Injury, Int. J.

Care Injured 42 (2011) 14081415

Contents lists available at SciVerse ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Prevalence of complications of open tibial shaft fractures stratied as per the

GustiloAnderson classication
Costas Papakostidis a, Nikolaos K. Kanakaris b, Juan Pretel c, Omar Faour c,d, Daniel Juan Morell b,
Peter V. Giannoudis c,*
a
Department of Trauma and Orthopaedics, Hatzikosta General Hospital, Ioannina, Greece
b
Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
c
Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
d
Orthopaedic Clinic, University Hospital of Valladolid, Valladolid, Spain

A R T I C L E I N F O A B S T R A C T

Article history: The aim of the present study was to comparatively analyse certain outcome measures of open tibial
Accepted 12 October 2011 fractures, stratied per grade of open injury and method of treatment. For this purpose, a systematic
review of the English literature from 1990 until 2010 was undertaken, comprising 32 eligible articles
Keywords: reporting on 3060 open tibial fractures. Outcome measures included rates of union progress (early union,
Open fracture delayed union, late union and non-union rates) and certain complication rates (deep infection,
Tibia compartment syndrome and amputation rates). Statistical heterogeneity across component studies was
GustiloAnderson classication
detected with the use of Cochran chi-square and I2 tests. In the absence of signicant statistical
Union
Nonunion
heterogeneity a pooled estimate of effect size for each outcome/complication of interest was produced.
Infection All component studies were assigned on average a moderate quality score. Reamed tibial nails (RTNs)
Compartment syndrome were associated with signicantly higher odds of early union compared with unreamed tibial nails
Clinical outcome (UTNs) in IIIB open fractures (odds ratio: 12, 95% CI: 2.461). Comparing RTN and UTN modes of
Review treatment, no signicant differences were documented per grade of open fractures with respect to both
delayed and late union rates. Surprisingly, nonunion rates in IIIB open fractures treated with either RTNs
or UTNs were lower than IIIA or II open fractures, although the differences were not statistically
signicant. Signicantly increased deep infection rates of IIIB open fractures compared with all other
grades were documented for both modes of treatment (RTN, UTN). However, lower deep infection rates
for IIIA open fractures treated with RTNs were recorded compared with grades I and II. Interestingly,
grade II open tibial fractures, treated with UTN, presented signicantly greater odds for developing
compartment syndrome than when treated with RTNs. Our cumulative analysis, providing for each grade
of open injury and each particular method of treatment a summarised estimate of effect size for the most
important outcome measures of open tibial fractures, constitutes a useful tool of the practicing surgeon
for optimal decision making when operative treatment of such fractures is contemplated.
2011 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1409
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1409
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1410
Stratication of the results according to the type of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1411
Outcomes of open tibial fractures treated with IMNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1411
Outcomes of open tibial fractures treated with Ex Fix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1412
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1412
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1414

* Corresponding author at: Academic Department of Trauma and Orthopaedics, Leeds General Inrmary, Clarendon Wing Level A, Leeds LS1 3EX, United Kingdom.
Tel.: +44 1133922750; fax: +44 1133923290.
E-mail addresses: epappa@ioa.forthnet.gr (C. Papakostidis), nikolaoskanakaris@yahoo.co.uk (N.K. Kanakaris), el_giova23@yahoo.com (J. Pretel), ofmartin@msn.com
(O. Faour), dmorell@doctors.org.uk (D.J. Morell), peter.giannoudis@leedsth.nhs.uk, pgiannoudi@aol.com (P.V. Giannoudis).

