Discussion
injury severities, infections, fingertip injury, pain, infection, trauma
INFECTION, INFECTIONS
The NINJA trial showed no statistically significant difference in early (day 7) infections or final cosmetic outcome between patients who had the fingernail replaced and those who had the fingernail discarded after nail bed repair. The early infection rate (day 7) was 2.2 per cent in the nail-replaced group There was no difference between groups in cosmetic outcome or satisfaction with appearance, suggesting that replacing the nail, or not, does not influence the appearance of the new nail that grows out.There was no evidence that replacing the nail after surgery can offer reduced pain at dressing change. A slightly larger number of children experienced pain in the nail-discarded group (47.8 per cent) compared with the nail-replaced group (40.5 per cent) but this did not reach statistical significance.The health economic analysis showed that replacing the nail was associated with significantly longer operating time and cost. This resulted in a statistically significant cost saving of £75 per patient if the nail was discarded. Nail bed repair is the commonest paediatric hand trauma operation performed globally; this represents a significant cost saving to healthcare systems. As 96 per cent of nail bed repair procedures currently involve replacement of the nailThe NINJA trial is the first large RCT investigating outcomes after paediatric fingertip injury, and provides strong evidence to direct practice. Development of the OFNAS has provided a more evidence-based tool for assessing nail cosmesis for future studies. The infection rate was lower than anticipated in both groups, and will have contributed to the lower level of statistical precision. The very low rate of missing data at 7–10 days for the infection rate is a great strength, but the later missing data at the final cosmesis time point is a limitation. However, the sensitivity analysis which looked at the potential impact of missing data (using the RCTmiss command) suggested the finding was robust. A further limitation was the necessary changeover of cosmetic assessment method to include parents reporting a large proportion of the final assessment.Compared with the published literature, this study provides more robust data on the potential harms and likely outcome of patients undergoing nail bed repair. This will support the counselling of parents and older children. Previous non-randomized studies reported higher rates of infection perhaps owing to the limitations of non-randomized retrospective studiesWhether to replace or discard the nail plate has been a longstanding source of contention among surgeons. This study has addressed this issue and laid the foundation for asking a further question: Should the nail bed be repaired or not? Nail bed injuries encompass a wide spectrum of injury severities. For instance, a sizeable proportion might be amenable to being cleaned in the emergency department and dressed with adhesive strips.