The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.