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To evaluate the efficacy of intramedullary nailing of distal tibia fractures using modern techniques, without fibula fixation, in obtaining and maintaining alignment.Retrospective case review.Level-I academic trauma center.One hundred thirty-two consecutive patients with distal tibia fractures.Intramedullary nail of distal tibia fracture, without fibula fixation, was performed in consecutive patients using modern reduction techniques.Malalignment and malunion were defined as >5 degrees of varus/valgus angulation or anterior/posterior angulation on the initial postoperative or final anteroposterior and lateral x-rays.There were 122 consecutive patients (86 men and 36 women) 16–93 years of age (average, 43 years) with 36 (30%) open and 85 (70%) closed fractures with complete follow-up. Mechanism of injury did not predict the presence or level of fibula fracture. Upon presentation, varus/valgus and procurvatum/recurvatum angulation was greatest when the fibula was fractured at the level of the tibia fracture (P = 0.001 and 0.028). The most common intraoperative reduction aids were nailing in relative extension, transfixion external fixation, and clamps at the fracture site. The OTA fracture type or level/presence of fibula fracture did not influence malalignment (P = 0.86 and 0.66), malunion (P = 0.81 and 0.79), or the change in alignment during union, which averaged 0.9 degrees.We found an overall low rate of both malalignment (2%) and malunion (3%) after intramedullary nailing of distal tibial shaft fracture without fibula fixation. We conclude that when modern nailing techniques are used, which allow for confirmation of reduction by visualization in fluoroscopy, from nail placement to distal interlocking, fibula fixation is not necessary to obtain or maintain alignment. Furthermore, standard 2 medial to lateral screws distally afford adequate stability to hold the reduction during union with a 0.9-degree difference in the initial postoperative and final united films.Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.