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Subungual Exostosis of the Toes: A Systematic Review

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Clinical Orthopaedics and Related Research®

A CORR Insights to this article was published on 13 December 2013



Subungual exostosis is a relatively common benign bone tumor that occurs in the distal phalanges of the toes and can be a source of pain and nail deformity. There is controversy about the treatment of these lesions and there are few studies that have synthesized what is known and provided meaningful information on treatment.


We performed a systematic review to address the following questions: (1) What is the best surgical approach for excising these lesions? (2) What is the age range, sex distribution, and presenting symptoms of subungual exostoses and which toe is most frequently affected? (3) What complications arise from treatment?


Two authors independently searched multiple databases (Medline, 1950–May 2013; Cochrane EBM database, and EMBASE, 1980–May 2013 provided by OVID; ACP Journal Club, 2003–May 2013; CINAHL by EBSCO, 1937–May 2013; and PubMed by NLM, 1940–May 2013), and key words were chosen to achieve a broad search strategy. We included studies on the management of toe exostoses with > 10 cases and we excluded studies that reported on upper extremity exostoses or osteochondromas. Demographic and treatment data were collected from each article by two independent authors and collated. A total of 124 abstracts were screened, and 116 articles were reviewed in full, of which 13 met the inclusion criteria.


Complete marginal excision through a fish mouth incision protecting the nail led to a recurrence rate of 4% and satisfactory clinical results, defined as no requirement for postoperative intervention and a satisfactory clinical appearance in 73%. Most studies provided incomplete descriptions of specific surgical techniques used. Fifty-five percent of the patients were younger than 18 years of age. A history of toe trauma before diagnosis was present in approximately 30% of the cases. Delayed diagnosis occurred in approximately 10% of the cases and onychodystrophy occurred in more than 10%.


There is weak evidence to guide management of subungual exostosis. Adequate wound management postexcision aiming to minimize disruption to the nail bed and matrix may prevent onychodystrophy, which is a common complication of treatment.

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Correspondence to Mark P. DaCambra MD, MSc.

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Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

This work was performed at the Alberta Children’s Hospital, Calgary, Alberta, Canada.

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DaCambra, M.P., Gupta, S.K. & Ferri-de-Barros, F. Subungual Exostosis of the Toes: A Systematic Review. Clin Orthop Relat Res 472, 1251–1259 (2014).

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