Thirty-six Types III and IIIa open fractures of the tibial shaft are presented with a treatment protocol based on early, aggressive wound management and fracture coverage utilizing muscle, myocutaneous, or free flap techniques. There were five amputations, seven deep infections, three nonunions, and no cases of chronic osteomyelitis in the series. The criteria for inclusion in the series were definitive wound coverage by 30 days after injury and end-result records including time of union. Wound coverage was classified as early (0-7 days) or late (8-30 days). Major and minor wound healing disturbances were found in 20.8% of the early and 83.3% of the late groups, with mean union times of 4.0 months and 6.4 months, respectively. Extensive and serial debridements, coverage within five to seven days, and early bone grafting produce a viable soft tissue envelope and a favorable mesenchymal milieu for the healing of complex open fractures. This significantly improves end results with respect to union, tissue loss from infection, healing time, and cost of hospitalization and rehabilitation.