Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis

Objectives: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures. Data Sources: MEDLINE, EMBASE, CENTRAL, and OpenGrey. Study Selection: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type. Data Extraction: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis. Data Synthesis: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]. Results: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43–1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37–1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58–1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage. Conclusions: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.