Over the past 4 years, a total of 33 patients, each with an open tibial wound in the distal third of the leg, underwent a skin-grafted muscle flap reconstruction according to the new treatment algorithm developed by the author. When the size of the soft-tissue defect was less than 50 cm2, a pedicled medial hemisoleus muscle flap was used for the soft-tissue coverage (n = 20). If the soleus muscle was traumatized, a small free muscle flap (ie, gracilis) was then used (n = 3). When the size of the soft-tissue defect was greater than 50 cm2, a larger free muscle flap (ie, rectus abdominis or latissimus dorsi) was selected (n = 10). All patients were followed for up to 4 years. Three patients with a medial hemisoleus muscle flap developed insignificant distal flap necrosis and were treated subsequently with debridement and flap advancement. Five patients with a free muscle flap required an additional operation, and 2 patients had a subsequent debulking procedure of the flap for contour improvement of the leg. Reliable soft-tissue coverage with a well-healed tibial wound, evident fracture healing, and good contour of the leg were achieved in all 33 patients during follow-up. Following this new treatment algorithm, a selected option for an open tibial wound in the distal third of the leg can provide reliable soft-tissue coverage for different sizes of open tibial wounds and may offer a more cost-effective approach for managing such a complex clinical problem.