00201383/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.10.015
 C. Papakostidis et al. / Injury, Int. J. Care Injured 42 (2011) 14081415
Introduction
Fractures of the tibial shaft have a recorded incidence of 1721
per 100,000 population, represent 2% of all fractures, and 36.7% of
all long-bone fractures in adults.1,2 Due to the specic anatomical
features of the tibia (limited soft tissue coverage), more than 15% of
its fractures are classied as open,1 representing the most
common (44.4%) open long-bone injuries.3
Open tibial fractures are mostly the result of high-energy
trauma.1,3 Due to the precarious blood supply of the tibial bone, the
initial and secondary contamination, and the often sub-optimal
conditions of their treatment as an urgent surgical priority, they
are associated with high rates of complications, such as nonunion,
malunion, infection and compartment syndrome.46
Efforts in classication of the complex soft tissue and tibial bone
injuries have started to form when Veliskakis7 introduced the
classication that 15 years later Gustilo and Anderson modied
and established.8,9 Since then, the grades of this classication are
universally accepted and routinely used in clinical and research
practice. Certain limitations of this classication scheme have been
identied in the progress of time. These include the underestima-
tion of damage to muscles and bone, the moderate-to-poor inter-
observer agreement, its subjective nature, and its variable
accuracy dependent on the experience of the surgeon.1012
However, one of the major strengths of the Gustilo and
Anderson classication is the association of its grades to the
incidence of complication rates and fracture prognosis.6,8,9,1320 No
cumulative data however exist to provide the clinicians with
substantial evidence with regard to the perioperative clinical
course and incidence of complications of these injuries. A
comprehensive review of the literature therefore was undertaken
in order to identify the overall evidence on the incidence of (a) the
progress of fracture consolidation (early union; delayed union; late
union and nonunion), (b) infection, (c) compartment syndrome
and (d) resulting amputations of open tibial fractures stratied per
Gustilo and Anderson grades. We also aimed to comparatively
analyse these outcome measures between different methods of
treatment.
Materials and methods
The PubMed search engine was used to identify all relevant
publications since 1976, wherein the clinical outcome of open
tibial shaft fractures, classied according to the Gustilo and
Anderson system, was described. Articles including the following
terms and Boolean operators: open AND fracture AND tibia
were initially searched for. Before commencing our search, certain
inclusion and exclusion criteria were dened. Articles were
considered eligible if they met the following inclusion criteria: (1)
the target population consisted of patients with open tibial shaft
fractures; (2) the method of treatment of these fractures was
described adequately; (3) at least one of the following outcomes/
complications was described: early union/nonunion/delayed
union/malunion/infection/compartment syndrome/amputation;
and (4) series with at least 50 consecutive patients. Case reports,
review papers, expert opinion articles, editorials, letters to the
editor, publications on congress proceedings, manuscripts with
incomplete documentation of the incidence of complications, or
wherein the results were described in mixed series of different
types of open fractures were excluded (Fig. 1). We limited our
search to papers published in the English language since 1990.The
titles of all retrieved citations were carefully reviewed by two
independently working reviewers (NKK, JP) and, when necessary,
the respective abstracts were obtained. Most of the citations were
immediately excluded on the basis of information provided by the
title or abstract. The complete manuscripts of the remaining
1409
papers were obtained and were carefully examined for eligibility
criteria. Moreover, their references along with the references of
relevant review articles were carefully scrutinised for potentially
eligible papers. The reviewers were not blinded to the names of
authors, institutions and journals. The period of patients
enrolment in each study was closely scrutinised to eliminate
the possibility of including relevant data described in many
reports. Any disagreement between the two reviewers was
resolved by consensus.
The quality of the reviewed manuscripts was evaluated by two
assessors (NKK, JP). They independently assessed the retrieved
manuscripts for their suitability and classied the reviewed
studies for their level of evidence.21 A self-made 10-point quality
instrument in the form of a questionnaire was utilised to evaluate
the methodological quality of each component study. Both follow
up methodology and research design were assessed in each study.
The follow up methodology was assessed on the basis of the
answers to the following questions:
- Were the treating surgeons concealed to the reviewers of
outcomes in each study?
- Were follow-up losses (drop-outs, etc.) less than 15% in each
study?
- Was follow-up performed in pre-specied intervals or was it
based on review of patients charts?
- Was the description of outcomes of interest complete?
A clearly afrmative answer received 2 points, a probably
afrmative answer (not explicitly described in the studys
Materials and Methods section, but the Discussion suggested
that the procedure was probably followed) received 1 point and a
clearly negative answer received 0 points. Research design was
rated as follows: randomised trials: 2 points; non-randomised
comparative studies: 1 point; observational studies: 0 points.
The quality score for each component study represented an
average value of the nal scores assigned to it by the two
reviewers. The agreement between the two reviewers was
evaluated with the Spearman correlation coefcient for interrater
agreement and intraclass correlation coefcient (ICC).
Relevant data of the included studies were inserted into an
electronic database (Microsoft1 Excel for Windows1 (Microsoft
Corp, Redmond, WA)) for further analysis and were grouped per
Gustilo and Anderson types (grades I, II, III IIIA/IIIB/IIIC). The
analysis focused on each outcome/complication variable per open
fracture type, method of xation (intramedullary nailing, external
xation, plating), and, particularly for intramedullary nail xation,
different mode of nailing (reamed (RTN) vs. unreamed nailing
(UTN)).
Clear denitions of outcomes of interest were used to ensure
consistency of the results. Fracture union was assumed when bone
healing occurred without any other surgical intervention apart
from the index procedure or early planned bone grafting. Early,
delayed and late unions were dened when complete bone healing
took place within the following time frames, respectively: <6
months, 69 months and >9 months. Apart from explicitly
documented, a deep infection was also considered to occur when
terms such as stula, deep abscess, sequestration and infected
non-union were used in the manuscripts.
The outcomes were expressed as proportions (of events to the
total number of included patients). The 95% condence intervals
(95% CI) for each outcome of interest were also calculated.
Statistical heterogeneity across the component studies was
detected using Cochrans chi-square test (Q test)22 and I-square
test.23 For the Q-test, signicance is usually set at 0.1 as this test is
characterised by low sensitivity for detecting heterogeneity.24
Consequently, when p < 0.1, signicant statistical heterogeneity
1410 C. Papakostidis et al. / Injury, Int. J. Care Injured 42 (2011) 14081415

