Comment on: Effectiveness of nail bed repair in children with or without replacing the fingernail: NINJA multicentre randomized clinical trial

Dear Editor

We commend Jain et al.¹ on publication of the NINJA trial, but wish to comment on a number of points.

An €85 cost of nail-plate replacement is suggested, comprising ‘additional’ suture material (€4.84) and 3.4 min operating time. First, we note that this is reported as 4.6 min in Table S1. Second, operating time was recorded in approximately 55% of operations, with a wide standard deviation. We presume that missing data were addressed through multiple imputation and bootstrapping, but remain concerned at the high level of missing data and subsequent conclusions drawn. The potential saving of €815 600 seems speculative. Suture used for repair is often sufficient for securing the nail plate, negating additional cost. Furthermore, 3.4 min does not translate into additional operative capacity in practice and would be dwarfed by the myriad causes of perioperative delay. Therefore, no cost is saved.

‘Perioperative’ antibiotics were given in around half of patients. Duration of treatment and whether this was from the time of injury, at induction or after intervention is not stated. If unnecessary, as suggested by the lack of difference in infection, omitting antibiotics would provide a tangible cost reduction, more so than decisions regarding nail-plate replacement.

Less than 2% of the cases appeared to involve the germinal matrix, which one might argue is the only indication for nail-plate replacement. We presume this was too small for subgroup analysis.

Was information collected on nail-plate preparation (trimming, fenestration, antimicrobial soaking)? Might this have had a significant effect on the rate of associated infection?

Hopefully, some of these issues may be addressed in the author’s planned future paper on the health economic conclusions. These points aside, we applaud the authors for their achievement. As stated before, NINJA’s greatest legacy may lie in demonstrating that surgical multicentre RCTs are deliverable and can challenge surgical dogma.

Author contributions

Lewis Dingle (Conceptualization, Writing—original draft, review & editing), and Daniel Jordan (Conceptualization, Supervision, Writing—review & editing)