title: The cost of infection in severe open tibial fractures treated with a free flap.
abstract: Open tibial fractures needing soft tissue cover are challenging injuries. Infection risk is high, making treatment difficult and expensive. Delayed skin closure has been shown to increase the infection rate in several studies. We aimed at calculating the direct and indirect cost of treatment, and to determine the effect of delayed skin closure on this cost.
  
  
  
  We reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013. We calculated direct costs based on length of stay (LOS) and orthopaedic and plastic surgical procedures performed, including medications and intensive care. We analysed indirect cost in terms of absenteeism and unemployment benefits. The primary goal was to establish the extra cost incurred by an infection.
  
  
  
  We analysed 46 injuries in 45 patients. Infection increased the LOS from 41 to 74 days and increased the cost of treatment from € 49,817 in uninfected fractures to € 81,155 for infected fractures. Employed patients spent 430 days more on unemployment benefits, than a matched cohort in the background population. Achieving skin cover within seven days of injury decreased the infection rate from 60 to 27 %.
  
  
  
  Severe open tibial fractures covered with free flaps, cause over a year of absenteeism. Infection increases direct cost of treatment over 60 % and roughly doubles LOS. Early soft-tissue cover and correct antibiotics have been shown to improve outcomes-underscoring the need for rapid referral to centres with an ortho-plastic set-up to handle such injuries.
authors.affiliation: Copenhagen Centre of Reconstructive Orthopaedic Surgery and Limb Lengthening, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark. ulrik.kaehler@gmail.com.
authors.forename: Ulrik Kähler
authors.initials: UK
authors.lastname: Olesen
authors.affiliation: Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Nicolas Jones
authors.initials: NJ
authors.lastname: Pedersen
authors.affiliation: University Hospital Basel, Basel, Switzerland.
authors.forename: Henrik
authors.initials: H
authors.lastname: Eckardt
authors.affiliation: Department of Finance, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Line
authors.initials: L
authors.lastname: Lykke-Meyer
authors.affiliation: Department of Plastic Surgery, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Christian Thorsten
authors.initials: CT
authors.lastname: Bonde
authors.affiliation: Copenhagen Centre of Reconstructive Orthopaedic Surgery and Limb Lengthening, Department of Orthopedic Surgery, Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark.
authors.forename: Upender Martin
authors.initials: UM
authors.lastname: Singh
authors.affiliation: Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: McNally
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005597:Fractures, Open / Q000150:complications / Q000191:economics / Q000601:surgery*; D058752:Free Tissue Flaps / Q000009:adverse effects*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000191:economics* / Q000628:therapy; D013977:Tibia / Q000601:surgery; D013978:Tibial Fractures / Q000150:complications / Q000191:economics / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Direct and indirect cost; Free flap; Infection; Open fractures; Osteomyelitis