REFERENCE DATABASE
(used keywords on 13-Dec-09)
open AND fracture AND tibia
MEDLINE
1919 - 2009
1,199 studies
Studies before 1990 (72)
1,127 studies
Exclusion of languages other
than English (215)
912 studies
Exclusion of studies in animals (58)
Exclusion of studies with children (102)
752 studies
SCREENED ABSTRACTS:
Exclusion of reviews (105) /
Case reports (245) /
Letters, comments, editorials (10)

392 studies
Plateau fractures (10) pilon and plafond fractures (23) osteotomy (11)

348 studies
Reviewed abstracts: exclusion of
articles without open fractures (208)
& series under 50 cases (91)
49 studies
Reviewed full text: Added
potential articles from references
59 studies

Exclusion of inappropriate articles

according to inclusion criteria (27)

32
4, 6, 10, 14, 18-20, 26-50

Fig. 1. Flowchart of literature review.

was thought to be present. The I-square test is bounded above by Results

100 and values close to 100 represent a very high degree of
heterogeneity. Values of I2 equal to 25%, 50% and 75% represent
low, moderate and high degree of statistical heterogeneity,
respectively.
In the absence of signicant statistical heterogeneity we
produced a combined estimate of effect size, for each outcome
of interest. This constituted a weighted average of the individual
study outcomes of interest (expressed as proportions) using the
inverse variance of each study as normalising weight (W) (W = 1/
V), where V (variance) represents the square of the standard error
(SE2) of the sample proportion (p). The latter was calculated
according to the formula: SE2 = p (1  p)/n, where p represents the
sample proportion and n the total number of adequately followed
fractures. For p-values close to 0 or 1 we used the formula proposed
by Agresti and Coul25 in order to calculate the respective
proportions and CI: p0 = n + 2/N + 4, where n = number of events
(i.e. non-unions, infection, etc.) and N = number of fractures. In
those cases SE2 and V were calculated according to the formula:
SE2 = V = p0 (1  p0 )/N + 4.
Of the 1199 papers initially retrieved 32 articles, reporting on
3060 open tibial shaft fractures in 3036 patients, met all selection
criteria for nal analysis4,6,10,14,1820,2650 (Fig. 1). According to the
Gustilo and Anderson classication8 527 (17.2%) were grade I, 779
(25.5%) grade II, and 1754 (57.3%) grade III. In 29 studies,6,10,14,18
20,26,28,29,3150
all grade III open fractures (n = 1680) were further
subdivided as IIIA: 643 (37.9%), IIIB: 790 (46.5%), and IIIC: 247
(14.5%).9
Quality score: The quality score ranged from 4 to 8.5 points with
a mean value of 5.5 points. Spearmans correlation coefcient for
interrater agreement was 0.77 (95% CI = 0.570.88) and ICC was
0.75 (95% CI = 0.560.87).
In the rst part of our analysis we summarised all outcomes of
interest stratied according to the grade of open injury, but
irrespective of the treatment method used. Table 1 presents the
details of this analysis. In the absence of statistical heterogeneity, a
combined estimate of effect size, along with respective 95% CIs,
was calculated for each outcome of interest. When statistical
 C. Papakostidis et al. / Injury, Int. J. Care Injured 42 (2011) 14081415 1411

Table 1
Overall outcomes of open tibial fractures, irrespective of the treatment method.

Outcome of interest/grade References n-Included open Pooled estimate of Range Statistical heterogeneity
tibia fractures effect size (95% CI)

