Background:  Motorcycle accidents constitute upto 20% of road accidents in India. Lower limb trauma occurs in half of them with Gustilo III fractures showing a rise.  Reconstruction requires stable soft tissue cover over aligned fractures. Morbidity results from poor tissue cover, osteomyelitis and non–union.  Despite evidence, few surgical approaches succeed in addressing the need for periosteal cover. This approach provides vascularized periosteal cover at fracture sites to promote bone healing, without sacrifice of muscle / neurovascular structures or function.

Methods:  22 patients comprising 21 Gustilo III B cases of open tibial fractures were included. All underwent a vascularized periosteal flap cover for the exposed fracture. This was achieved by employing composite myoperiosteal, periosteocompartment or periosteomusculocutaneous slide.Residual cover was completed by split skin grafting or perforator plus flaps.

Results:  Fractures were segemental or distributed across all thirds of tibial shaft.  Bony and soft tissue cover was achieved in all employing subperiosteally elevated sliding muscle flaps and perforator–based flaps respectively.Early results were assessed at 4 weeks with follow up up to 2 years. Healing of fractures and stable cover was achieved in 16 cases.  Bony union was evident in another 3 despite osteomyelitis. The remaining 3 patients with intramedullary nails had endosteal infection and non–union.

Conclusions:  Current approach to managing compound leg fracturesstresses need for vascularized stable soft tissue cover while bony union is considered to occur by default. Experimental evidence of improved fracture healing using vascularized periosteum has rarely been translated to clinical studies.  Vascular periosteal flaps based on muscle pedicles are a viable, easily executed and safe option and help in bone regeneration. Well perfused periosteal bone and soft tissue cover, both are achievable by this approach.