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Infection Rate by Gustilo-Anderson Classification in Open Tibial Shaft Fractures Treated With an Intramedullary
Janse T Schermerhorn1,2, Patrick J McGlone1,2, Arissa M Torrie2,3
1Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
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.
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