Early union rate

34,42
Grade I 40 97% (91100%) 96.8100% I2 = 0, Q = 0.38, df = 1, p > 0.1
24,34,42
Grade II 90 Not estimablea 4095% I2 = 95, Q = 42, df = 2, p < 0.01
24,27,32,34,42
Grade IIIA 180 Not estimablea 2291% I2 = 96.5, Q = 113.6, df = 4, p < 0.01
20,24,34,37,42
Grade IIIB 199 Not estimablea 2079% I2 = 96.5, Q = 113, df = 4, p < 0.01
Delayed union rate
19,42
Grade I 57 9% (5%17%) 010.4% I2 = 0, Q = 0.9, df = 1, p > 0.1
24,34
Grade II 78 Not estimablea 5.327.5% I2 = 87.2, Q = 7.8, df = 1, p < 0.01
24,27,42
Grade IIIA 125 Not estimablea 9.360% I2 = 80, Q = 10.1, df = 2, p < 0.01
20,24,34,37,42
Grade IIIB 199 Not estimablea 1080% I2 = 90, Q = 40, df = 4, p < 0.01
Late union rate
31,34
Grade I 64 3.1% (0%7.3%) 33.2% I2 = 0, Q = 0.002, df = 1, p > 0.1
24,31,34
Grade II 135 Not estimablea 5.325% I2 = 69, Q = 6.5, df = 2, p < 0.05
24,34
Grade IIIA 77 Not estimablea 8.759% I2 = 97, Q = 32, df = 1, p < 0.01
20,24,34
Grade IIIB 111 Not estimablea 1443.7% I2 = 68, Q = 6.2, df = 2, p < 0.05
Non-union rate
19,29,30,3235,41
Grade I 280 Not estimablea 052% I2 = 84.4, Q = 45, df = 7, p < 0.01
19,24,29,30,32,34,35,41
Grade II 409 Not estimablea 048.6% I2 = 91.6, Q = 84, df = 7, p < 0.01
8,17,27,30,32,34,35,52,54,56
Grade IIIA 325 Not estimablea 1.650% I2 = 77.6, Q = 40, df = 9, p < 0.01
8,17,30,34,35,37,41,48,54,55
Grade IIIB 332 Not estimablea 054% I2 = 83.3, Q = 54, df = 9, p < 0.01
8,30
Grade IIIC 150 Not estimablea 1764% I2 = 90, Q = 10, df = 1, p < 0.01
Deep infection rate
5,19,2831,3335,42,49,50,56
Grade I 511 1.8% (03.5%) 03.6% I2 = 0, Q = 3.8, df = 12, p > 0.1
2,5,10,12,19,2831,3335,42,45,49,50,54,56,57
Grade II 739 3.3% (04.7%) 011% I2 = 0, Q = 17, df = 18, p > 0.1
2,5,8,12,13,17,27,30,32,34,35,42,45,50,52,5456
Grade IIIA 468 5% (2.67.1%) 028.6% I2 = 0, Q = 15, df = 17, p > 0.1
2,5,8,10,12,13,17,30,34,35,37,41,42,45,48,5457
Grade IIIB 497 12.3% (9.415.1%) 036% I2 = 46, Q = 33.4, df = 18, p < 0.05
8,30
Grade IIIC 150 16.1% (10.222%) 1618% I2 = 0, Q = 0.03, df = 1, p > 0.1
Compartment syndrome rate
19,29,33,34
Grade I 154 Not estimablea 020.8% I2 = 74, Q = 11.4, df = 3, p < 0.01
2,19,29,33,34
Grade II 170 10% (515%) 019% I2 = 56, Q = 9, df = 4, p < 0.1
32,34,55
Grade IIIA 62 5% (010.7%) 06.3% I2 = 0, Q = 0.3, df = 2, p > 0.1
13,37,55
Grade IIIB 138 7% (2.811.3%) 4.217.6% I2 = 29, Q = 2.8, df = 2, p > 0.1
13
Grade IIIC 14 12/14:85.7% (57.198.2%)
Amputation rate
13,17,20,30,34,37,40,41,48,55
Grade IIIB 398 6.2%b (3.88.6%) 017.6% I2 = 10.3, Q = 10, df = 9, p > 0.1
13,30
Grade IIIC 25 79.6%b (64.395%) 6486% I2 = 39, Q = 1.6, df = 1, p > 0.1
a
Not estimable means that we were unable to produce a pooled estimate of effect size, using the methods of our analysis, due to the presence of signicant statistical
heterogeneity.
b
Odds ratio: 62 (95% CI: 22180).

heterogeneity was present, the range of the particular outcome of
interest within the included studies was documented.
In the second part of the analysis we further stratied all
outcomes of interest according to the type of treatment reported in
the eligible studies: intramedullary nailing (IMN) and external
xation (Ex Fix).
Stratication of the results according to the type of treatment
almost reached the level of statistical signicance (Table 3).
Comparing RTN and UTN modes of treatment, no signicant
differences were documented per grade of open fractures with
respect to both delayed and late union rates (Table 3). Late union
rates increased from grade I through grade IIIB, but the
documented differences between the grades of open injury per
mode of treatment (RTN/UTN) did not reach statistical signi-
cance (Table 3).

Outcomes of open tibial fractures treated with IMNs
Table 2 provides relevant details.
In order to reduce heterogeneity we further analysed the above
material according to the specic mode of IMN technique used
(RTN or UTN).
Union rates. The analysis of early, delayed and late union rates of
open tibial fractures treated with either RTNs or UTNs is
summarised in Table 3. Early union rates decreased from grade
I through grade IIIB in both modes of treatment (RTN, UTN). The
odds of early union were signicantly lower in grade IIIB
compared to grades I and II open fractures in both modes of
treatment (Table 3). In the IIIB open fractures treated with RTNs
the odds of early union were proved 12 times greater compared to
UTNs (Table 3). When RTNs were used, the odds of delayed union
were signicantly higher in IIIB open fractures than grades I and II.
In UTNs the odds of delayed union in grade II open fractures were
2.5 times higher than grade I open fractures and this difference
Non-union rates. Surprisingly, non-union rates in IIIB open
fractures treated with either RTNs or UTNs were lower than IIIA
or II open fractures, although the differences were not statistically
signicant (Table 4).
Deep infection rates. Signicantly increased deep infection rates of
IIIB open fractures compared with all other grades were
documented for both modes of treatment (RTN, UTN) (Table 4).
Unexpectedly, in RTN, IIIA open fractures presented lower deep
infection rates than grades I and II, though not in a statistically
signicant level (Table 4).
Compartment syndrome rates. We recorded lower compartment
syndrome rates in IIIA compared with grade II open tibial fractures
for both modes of treatment (RTN,UTN) (Table 4). On the other
hand, grade II open tibial fractures, treated with UTN, presented
signicantly greater odds for developing compartment syndrome
than when treated with RTNs (Table 4).
1412 C. Papakostidis et al. / Injury, Int. J. Care Injured 42 (2011) 14081415

Table 2
Overall outcomes of open tibial fractures treated with IMN.

