Purpose: Centromedullary nailing with reaming is a recognised treatment for open leg fractures with a well-measured risk of postoperative infection. The development nailing procedures without reaming might reduce this risk.

Material and methods: We performed a Medline search using the following key words: nailing, tibia, open fracture, infection. To be retained for analysis, articles had to evaluate infectious risk of nailing with or without reaming, in clinical trials or experimental studies, with precise diagnostic criteria. Clinical articles retained were classed in three categories by decreasing value of their methodology: prospective randomised comparative studies, case-control studies, comparative observation studies, simple observation studies. Only comparative experimental and prospective comparative randomised studies were considered to be pertinent.

Results: Five articles met the predefined quality inclusion criteria and were retained for analysis: three experimental studies and two clinical trials. The experimental studies by Melcher (1995 and 1996) demonstrated a significant increase in infection rate and bacterial counts after nailing with reaming; there were two confounding factors however, steel or titanium nail and full or hollow nail which also had a significant effect on the rate of infection. The experimental work by Curtis (1995) did not find any difference in incidence and severity of infection between nailings with and without reaming. The two prospective comparative randomised clinical trials by Keating (1007) and Finkemeier (2000) included a total of 132 cases. the risk of infection was 8% after nailing with reaming and 7% after nailing without reaming (NS). The relative risk of infection after nailing with reaming was 1.02-fol greater than that without reaming (NS).

Discussion, conclusion: There is experimental evidence that would tend to prove that the risk of infection is lower after nailing with reaming, but it is insufficient to explain the mechanism of this lower rate. Inversely, although the clinical observation series tend to confirm these results, the two methodologically valid prospective comparative randomised studies did not find any difference. To date, there is no objective evidence ruling out the usefulness of nailing with reaming because of higher infection risk in open leg fractures.