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; Shannon R. Garvey; Amy Chen; Valeria P. Bustos; Monica Morgenstern; Rosie Friedman; Bernard T. Lee; Arriyan S. Dowlatshahi; Ryan P. Cauley

doi:10.1055/a-2102-0147

Journal of Reconstructive Microsurgery, Table of Contents

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‡^*

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Shannon R. Garvey‡^*

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Amy Chen

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Valeria P. Bustos

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Monica Morgenstern

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Rosie Friedman

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Bernard T. Lee

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Arriyan S. Dowlatshahi

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

,

Ryan P. Cauley

¹Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

› Author Affiliations

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

Full Text

References

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Supplementary Material

Supplementary Material