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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Discarding the fingernail during nail bed repair surgery may be as good as replacing the dead nail and could save money, research suggests. In a randomised trial, the number of infections and the appearance of the new nail was similar.

Nail bed repair surgery is common, especially in children, after a finger has been crushed in a door, for example. Usually, the nail is removed during surgery and the cut beneath it stitched up. Most surgeons put the dead nail back, or use foil as a substitute if the nail is too damaged.

An alternative approach is to discard the nail and just dress the injury after repairing the nail bed. Before this study, there was a lack of research to show which approach is best (in terms of infections, appearance and cost). The researchers say that either option is good, but discarding the nail during nail bed repair surgery could save the NHS money.

These findings will interest surgeons and may encourage them to discard the nail during this nail bed repair surgery. Parents will be reassured that discarding the nail does not worsen the appearance of the nail.

Individual NHS trusts provide information about nail bed repair surgery; one example is from St George's NHS Foundation Trust.

The issue: should the fingernail be discarded during nail bed surgery?

Nail bed injuries are usually caused when a fingertip is crushed in a closing door. They are the most common hand injury in children; more than 10,000 nail bed repairs are done in the UK each year.

Nearly all (96%) surgeons remove the nail, stitch the cut beneath it and put the dead nail back on. This is thought to protect the repair, reduce infections and reduce pain when dressings are changed. But there is little research into whether this is the best way to manage these injuries. Surgeons could instead just dress the injury and discard the nail.

Researchers investigated whether discarding the fingernail was better (in terms of infection and appearance) than keeping it. They also evaluated the costs of the two approaches.

What’s new?

The study included children under 16 years who had nail bed injuries. They were treated at 20 NHS hand surgery clinics. Half were randomly assigned to have their nail replaced, the others had the nail discarded during surgery.

Researchers assessed the fingernail for infection before surgery, 7 – 10 days afterwards, then again at 4 – 12 months. They evaluated nail appearance at 4 – 12 months.

The study found:

  • at 7 days among 440 children, the number of infections was similar: 5 infections in the nail replacement group (222 children) and 2 infections in the nail discard group (218 children)
  • at 4 – 12 months among 295 children, there was little difference in nail appearance between groups.

The average cost in the 4 – 12 months after surgery was £75 more for the nail replacement group than the nail discard group. This was mostly due to additional stitches and longer operating times.

Why is this important?

The differences between nail replacement and nail discard were small, but the cost savings favour nail discard. If all nail bed repair surgeries discarded the nail, the NHS could save £720,000 per year, the researchers say.

Replacing the nail did not reduce pain when dressings were changed in this study. Nor did it influence the appearance of the new nail when it grew back.

Reflections for surgeons…

Will these findings change my practice and encourage me to discard rather than replace fingernails?

How will I advise parents about the options before their child’s surgery?

What’s next?

Surgeons disagree whether it is best to replace or discard the nail during surgery. The results support discarding the nail, the researchers say.

The researchers have shared their findings with the British Association of Plastic Reconstructive and Aesthetic Surgeons, British Society for Surgery of the Hand and Australian Hand Surgery Society. They plan to carry out a survey in 2024 to find out if practice has changed since these findings were published.

You may be interested to read

This Alert is based on: Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial. Jain A, and others. British Journal of Surgery 2023; 110: 432 – 438.

Patient information leaflet from St George's NHS Foundation Trust about nail bed repair surgery.

Conflict of interest: None declared.

Funding: This study was funded by the NIHR Research for Patient Benefit programme.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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