Purpose: Prognosis of open leg fractures is better when cover flaps are used early to cover tissue loss. Beyond eight days after high-energy trauma (Byrd stage III and IV), the therapeutic strategy requires discussion. The purpose of this study was to analyse the influence of flap covers on these complex fractures.

Material and methods: We conducted a retrospective analysis of 26 patients operated on from 1996 to 201. The therapeutic sequence was debridement, external fixation, and flap cover. High-energy trauma predominated (n=21). We used homolateral leg flaps (n=24, ten muscle flaps and 14 fasciocutaneous flaps) and free latissimus dorsi flaps (n=2). Flap cover was performed on day 8 (n=13), between day 8 and day 45 (n=11), or after day 45 (n=2).

Results: Cover flaps failed in eight cases requiring revision surgery. Time to cover or type of flap was not statistically related with initial severity of the injury. Time to cover influenced the type of flap chosen by the surgeons: 8/13 muscle flaps performed before day 8 versus 10/13 fasciocutaneous flaps after day 8 (p< 0.05). Complementary bone grafts were used for 18 patients before the third month leading to bone healing before ten months. Serious infection occurred in 16.6% of patients in the group treated before day 8 and in 36.66% of patients in the group treated after day 8. The severity of the initial injury and time to cover were not predictive of functional outcome.

Discussion: Proper management of high-energy leg fractures (Byrd stage III and IV) remains controversial. Most authors prefer external fixation to achieve skeletal stability. The growing interest for plastic surgery techniques for the leg segment has led to using locoregional homolateral leg flaps even after day 8. At this phase, we prefer muscle flaps. This attitude has demonstrated its usefulness in terms of healing time and its limitations due to the high risk of infection. Complementary bone grafting is performed before three months if signs of correct bone healing are absent on the control x-rays.