A comprehensive review and network meta-analysis was conducted looking at the complication rates requiring reoperation for all stabilization techniques for open tibial shaft fractures (Gustilo Types I – IIIB). Treatments evaluated were plate fixation, external fixation (by any method), reamed and unreamed intramedullary nailing, and Ender intramedullary nailing. Fourteen trials including 1279 patients demonstrated that unreamed intramedullary nailing had highest likelihood of being the superior treatment (Sucra score 86.3% versus 54.4% for reamed intramedullary nailing). When considering unreamed versus reamed nailing, there was inconsistency between direct (head-to-head trials) and indirect evidence (network estimates generated from trials with common comparators). Direct evidence was therefore considered best evidence and showed a nonsignificant trend toward reduced complications with unreamed over reamed nailing (OR, 0.74; 95% CI, 0.45–1.24; moderate confidence). Unreamed nailing was also associated with a much lower complication rate than external fixation (network estimate OR, 0.38, 95% CI, 0.23–0.62; moderate confidence). All other comparison between other fixation methods were based on low or very low quality evidence but in general favored unreamed nailing.