One hundred and twenty-six patients with open tibial shaft fracture were included in this 3-5 year observational follow-up study comparing intramedullary nailing (n=67) and external fixation (n=59). The primary outcome of interest was a composite of death, reoperation for deep infection, non-union, and malalignment. Unresolved complications, quality of life, radiographic alignment, and function were also assessed. The results revealed comparable rates of death and reoperation due to deep infection, non-union, and malalignment. 25% of patients who reported a primary outcome event had unresolved complications (fracture-related infection or non-union). Quality of life & functional outcomes were also similar between groups. The rate of malalignment was slightly higher in the external group. Unresolved infection and non-union continue to be a concern in both groups, with a roughly 6% incidence rate.