Outcome of interest/grade References n-Included open tibia Pooled estimate of Range Statistical heterogeneity
fractures (type of IMN) effect size (95% CI)

Early union rate

34,42
Grade I 40 (RTN:31/UTN:9) 97.3% (91.5100%) 97100% I2 = 0, Q = 0.08, df = 1, p > 0.1
34,42
Grade II 50 (RTN:38/UTN:12) 94% (87.3100%) 83.395% I2 = 6, Q = 1.1, df = 1, p > 0.1
32,34,42
Grade IIIA 65 (RTN:23/UTN:42) Not estimablea 4091% I2 = 80, Q = 9.8, df = 2, p < 0.01
34,42
Grade IIIB 35 (RTN:20/UTN:15) Not estimablea 2075% I2 = 93, Q = 15, df = 1, p < 0.01
Delayed union rate
19,29,34,42
Grade I 118 (RTN:61/UTN:57) 2.8% (07.4%) 010.4% I2 = 25.8, Q = 4, df = 3, p > 0.1
19,29,34,42
Grade II 148 (RTN:38/UTN:110) Not estimablea 022% I2 = 64, Q = 8.4, df = 3, p < 0.05
27,42
Grade IIIA 39 (RTN:26/UTN:13) Not estimablea 1060% I2 = 89, Q = 9.2, df = 1, p < 0.01
34,37,42
Grade IIIB 61 (RTN:26/UTN:35) Not estimablea 1080% I2 = 93, Q = 33, df = 2, p < 0.01
Late union rate
31,34
Grade I 64 (RTN:31/UTN:33) 3.1% (07.4%) 33.2% I2 = 0, Q = 0.002, df = 1, p > 0.1
31,34
Grade II 95 (RTN:38/UTN: 57) 7.6% (2.313%) 5.310.5% I2 = 0, Q = 0.9, df = 1, p > 0.1
34
Grade IIIA 23 (RTN) 2/23: 8.7% (128%)
34
Grade IIIB 20 (RTN) 3/20: 15% (3.238%)
Non-union rate
19,29,31,3335
Grade I 201 (RTN:85/UTN:116) 0.9% (03.6%) 07% I2 = 0, Q = 1.7, df = 5, p > 0.1
19,29,31,34,35
Grade II 227 (RTN:56/UTN:171) 4.3% (1.67%) 012.2% I2 = 31, Q = 5.8, df = 4, p > 0.1
27,32,34,35,54,56
Grade IIIA 154 (RTN:52/UTN:102) 7.1% (3.111.2%) 3.413% I2 = 0, Q = 2.3, df = 5, p > 0.1
34,35,37,48,54
Grade IIIB 87 (RTN:53/UTN:34) 3.4% (09.3%) 018% I2 = 15, Q = 4.7, df = 4, p > 0.1
Deep infection rate
5,19,2831,3335,42,56
Grade I 425 (RTN:272/UTN:153) 1.7% (03.6%) 03.6% I2 = 0, Q = 3.1, df = 10, p > 0.1
5,10,12,19,2831,3335,42,54,56,57
Grade II 557 (RTN:314/UTN:243) 3.1% (1.64.6%) 011% I2 = 0, Q = 12.7, df = 14, p > 0.1
5,12,27,32,34,35,42,54,56
Grade IIIA 200 (RTN:70/UTN:130) 2.4% (05.6%) 010% I2 = 0, Q = 4.3, df = 9, p > 0.1
5,10,12,34,35,37,42,48,54,56,57
Grade IIIB 214 (RTN:109/UTN:105) 9.2% (5.313%) 025% I2 = 16, Q = 11.9, df = 10, p > 0.1
Compartment syndrome rate
19,29,33,34
Grade I 154 (RTN:76/UTN:78) Not estimablea 020.8% I2 = 74, Q = 11.4, df = 3, p < 0.01
19,29,33,34
Grade II 157 (RTN:139/UTN:18) 11% (5.916.2%) 018.7% I2 = 58, Q = 7.2, df = 3, p < 0.1
32,34
Grade IIIA 55 (RTN:23/UTN:32) 5.3% (011.1%) 4.36.3% I2 = 0, Q = 0.1, df = 1, p > 0.1
a
Not estimable means that we were unable to produce a pooled estimate of effect size, using the methods of our analysis, due to the presence of signicant statistical
heterogeneity.

