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Between 1987 and 1991, 114 fresh tibial shaft fractures with severe soft tissue injury, which met the inclusion criteria, were treated and retrospectively reviewed. There were 48 cases in the unreamed nail (unreamed tibial nail (UTN)) group and 66 cases in the external fixation (EF) group. Soft tissue injury was classified by the Gustilo and Tscherne methods. There were 18 AO type A, 56 type B, and 40 type C fractures. There was no significant difference in fracture type, soft tissue injury, age, and additional injury between the groups. Outcome was assessed using the Karlstrom score after 28 months. There were a significantly higher number of reoperations in the EF group. Mean time to bony healing was 25.8 weeks. In the EF group, there was a 26% rate of pin tract infection, whereas 19% of cases had bolt breakages in the UTN group. In the UTN group, 40% had good results, compared with 27% in the EF group. In the UTN group, there were significantly fewer ante- and recurvatum deformities of more than five degrees. Treatment of tibial fractures by UTN, compared with EF, gave a lower reoperation rate and better functional outcome.