Intramedullary nailing is the treatment of choice for unstable or displaced tibial fractures. Titanium nails have been advocated for their improved biocompatibility and biomechanical properties but concerns are held about increased complications. We present results of 225 tibial fractures in 221 patients (90% follow-up) treated with the ACE titanium tibial nail (DePuy International Limited, Leeds, UK) inserted between 1995 and 2003 in one hospital department, which show no increased complications compared with the published literature. Eighty-two percent of the patients were male with a median age of 33 years. The mechanism of injury was RTA (52%), Sport (22%) and other (26%). Forty-one percent of the fractures were open. The general complication rate represents the published literature whereas only 32% patients developed knee pain compared with the 40â€“57% previously reported. Median union time was unaffected by open injury, reaming or age. Ninety (43.3%) patients required re-operation of which 23 (11%) had a second re-operation. In total 43 (20.7%) nails were removed, without any complication as previously reported for this nail.