Outcomes of open tibial fractures treated with Ex Fix
Details of all available outcomes of interest are summarised in
Table 5.
Available data documented a 3-fold increase of the odds of deep
infection in IIIB open fractures treated with Ex Fix compared to IIIA
open fractures treated in the same manner (odds ratio: 3, 95%CI:
1.37, Table 5).
Amputation rates. For this outcome of interest no stratication
with respect to type of treatment was done, as apparently
amputation does not depend on the type of treatment but rather
on the severity of the initial injury (Table 1).
Discussion
Open fractures of the tibial shaft are the most common open
long bone injuries due to the limited soft tissue coverage of the
tibial bone anteriomedially, and the high incidence of tibial shaft
fractures in general.1,3 In clinical practice and from a research
perspective these injuries are used as the typical paradigm of the
compound fracture sub-category of a long bone fracture. Their
classication represents the template of almost all open long bone
fractures since the 70s.79 These injuries constitute a difcult
clinical problem to deal with,5159 as despite the evolution of
modern techniques in open wound care and xation of the
osseous injury, tailored according to the degree of open injury
(Gustilo and Anderson classication), their nal outcomes remain
unpredictable. In the present article, we attempt to summarise the
published evidence over 2 decades on essential outcome
measures of open fractures of the tibial shaft, and subsequently,
to comparatively analyse them according to the degree of the open
fracture and method of xation. To the best of our knowledge
current literature is lacking such a cumulative, comparative study,
which could offer useful guidance to clinicians for optimal
decision making.
All included studies received on average a moderate quality
score. Causes for moderate rating were study design (most of them
being case series studies) and aws in follow up methodology.
Most of the studies included in our review were observational
and thus prone to confounding and biassed results. Unfortunately
these studies comprised the best available data relevant to our
review question.
Systematic literature reviews are generally prone to publication
and detection bias. Although we undertook a thorough search of
the published literature, we recognise that limiting our search to
reports published only in the English language, failure to include
congress publications or unpublished data and possible errors in
our search strategy could have resulted in missing data. On the
other hand we managed to include a signicant number of reports
(32) and we observed that most of our estimates were not affected
by signicant statistical heterogeneity. Our estimates were also
characterised by short condence intervals. We, therefore, strongly
believe that it is quite unlikely to have missed sizeable reports that
would have signicantly affected our calculated estimates of effect
size for each outcome of interest.
Several authors have shown a strong association between the
grade of open tibial fracture (Gustilo and Anderson classication)
and the risk of complications.9,14,18,27,30,31,35,36,39,40,42,4446,48 Our
results show a strong association between Gustilo and Anderson
grade and certain outcomes. Thus, the odds of early union were
signicantly diminished from grade I through grade IIIB for both
RTNs and UTNs (Table 3). However, such an association could not
be established for delayed and late union rates (Table 3). When the
two modes of intramedullary nailing (reamed and unreamed
nailing) were directly compared per grade of open injury, no
statistically signicant differences were recorded with respect to
 C. Papakostidis et al. / Injury, Int. J. Care Injured 42 (2011) 14081415 1413

Table 3
Union (early, delayed and late) rates in RTNs and UTNs.

N-studies [Ref.], n-included frx Pooled estimate of effect Odds ratios RTN/UTN
size (95% CI), statistical heterogeneity (95% CI)

RTN UTN RTN UTN

Early union rate

34 42
Grade I 1 , 31 frx 1 , 9 frx 30/31: 97% (83.3100%) 9/9: 100% (65100%) 0.3 (030)
34 42
Grade II 1 , 38 frx 1 , 12 frx 36/38: 95% (82.299.3%) 10/12: 83.3% (51.698%) 4.6 (0.449)
34 32,42
Grade IIIA 1 , 23 frx 2 , 42 frx 20/23: 87% (6697%) Not estimable
I2 = 90, Q = 9.8, df = 1, p < 0.01
(range: 4091%)
Grade IIIB 1 34, 20 frx 1 42, 15 frx 15/20: 75%(5191.3%) 3/15: 20% (448%) 12 (2.461)
Grade of open fr Odds ratios (95% CI) (II,I) 0.6 (0.16.2) 0.2 (02.8)
(IIIA,I) 0.3 (01.9)
(IIIA,II) 0.4 (0.12.3)
(IIIB,I) 0.1 (00.7) 0 (00.2)
(IIIB,II) 0.2 (00.8) 0 (00.6)
(IIIB,IIIA) 0.5 (0.12.1)

