Comparing infection rates between hollow and solid intramedullary nails in long bone fracture fixations: a formal systematic review and meta-analysis (2000-2024)

Abstract

Whether solid intramedullary nails reduce postoperative infection risk compared with hollow (cannulated) designs in long bone fracture fixation remains controversial. A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines, with Pubmed, Embase, central, and Google Scholar searched from January 2000 to May 2024 for comparative studies reporting infection outcomes after solid versus hollow intramedullary nailing of femoral or tibial shaft fractures. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using fixed- and random-effects models, and heterogeneity and sensitivity analyses were performed. Four studies, including one randomized controlled trial, two retrospective cohort studies, and one quasi-experimental study, involving 288 patients were included. Infection rates ranged from 0% to 56% across studies. The fixed-effect model suggested lower infection risk with solid nails (RR=0.62; 95% CI 0.42-0.92), whereas the random-effects model showed no significant difference (RR=0.71; 95% CI 0.32-1.56), with moderate heterogeneity (I²=45%). Sensitivity analyses demonstrated that pooled estimates were highly dependent on a single observational study with unusually high infection rates and short follow-up. Current evidence does not demonstrate a consistent reduction in infection risk with solid compared to hollow intramedullary nails, and overall certainty of evidence is very low, indicating that implant choice should prioritize technical considerations and established infection prevention strategies rather than unproven differences in nail design.