In this multicenter study we have estimated the cost-of-illness of open lower limb fractures in the Netherlands. We evaluated the one-year direct hospital costs and reported a median total hospital cost of €31,258 in an academic level 1 trauma center setting. Factors associated with higher healthcare costs were FRI, multitrauma and severity of the injury (GA grade IIIA or higher). FRI led to a three-fold increase in the overall direct one-year cost to a median of €90,662. Costs were primarily attributed to the length of hospital stay, followed by surgical procedures.

Severely, and or multitrauma patients are at a higher risk of infection due to the extent of soft tissue damage, contaminated wounds and the immunological response to trauma. High injury severity scores are associated with an increase in emergency interventions and complications rates [20]. In this study we found that FRI’s were associated with an increase in healthcare use and consequent costs, however, interestingly, ICU admission was not a predictive or confounding factor for higher healthcare costs. Therefore, it is possible that the extent of the injuries associated with ICU admission, for example in concomitant neurotrauma, are of less of a financial impact compared to the extent of the soft tissue injuries of the tibia/fibula and the risk of FRI.

Similar to previous research on the direct costs of open lower limb fractures from countries such as the USA, Canada, Denmark, and Belgium, we found that these injuries are associated with significant healthcare utilization and consequent costs [11, 21]. Schade et al. (2021) reported in a systematic review on open tibia fractures (n = 17,073) that the duration of stay and total costs varied widely, even within countries. The costs in pounds converted to euros ranged from £5,705 to £126,479 (€6,680–€148,157) in high income countries, with the highest costs in the USA population. The median costs for open tibia fracture treatment in this study corresponds to the one year costs for a kidney transplant (36,036–38,666) [22]. Variation in costs in the present study may partly be attributed to the varying severity levels and nature of the injuries, as some patients with concomitant injuries were admitted for a longer period. Nonetheless, it was deemed inappropriate to compare these specific costs between countries as the individual healthcare systems, the methods for data collection, and the financial valuation vary substantially.

Schade et al. reported a substantially higher mean length of hospital stay of 56 days compared to our study, but included studies published before and after 2000, some of which were primarily focused on complex reconstruction and amputations. Two other recent studies reported a median length of stay of 10–12 days during the stay for definitive treatment, excluding readmissions [12, 23]. In line with previous findings, we found that hospital length of stay was the main driver of total hospital costs. It was previously reported that infection and nonunion increase the hospital costs and length of stay [11, 24]. Hoekstra et al. reported a fivefold increase in costs in patients with deep infections after two years follow-up [12]. It is possible that the total costs in this current study would have further increased, as late complications, such as low-grade FRI, associated non-unions, and osteomyelitis can occur after the 12-month period. Moreover, the question remains if adherence to the guidelines, such as timely treatment and prompt soft tissue coverage, is cost-effective and effective in preventing (infectious) complications. These are important issues for future research. Moreover, FRI is associated with prolonged periods of decreased quality of life (QoL) and substantial absenteeism, potentially adding 3–50% to the total health care expenditure [25,26,27]. Indirect costs, such as absenteeism from paid and unpaid work as well as decreased productivity, lead to further increases in costs for society.

Strategies to prevent complications and reduce healthcare costs in open lower limb fractures should focus on the following three pillars; (1) developing practice standards (2) prevention of (deep) infections, and (3) early detection and treatment of FRI. The first pillar is supported by the findings of our recent systematic review which showed that direct admission to a specialized center reduces the likelihood of both overall and deep infections, possibly decreasing the LOHS and total costs [28]. Examples include developing practice standards in terms of infrastructure and agreements on rapid fix and flap by means of early plastic surgery consults in case of severe open fractures, available microsurgical services and multidisciplinary teams with scheduled day time joint OR time. Furthermore, methods of prevention such as timely soft tissue coverage, prophylactic (local) antibiotics are strategies that have been shown to lead to reduced infection rates [14, 28,29,30]. Lastly, the consensus definition of FRI, published in 2018 facilitates a diagnostic algorithm, enabling earlier diagnosis and treatment according to the practice standards as defined in the Dutch FRI guideline [31]. Future research should aim to further improve these strategies and include focus on the rehabilitation process and socio-economic impact.

Inherent to the retrospective nature of this study there are limitations. Our study focused on patients treated primarily in an academic hospital setting, therefore it is possible that the injuries had a higher complexity compared to the general hospitals, with consequent higher costs. Furthermore, productivity losses in terms of absenteeism are part of the total societal costs as stated above, but we were unable to collect these data due to the retrospective nature of this study [25,26,27]. However, as we approached the economic burden from a healthcare provider perspective, taking into account the Dutch healthcare reimbursement system and guidelines, we estimated the total overall healthcare costs in relation to this perspective, shedding light on the importance of infection prevention. Moreover, inherent to this type of study, an important limitation is that these findings are applicable specifically to the Dutch Healthcare system; differences in reimbursement and healthcare systems limit the possibility of extrapolating to other countries.

Future research involving a larger population with more extensive follow-up is required to evaluate treatment options and their impact on total healthcare-related expenditures, particularly in the context of preventing and promptly treating FRI. This research should include a prospective follow-up of patients spanning both academic and non-academic settings, and account for out-of-pocket expenses and indirect costs, such as productivity losses. By including these economic factors, we hope to assess the overall economic burden and evaluate strategies to further improve patient outcomes. Specifically, it should consider the costs associated with adhering to treatment guidelines, such as prompt soft tissue coverage, to determine effective approaches for enhancing outcomes and reducing costs.