Delayed union rate

34 19,29,42
Grade I 1 , 31 3 , 87 0/31: 0% (013%) 4.4% (010%) 0.3 (02.5)
I2 = 38, Q = 3.2, df = 2, p > 0.1
34 19,29,42
Grade II 1 , 38 3 , 110 0/38: 0% (011.6%) 11.7% (5.717.7%) 0.2 (0.18.5)
I2 = 0, Q = 1.6, df = 2, p > 0.1
27,42
Grade IIIA 2 , 39 Not estimable
I2 = 89, Q = 9.2, df = 1, p < 0.01
(range: 1060%)
34,37 37,42
Grade IIIB 2 , 46 2 , 41 15.2% (525%) I2 = 0, Not estimable
Q = 1.5, df = 1, p > 0.1. I2 = 94.6, Q = 18.6, df = 1, p < 0.01
(range: 823%)
Grade of open fr Odds ratios (95% CI) (II,I) 2.5 (0.96.8)
(IIIB,I) 6.2 (1.330)
(IIIB,II) 7.2 (1.534)

Late union rate

Grade I 1 34, 31 1 31, 33 1/31: 3.2% (017%) 1/33: 3% (016%) 1.1 (0.117)
Grade II 1 34, 38 1 31, 57 2/38: 5.3% (0.618%) 6/57: 10.5% (421.5%) 0.5 (0.12.2)
Grade IIIA 1 34, 23 2/23: 8.7% (128%)
Grade IIIB 1 34, 20 3/20: 15% (3.238%)
Grade of open fr (95% CI) Odds ratios (II,I) 1.6 (0.216) 2.8 (0.614)
(IIIA,I) 2.8 (0.329)
(IIIA,II) 1.7 (0.214)
(IIIB,I) 5 (0.639)
(IIIB,II) 3.4 (0.523)
(IIIB,IIIA) 1.8 (0.312)
Not estimable means that we were unable to produce a pooled estimate of effect size, using the methods of our analysis, due to the presence of signicant statistical
heterogeneity.

the above outcomes of interest (early, delayed and late union rates)
(Table 3). The use of RTNs in IIIB open tibial fractures was
associated with signicantly increased odds for deep infection
compared with all other lower grades of open injury (Table 4).
Almost the same applied for UTNs, with the exception that
between IIIB and IIIA grades the recorded difference in the odds of
deep infection did not reach the level of statistical signicance. We
have to emphasise, however, that the calculation of odds ratios
(ORs) in our analysis was based on the assumption that there were
no between study differences. Utilisation of generalised mixed
models could be a more appropriate method of analysis, as it
allows for between study differences. During our analysis we came
across some unexpected results. We have found, for instance, that
the rate of deep infection in grade IIIA open tibial fractures treated
with reamed intramedullary nails was lower (although not in a
statistically signicant level) than that of grades I or II treated in
the same manner (Table 4). Similarly, we observed that non-union
rates were lower (not in a statistically signicant degree) in grade
IIIB than in grade IIIA or II open tibial fractures of the tibial shaft
treated either with RTNs or UTNs.60,61 With regard to compartment
syndrome, we detected a higher incidence in grade II than in grades
IIIA and IIIB fractures (Table 1). The same situation was observed
when open tibial fractures were treated with either RTNs or UTNs.
We have also documented an unexpected 3-fold increase in the
odds of compartment syndrome for grade II open tibia fractures
treated with UTN compared with open fractures of the same grade
treated with RTNs (Table 4). Most of our comparisons are
characterised by lack of power, because of small sample sizes.
As a consequence, some genuine differences would have been
probably found insignicant. These effects may well explain some
of the unexpected results of our analysis, although we feel that
the above unexpected results underline the weakness of the
Gustilo and Anderson Classication system in providing compre-
hensively reliable and reproducible results.
It is well established in literature that pre-existing co-
morbidities may have a signicant inuence on the development
of complications unrelated to the degree of the open fracture.6266
As a consequence, new classication systems of open fractures
have been proposed, incorporating the above factors.67,68
In conclusion, the purpose of current study was to provide
summarised estimates of effect size for the most important outcome
measures of open fractures, stratied per type of treatment and
grade of open injury and based on a thorough review of existing
literature over two last decades. Despite some unexpected and
unreasonable results, reecting the inherent weaknesses of the
Gustilo and Anderson Classication system, we feel that we have
provided the reader with important data that could assist in optimal
decision making, when treating open tibial fractures.
1414 C. Papakostidis et al. / Injury, Int. J. Care Injured 42 (2011) 14081415

Table 4
Non-union rate, deep infection rate and compartment syndrome rate of open tibia fractures treated with IMNs, stratied according to the grade of open injury and type of IMN
technique (RTN/UTN).

