Background: Chronic tibial osteomyelitis is one of the most challenging problems encountered by orthoplastic surgeons. The purpose of this study is to compare the outcome of fascio-cutaneous versus muscle flaps in management of tibial osteomyelitis. Methods: This is a prospective randomized study that has been conducted in the period from February 2021 to September 2022 for 40 patients with tibial osteomyelitis. The patients have been randomly assigned into 2 equal groups, group (A) and group (B). All the patients have been subjected to adequate bone and soft tissue debridement. Group (A) included 20 patients that were covered by fascio-cutaneous flaps. Group (B) included 20 patients that were covered by muscle flaps. Results: The results revealed that both methods have provided good soft tissue coverage for the defect and allow a chance for secondary orthopedic intervention. Fascio-cutaneous flaps had some advantages including decreased donor site morbidity, better color matching, better contour, easier debulking as well as more patient aesthetic satisfaction. Muscle flaps were associated with a lower rate of recurrence of infection as well as better filling of dead space after debridement. Conclusions: Fascio-cutaneous flaps are recommended in cases of low grades of osteomyelitis and when secondary flap re-elevation is intended. However, muscle flaps are recommended in cases with high grade osteomyelitis or when a large dead space is left after debridement.