Tibial fractures often require the option of surgical treatment due to special anatomical sites or other reasons. The author collected 67 cases of tibial stem fractures treated with interlocking intramedullary nail, compression plate or external fixation brace from 1992 to 2001, and observed the clinical efficacy of the three methods, and then discussed the suitable treatment methods for tibial stem fractures. I. Materials and methods 1. Clinical data: There were 67 patients with fresh fractures of the tibial stem in this group, 46 males and 10 females, aged 19-62 years (34±8 years). Among them, there were 10 open fractures, 6 cases of Gustilo degree I injury, 3 cases of degree II injury and 1 case of degree III injury; 57 cases of closed fractures. Causes of injury: traffic injury in 38 cases, smash injury in 15 cases, fall injury in 14 cases. Treatment: 28 cases in the pressurized plate fixation group, 16 cases in the external fixation bracket fixation group, and 23 cases in the locked intramedullary nail fixation group (marrow expansion); among them, the pressurized plate fixation group used incisional reduction, and the external fixation bracket and locked intramedullary nail fixation groups both used closed reduction. The fracture sites and types are shown in Table 1, with a mean follow-up of 14 months (4-25 months). Table 1 Fracture site and type Group Department Type Upper Middle Lower Transverse and short oblique Spiral Oblique Crushed Segment Compression plate group 8 14 6 3 4 11 7 3 External fixation brace group 4 7 5 5 2 5 4 0 Intramedullary nail group 7 11 5 4 3 8 6 2 2. Evaluation criteria for fracture healing: According to clinical and X-ray performance, the fracture was classified as: ① healing: within 4 months after surgery, the affected limb had no deformity, no pain, no pseudo-articular activity, and the affected limb could bear weight; X-ray showed the appearance of bone scabs at the fracture site and blurred fracture line. ② Delayed healing: within 4-8 months, the affected limb still had pain, pressure pain in the affected area, and the affected limb was difficult to bear weight; the X-ray showed that the fracture line was clearly visible; ③ Non-healing: more than 8 months, the affected limb still had pain and deformity, there was pseudo-articular activity in the affected area, and the affected limb could not bear weight; the X-ray showed that the fracture gap was enlarged, the fracture end was sclerotic and the medullary cavity was occluded. 3. Statistical treatment: statistical extrapolation of rates was performed by 2×K table and R×C table χ2 test. II. RESULTS The results of the three surgical treatments for tibial stem fractures are shown in Table 2. χ2 test showed that the fracture healing rate was significantly higher in the intramedullary nailing group than in the other two groups (χ2 =3.86, P<0.05), the fracture delayed healing rate was significantly higher in the external fixation group than in the other two groups (χ2 =6.08, P<0.05), and the fracture nonunion rate was higher in the intramedullary nailing and compression plate groups than in the external fixation frame group (χ2 = Among the 9 cases of bone nonunion, 1 case of poor repositioning, 1 case of plate fracture, 1 case of screw loosening, 2 cases of screw fracture, 1 case of locking failure of intramedullary nail, 1 case of splitting of fracture end due to nail penetration, 1 case of osteomyelitis of trauma, and 1 case of premature weight bearing; among the fracture healing cases, 4 cases of ankle and knee stiffness were observed in the compression plate group, and 2 cases of deformity were observed in the external fixation frame group healing. The incidence of complications was 22.4%, of which the incidence of bone nonunion was 13.4%. In addition, two cases of osseous nonunion were reoperated and treated with locking intramedullary nails, and satisfactory results were obtained in both cases. The frequency distribution of the surgical treatment results in each group is shown in Figure 1. Table 2 Results of three surgical treatments for 67 tibial stem fractures Group Number of cases Healing Delayed healing Non-healing Healing rate (%) Compression plate group 28 16 8 4 57.1 External fixation frame group 16 8 6 2 50.0 Intramedullary nail group 23 18 2 3 78.3* Total 67 42 16 9 62.7 * indicates P<0.05 compared with the other two groups III. The incidence of delayed healing and non-healing is high. It is of practical significance to compare the clinical efficacy of different treatment methods, analyze the causes of internal fixation failure, and discuss the corresponding preventive measures. A retrospective study showed that the fracture healing rate in the intramedullary nailing group was significantly higher than that in the compression plate group and the external fixation brace group, indicating that the locked intramedullary nailing has good efficacy in the treatment of tibial stem fractures. The principles and methods of early AO/ASIF surgical treatment of fractures, mechanical properties of internal fixation and absolute stability of all fracture blocks; subsequent studies found that the osteoporosis or accelerated remodeling of the Harvard's system that occurs after application of plate fixation is not a result of stress protection but of hematological disruption of the bone, which is particularly important in the treatment of long tubular bones, especially tibial fractures [1]. Accelerated Harvard's system remodeling is also present along the endosteum in long bones fixed by intramedullary nailing, and the appearance of these remodels parallels the distribution of dead bone produced during the reaming and the driving of the intramedullary nail; only viable bone heals in the presence of relative stability, because only viable bone can overcome the effects of activity and achieve stability and thus bone healing through the formation of