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J Reconstr Microsurg 2024; 40(02): 163-170
DOI: 10.1055/a-2102-0147
Original Article

Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

Emmeline Jia‡   *
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Shannon R. Garvey‡   *
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Amy Chen
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Valeria P. Bustos
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Monica Morgenstern
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Rosie Friedman
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Bernard T. Lee
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Arriyan S. Dowlatshahi
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
,
Ryan P. Cauley
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
› Author Affiliations Funding R.F. is supported by the 2022 JOBST Lymphatic Research Grant awarded by the Boston Lymphatic Symposium, Inc.
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Abstract

Background Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer.

Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010–2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed.

Results In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities—including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications—with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47–2.05).

Conclusion While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

Keywords

limb salvage - free flap - lower extremity wounds - frailty index

Presentations

Presented at: 2023 American Society for Reconstructive Microsurgery Annual Meeting; Miami, FL, USA.


* These authors contributed equally to this work.


Supplementary Material



Publication History

Received: 10 March 2023

Accepted: 23 May 2023

Accepted Manuscript online:
26 May 2023

Article published online:
12 July 2023

© 2023. Thieme. All rights reserved.

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