Background: The open tibial diaphyseal fracture remains a treatment challenge. The purpose of the present analysis of the long-term follow-up data on a previously reported cohort of patients was to identify surgeon-controlled variables that affected fracture union, complications, and final outcome in patients who had sustained a severe open tibial shaft fracture. Methods: A cohort of 156 patients with a limb-threatening open tibial diaphyseal fracture was identified from the Lower Extremity Assessment Project (LEAP) study group. The patients were prospectively followed for two to seven years. In addition to the Sickness Impact Profile, other outcome metrics included the time to fracture union as well as the occurrence of infection and other complications that required rehospitalization. Statistical differences between groups were calculated. Results: Within the parameters of the present study, the timing of debridement, the timing of soft-tissue coverage, and the timing of bone-graft placement had no effect on outcome. Patients in whom the fracture was definitively treated with an external fixator had more surgical procedures, took longer to achieve full weight-bearing status, and had more read-missions to the hospital for the treatment of infection and nonunion than did those in whom the fracture was treated with an intramedullary nail. Patients undergoing external fixation who also had a muscle flap for wound coverage had more physical impairment and a worse functional outcome than did patients who had an amputation. Conclusions: Surgeons should carefully consider alternative treatment options for patients who have a severe open tibial fracture when limb salvage is perceived to require the combination of external fixation for fracture fixation and a muscle flap for wound coverage. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.