bone scabs [2]. Considering the fact that manipulation of the internal fixation and fracture fragments disrupts their hemodynamics and may lead to non-healing, and the shift from an emphasis on absolute stability to an awareness of the need to protect the blood supply and the biomechanical requirements of the different parts of the bone, intramedullary nailing with locking is increasingly used in the treatment of long tubular bones, especially in the lower limb. The surgical operation of intramedullary nailing with locking is far away from the fracture end, which causes little disturbance to the bone and surrounding soft tissues and is a "minimally invasive technique" for fracture treatment, avoiding further damage to the blood flow of the fracture end and facilitating fracture healing [3]; the fracture end is evenly subjected to axial compressive stress during weight-bearing, overcoming stress masking; the medullary cavity is enlarged during surgery and the biostimulation effect The bone debris produced during marrow expansion is a good material for bone grafting; however, intramedullary nail fixation is not an absolutely strong fixation, and the presence of small movements at the fracture end during active limb movement or partial weight-bearing is beneficial to bone scab production and increases the firmness of early fracture healing [4]. Compared to locked intramedullary nailing, compression plate fixation has a large area of injury and affects postoperative rehabilitation and joint movement, in addition to more extensive periosteal stripping that interferes with the periosteal blood supply and soft tissue stripping [5]. The stability of the external fixation bracket for fracture end fixation is often less than that of intramedullary nailing or compression plate, so the delayed healing rate of this group of fractures is higher, and it is easy to complicate the deformity healing; however, the operation is simple and has more advantages, especially in the treatment of Gustilo Ⅲb degree injury with external fixation bracket has obvious advantages. In addition to the supportive role, surgical treatment of tibial fractures can maintain the position after repositioning, prevent fracture displacement, and maintain the anatomical and functional integrity of the fracture early to facilitate healing. The correct choice of surgical procedure is often a key factor in determining the prognosis, and clinical indications should be strictly controlled. The application of intramedullary nailing, especially closed penetration nailing for fractures, allows for less soft tissue exposure and provides good stability; the muscles and fascia surrounding the fractured bone protect the blood supply around the fractured bone, which facilitates the revascularization of the injured bone and the formation of epicondylar scab, making the fracture easier to heal. Internal fixation with locking intramedullary nail is suitable for transverse, short oblique and spiral fractures of the femur and upper middle tibia; if used for comminuted or long tubular middle and lower fractures, it is likely to cause postoperative pin bending, limb shortening and rotational deformity. For a long time there has been much controversy about intramedullary nailing for open fractures, and with the increased application of internal fixation, a large number of clinical studies have shown that Gustilo Ⅰ and Ⅱ degree open tibial fractures can still be applied with intramedullary nailing; for Ⅲa degree open fractures, limited reaming or non-reaming intramedullary nailing can be selected, but should be used with caution; Ⅲb degree open fractures are a contraindication to the application of intramedullary nailing. Data showed [6] that non-expandable intramedullary nailing with locking intramedullary nails for Gustilo degree I and II open fractures has a high bone healing rate and good functional recovery, while the infection rate is similar to other methods and can be the preferred method of internal fixation. In addition, intramedullary nailing with locking has its unique advantages in the treatment of non-union of fractures: the use of closed-piercing nailing technique, less trauma and low infection rate; the application of anti-rotation nails at both ends of the fracture provides a stable mechanical environment for the fracture; the treatment of sclerotic non-union can achieve healing without bone grafting as long as the fracture end is stabilized after marrow expansion. 3. Clinical analysis of postoperative fracture complications With the increasing application of various clinical fixation devices, their complications are also on the rise. The higher incidence of complications in this group may be related to the fact that the statistics included cases transferred from outside hospitals due to failure of internal fixation; given the small number of cases collected by the authors, it is not yet possible to compare the complications of each group for study. The data showed that the main complications included bone discontinuity, deformity healing and joint stiffness; among them, bone discontinuity was caused by various factors, including poor repositioning, plate fracture, screw loosening and breaking, failure of intramedullary nail locking, splitting of the fracture end due to nail penetration, osteomyelitis of the trauma, and premature weight-bearing. Delayed fracture healing can be caused by poor quality of internal fixation materials, destruction of blood flow during internal fixation, difficulty in controlling the appropriate pressure, bone defect without bone grafting, stress masking after internal fixation, and foreign body reaction; postoperative infection, incorrect functional exercise methods, and bending and breaking of stress-concentrated plates and intramedullary nails due to premature weight bearing are also important factors leading to delayed fracture healing [8].