N-studies [Ref.], n-included frx Pooled estimate of effect size Odds ratio
(95% CI), statistical heterogeneity (95% CI)

RTN UTN RTN UTN

Non-union rate
3335 19,29,31
Grade I 3 , 85 frx 3 , 111 frx 1.8% (05.8%) 0% (03.7%)
I2 = 0, Q = 1.4, df = 2, p > 0.1
34,35 19,29,31,35
Grade II 2 , 56 frx 4 , 171 frx 5.4% (011.3%) 3.9% (0.96.9%) 1.4 (0.36.3)
I2 = 0, Q = 0, df = 1, p > 0.1 I2 = 48, Q = 5.8, df = 3, p > 0.1
34,35,56 27,32,35,54
Grade IIIA 3 , 52 frx 4 , 102 frx 6.7% (014.6%) 6.7% (211.5%) 1 (0.23.8)
I2 = 0, Q = 1.8, df = 2, p > 0.1 I2 = 0, Q = 2.6, df = 3, p > 0.1
34,35,37 48,54
Grade IIIB 3 , 53 frx 2 , 30 frx 5% (012.5%) 0% (010%) 4.9 (0.462)
I2 = 58, Q = 4.7, df = 2, p < 0.1
Grade of open fr Odds ratios (95% CI) (II,I) 3.2 (0.521) 5.4 (1.126)
(IIIA,I) 4 (0.725) 8.6 (1.939)
(IIIA,II) 1.2 (0.36.2) 1.8 (0.65.6)
(IIIB,I) 3 (0.422)
(IIIB,II) 0.9 (0.25) 0.3 (02.6)
(IIIB,IIIA) 0.7 (0.13.7) 0.26 (01.6)

Deep infection rate

28,30,3335,56 5,19,29,31,42
Grade I 6 , 272 frx 5 , 148 frx 2.1% (04.5%) 0.9% (04.1%) 1.5 (0.512)
I2 = 0, Q = 1.9, df = 5, p > 0.1 I2 = 0, Q = 0.7, df = 4, p > 0.1
12,28,30,3335,56 5,10,19,29,31,35,42,54,57
Grade II 7 , 310 frx 9 , 243 frx 5.1% (2.67.6%) 1.9% (03.8%) 2.1 (0.410)
I2 = 21, Q = 7.6, df = 6, p > 0.1 I2 = 0, Q = 2.7, df = 8, p > 0.1
12,34,35,56 5,27,32,35,42,54
Grade IIIA 4 , 70 frx 6 , 130 frx 1.7% (07.5%) 3% (07.2%) 0.6 (0.13.8)
I2 = 0, Q = 0.7, df = 3, p > 0.1 I2 = 0, Q = 3.3, df = 5, p > 0.1
12,34,35,37,56,57 5,10,42,48,54,57
Grade IIIB 6 , 109 frx 6 , 101 frx 11.6% (5.717.5%) 7.4% (212.8%) 1.6 (0.64)
I2 = 0, Q = 3.2, df = 5, p > 0.1 I2 = 39, Q = 8.1, df = 5, p > 0.1
Grade of open fr Odds ratios (95% CI) (II,I) 2.3 (15.5) 1.9 (0.3510.5)
(IIIA,I) 0.8 (0.15.3) 3.16 (0.5618)
(IIIA,II) 0.45 (0.11.6) 1.8 (0.47.4)
(IIIB,I) 7.9 (2.822) 6.8 (1.726.6)
(IIIB,II) 2.8 (1.26.6) 5.4 (1.519)
(IIIB,IIIA) 4 (1.312) 2.5 (0.78.2)

Compartment syndrome rate

33,34 19,29
Grade I 2 , 76 frx 2 , 78 frx 2% (06.5%) Not estimable
I2 = 33, Q = 1.5, df = 1, p > 0.1 I2 = 88, Q = 8.5, df = 1, p < 0.01
(range: 020.8%)
33,34 19,29
Grade II 2 , 59 frx 2 , 98 frx 5.7% (013%) 16.7% (9.324%) 0.4 (0.11)
I2 = 51, Q = 2, df = 1, p > 0.1 I2 = 0, Q = 0.8, df = 1, p > 0.1
34 32
Grade IIIA 1 , 23 frx 1 , 32 frx 4.3% (0.122%) 6.2% (0.821%) 0.7 (0.17.2)
Grade of open fr (95% CI) Odds ratios (II,I) 2.9 (0.518)
(IIIA,I) 2.4 (0.229)
(IIIA,II) 0.8 (0.15) 0.4 (0.11.3)

Table 5
Overall outcomes of open tibial fractures treated with Ex Fix.

Outcome of interest/grade References n-Included open Pooled estimate of effect Range Statistical heterogeneity
tibia fractures size (95% CI)

Non-union rate
27
Grade IIIA 32 0% (011%)
37
Grade IIIB 45 4.4% (0.515%)
Deep infection rate
2,13,27
Grade IIIA 82 5.7% (0.710.7%) 56% I2 = 0, Q = 0.03, df = 2, p > 0.1 Odds ratio: 3,
2,13,37,55
Grade IIIB 117 19% (1226%) 1336% I2 = 27, Q = 4.1, df = 3, p > 0.1 95% CI: 1.37
Compartment syndrome rate
2
Grade II 13 0/13: 0% (026.6%)
13
Grade IIIB 17 3/17: 17.6% (3.843.4%)
13
Grade IIIC 14 12/14: 85.7% (57.198.2%)

Conict of interest statement
The authors declare that there are no conicts of interest.
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