Wound Irrigation in Initial Management of Open Fractures.

To the Editor: In reporting on the results of the Fluid Lavage of Open Wounds (FLOW) trial, Bhandari et al. (Dec. 31 issue)1 describe the initial management of open fracture wounds. According to their protocol, the investigators aimed to perform irrigation and débridement for skin and soft-tissue defects or to close wounds that had delayed union or nonunion with the use of grafting or muscle flaps within 7 to 14 days after the initial surgery. The use of low-pressure wound therapy (vacuum-assisted closure) was described. We wonder whether the investigators adhered to the protocol regarding definitive wound coverage, and we wonder about the number and duration of vacuum-assisted closure procedures used in the trial, since the application of these techniques is controversial. Delayed wound healing may result in exogenous superinfection, which is often polymicrobial.2 In our experience, superinfection is not prevented but may be facilitated by prolonged vacuum-assisted closure therapy.3 Skin flora microorganisms can migrate into the wound and adhere to internal fixation material, leading to nonunion or a high rate of recurrent infection.4 One of the primary end points of the trial was reoperation at the operative site within 12 months after the initial procedure in order to treat an infection. Information on the number and duration of vacuum-assisted closure procedures used in the trial might provide valuable insight into the association of the use of this procedure with later infection.