JOT - 2026-09-01 - Journal Article; Meta-Analysis; Systematic Review
Infection Rate by Gustilo-Anderson Classification in Open Tibial Shaft Fractures Treated With an Intramedullary Nail-A Meta-Analysis.
Schermerhorn JT, McGlone PJ, Torrie AM, Carlini AR, Castillo RC, Abar B, Hendren S, Wesorick BR, Helbling AV, Zhang Y, Mann TK, Kelly C, O'Toole RV
Topics
Key Takeaway
Deep SSI rates after IMN of open tibial shaft fractures escalate from 6.2% (G-A Type I) to 41.8% (G-A Type IIIC), with a pooled overall rate of 13.2% across 2,063 patients.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This PRISMA-compliant single-arm meta-analysis quantified pooled deep SSI rates after locked IMN of open tibial shaft fractures (OTA/AO 42) stratified by Gustilo-Anderson classification using fixed- and random-effects models. Pooled SSI rates were 6.2% (Type I), 7.6% (Type II), 11.9% (Type IIIA), 25.0% (Type IIIB), and 41.8% (Type IIIC), with significant between-classification heterogeneity (Q=104.85, P<0.001). Between-study heterogeneity was low for most subgroups but moderate for Type IIIB (I²=50.7%).
Key Limitation
The Type IIIC pooled estimate carries a 95% CI of 21.3%–65.5%, reflecting sparse data and extreme heterogeneity that renders this subgroup rate unreliable for clinical benchmarking.
Original Abstract
OBJECTIVES
To quantify deep surgical site infection (SSI) rates after intramedullary nailing of open tibial shaft fractures stratified by Gustilo-Anderson (G-A) classification.
DATA SOURCES
A systematic review of MEDLINE, Embase, and Scopus screened for English language studies published from January 2000 through May 2025 in accordance with PRISMA guidelines.
STUDY SELECTION
Studies included skeletally mature patients with open tibial shaft fractures (OTA/AO 42) treated with locked intramedullary nailing and reporting deep SSI rates by G-A type.
DATA EXTRACTION
Two independent reviewers screened studies and extracted data, with conflicts resolved through consensus or adjudication by a third independent reviewer.
DATA SYNTHESIS
A single-arm meta-analysis was performed to estimate pooled infection rates using fixed-effects and random-effects models, with between-study heterogeneity assessed using Cochran Q and the I2 statistic.
RESULTS
Seventeen studies composed of 2063 total patients met inclusion criteria. The overall pooled deep SSI rate was 13.2% [95% confidence interval (CI), 11.8%-14.8%]. Stratified pooled infection rates were 6.2% (95% CI, 3.7%-10.3%) for G-A type I, 7.6% (95% CI, 5.6%-10.1%) for type II, 11.9% (95% CI, 9.5%-14.6%) for type IIIA, 25.0% (95% CI, 18.6%-32.6%) for type IIIB, and 41.8% (95% CI, 21.3%-65.5%) for type IIIC fractures. Subgroup analysis demonstrated a significant difference in pooled deep SSI rates across G-A fracture classifications (Q = 104.85, df = 4, P < 0.001), indicating substantial heterogeneity attributable to fracture severity. Between-study heterogeneity was low across most analyses, with moderate heterogeneity observed for type IIIB fractures (I 2 = 50.7%), indicating increased variability in this subgroup.
CONCLUSIONS
Deep SSI rates after intramedullary nailing of open tibial shaft fractures increased with G-A severity. High-grade injuries, particularly G-A types IIIB and IIIC, remain associated with substantial fracture-related infection risk.
LEVEL OF EVIDENCE
Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.