The availability of unreamed interlocked nails for fixation of tibia fractures has raised the issue of what effect reaming the intramedullary canal has on the clinical outcome after tibial nailing. A retrospective review was performed of all tibial fractures treated with interlocking nailing at the authors' institution over the past 5 years in order to compare reamed and unreamed nailing. Forty-five nailings were identified of which 38 had adequate follow-up information to be considered healed or non-united at 1 year. Thirteen reamed and 23 unreamed tibial nailings were followed to healing; there were 6 nonunions. The unreamed nailings had lower average operative times and lower average estimated blood loss, although the results did not reach statistically significant levels. There was a statistically significant difference in healing times, with unreamed nailings taking an average of 242 days to heal while reamed nailings took 158. This difference held for subgroups such as isolated tibia fractures, closed tibial fractures, and high-energy tibial fractures. Six non-unions occurred, one in a reamed nailing and five in unreamed nailings. Malunions occurred in four reamed nailings and six unreamed nailings, most often in distal third fractures, interlocked on only one side of the fracture. Patellofemoral complications were more common in unreamed nailings. Although this study is limited by retrospective, nonrandom design, it raises questions about the routine use of unreamed nailing with regard to healing potential and other postoperative complications. Further study is warranted.