SummaryModern advances in plastic surgery have significantly improved the outcome of severe open tibial fractures. An improved understanding of cutaneous blood supply combined with advances in microsurgical techniques has led to reliable coverage of large soft tissue defects by either local or free tissue transfer, and a significant reduction in the incidence of deep infection. The method of skeletal stabilization of open tibial fractures remains controversial. Although intramedullary nailing (IMN) is increasingly used for the stabilization of both closed and open tibial diaphyseal fractures, we advise caution in the use of IMN in severe open fractures because of the high risk of deep sepsis. We believe that external fixation continues to have a key role in the stabilization of the more severe open tibial fractures, particularly heavily contaminated injuries, fractures associated with significant bone loss, and cases associated with a high risk of infection. However, the use of external fixation in open fractures demands a close cooperation between orthopaedic and plastic surgeons to maximize wound access without compromising skeletal stability. We advocate unilateral external fixation with individual pin clamps and multiple longitudinal bars for stable open fractures with minimal bone loss. Improved materials, modern surgical techniques, and close postfixation monitoring of fracture healing have reduced the incidence of problems such as pin-site infection and loosening, delayed union, and malunion. The advent of the Ilizarov method and small wire circular external fixation has rationalized the management of the open tibial fracture associated with significant bone loss and reduced the need for autogenous bone grafting. We prefer local or free tissue transfer by plastic surgeons rather than the transport of poor quality soft-tissues that accompanies the Ilizarov method. The ability to reliably reconstruct large soft-tissue and bone defects allows an aggressive debridement, similar to a radical tumor resection, which is essential to prevent deep infection.