Sir: A succession of Apert syndrome patients with infection and graft loss after acrosyndactyly correction with the trilobed flap technique and at our medical center prompted a modification of the conventional surgical prophylactic protocol used by the senior author (J.H.C.). Conventionally, patients undergoing syndactyly release would receive one intravenous dose of antibiotics (amoxicillin/clavulanate) at induction with, apart from a sterile nonadherent paraffin gauze dressing (Unitulle; Roussel B.V., Hoevelaken, The Netherlands), no added measures for the graft recipient site. The modified or extended protocol involved 7 days of oral antibiotics (amoxicillin/clavulanate) in additional to the conventional single intravenous antibiotic dose given at induction and treatment of the graft recipient sites with Unitulle dressings impregnated with an antibiotic 0.2% nitrofurazone solution (Furacine; Norgine, Heverlee, Belgium). A preliminary retrospective study was performed to study the effectiveness of the new protocol compared with the conventional protocol for reducing the postoperative infection and revision rate, to evaluate whether an objective justification exists for empirically prescribing the prolonged use of antibiotics. The group of procedures (27 webs in nine patients with Apert syndrome) performed by the senior author between January of 2004 and December of 2005 could be divided into two cohorts (Table 1): (1) 15 web corrections in nine patients under the conventional antibiotic prophylaxis, and (2) 12 webs in six patients under extended prophylaxis. It should be noted that all patients represented in the second cohort were also represented in the first. All cases were corrected with the dorsal trilobed flap technique, and all had secondary defects that required coverage with full-thickness skin grafts taken from the groin.Table 1: Demographics of Patients with Apert Syndrome Operated on for Primary Syndactyly of the HandAlthough we found a lower incidence of postoperative infections and reoperations in the extended compared with the conventional group (25 percent versus 46 percent and 8 percent versus 13 percent, respectively), the difference was not statistically significant (p = 0.35 and p = 0.69, respectively). Similar techniques for syndactyly release and web reconstruction using local transposition flaps and full-thickness skin grafts in patients with Apert syndrome have been reported in the literature, with infection rates ranging between 6 and 8 percent and revision rates ranging between 13 and 18 percent.1–3 Skin grafts are associated with poor surgical outcome,4 but their use is often unavoidable in complex abnormalities, such as those presented here. Different techniques, such as tissue expansion, defatting, and novel commissural flap designs, that omit the use of large skin grafts, may reduce the need for reoperation. These techniques, however, have not yet been widely accepted, and their place in the treatment algorithms remains to be determined. We acknowledge that this study has major limitations, including those inherent in the retrospective design, and the preliminary data do not provide enough evidence to recommend a prolonged course of antibiotics. Also, although meticulous surgical technique, adequate postoperative dressings, and splinting are crucial for a successful outcome, we do feel that the described prophylactic protocol could be a useful adjuvant in complex cases such as those presented here. We therefore suggest a prospective, randomized trial with a larger cohort of patients be performed to validate our findings. Michael Ananta, M.D. University College London Institute of Orthopaedics and Musculoskeletal Sciences Stanmore, Middlesex, United Kingdom J. Henk Coert, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Erasmus Medical Center Rotterdam, The Netherlands