Infection Rate by Gustilo-Anderson Classification in Open Tibial Shaft Fractures Treated With an Intramedullary Nail-A Meta-Analysis.

Abstract

To quantify deep surgical site infection (SSI) rates after intramedullary nailing of open tibial shaft fractures stratified by Gustilo-Anderson (G-A) classification. 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. 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. Two independent reviewers screened studies and extracted data, with conflicts resolved through consensus or adjudication by a third independent reviewer. 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. 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. 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. Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.