Summary:The results are reviewed of the treatment of 30 tibial fractures with significant bone loss in 29 patients treated in the Edinburgh Orthopaedic Trauma Unit. A protocol of early aggressive soft tissue and bony debridement followed by primary locked intramedullary nailing was used. Subsequently, definitive closure was obtained, usually with a soft-tissue flap within the first 48 h after injury, followed by elective bone-grafting procedures, which were delayed for 6 weeks after primary surgery. The times to fracture union and subsequent functional outcome were largely dependent on the severity and extent of bone loss, which we have classified. Twenty-nine fractures eventually achieved full bony union at a mean of 53.4 weeks, with delayed amputation required in only one patient. Poor functional outcome and complications of treatment were usually attributable to a departure from the standard treatment protocol in the primary management. We conclude that the protocol produces reliably satisfactory results in the management of these difficult fractures, and we consider that the use of intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilization.