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Introduction The reported rate of subsequent surgery after intramedullary nailing (IMN) of tibial shaft fractures (TSFs) is as high as 21%. However, most studies have not included the removal of symptomatic implant in these rates. The purpose of this study was to evaluate the subsequent surgery rate after IMN of TSFs, including the removal of symptomatic implants. Secondly, this study aimed to assess what factors are associated with subsequent surgery (1) to promote fracture and wound healing and (2) for the removal of symptomatic implants. Methods One-hundred and ninety-one patients treated with IMN for TSFs were retrospectively included. The rate of subsequent surgery was determined. Bi- and multivariable analysis was used to identify variables associated with subsequent surgery. Results Approximately half of patients (46%) underwent at least one subsequent surgical procedure. Forty-eight (25%) underwent a subsequent surgical procedure to promote fracture or wound healing. Age ( P < 0.01), multi-trauma ( P < 0.01), open fracture ( P < 0.001) and index surgery during weekdays ( P < 0.05) were associated with these procedures. Thirty-nine patients (20%) underwent a subsequent surgical procedure for removal of symptomatic implants. There was a significantly lower rate of implant removal in ASA II (11%) and ASA III–IV (14%) patients compared to ASA I patients (29%) ( P < 0.05). Conclusions Patients treated with IMN for TSFs should be consented that about one-in-two patients will undergo an additional surgical procedure. Half of these procedures are required to promote wound or fracture healing; the other half are for symptomatic implant removal. Level of evidence Therapeutic level-IV.