known
N O T E S
This review is currently being updated by a new team of authors. Until this update is published, please be aware that this review was
last assessed as up-to-date in 2002.
35Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
I N D E X T E R M SMedical Subject Headings (MeSH)
Combined Modality Therapy; Nails, Ingrown [prevention & control; ∗surgery]; Phenol [therapeutic use]; Randomized Controlled
Trials as Topic; Recurrence [prevention & control]; Toes
MeSH check words
Humans
36Surgical treatments for ingrowing toenails (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.