Introduction. Managing open tibial fractures according to national guidelines is a primary focus for major trauma centres, however pressures of capacity and expertise limit the capability to achieve all of these standards for every patient. Debate remains over the impact of particular aspects of guidance, especially in relation to the timing of surgical interventions. Evaluation of these tenants of care predominantly hinge on trends derived from low level scientific evidence, mainly due to the difficulty in completing high level studies. The aim of this study is to assess the complication rates and the associations with difficulties in achieving the national guidance standards. Methods. Retrospective analysis of the 2015/2016 cohort of 3B open tibial fractures treated at the Queen Elizabeth Hospital Birmingham. Data collected, through the use of the patient electronic records, cross referenced against hospital coding and trauma injury database, included patient demographics, injury details, clinical interventions, surgical management, complications and time to bony union. Results. During the studied period, 40 patients were identified with 3B open tibial fractures. 2 patients died during the period of management, 3 patients were lost to follow up. Median time to definitive soft tissue coverage was achieved at 5 days post injury, definitive fixation at 6 days post injury. 25% of the cohort breached the 7 day maximum recommended limit. Overall complication rate was greater than 50%, with deep infection rate of 11% and non-union rate of 9%. Median time to union was 9 months. Conclusions. Missed opportunities to provide optimal patient care for severe lower limb open fractures are contributing to the high complication rates for these injuries. In order to aim for improvements in clinical outcomes, considered multispecialty clinical decision making needs to be coupled with institutional support and resources to adequately provide care for this injury cohort