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

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.