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

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.

Publication History

Received: 10 March 2023

Accepted: 23 May 2023

Accepted Manuscript online:
26 May 2023

Article published online:
12 July 2023

• References

• 1 Kowal P, Goodkind D, He W. U.S. Census Bureau. An Aging World: 2015, International Population Reports. U.S. Government Printing Office, Washington DC: http://www.census.gov/library/publications/2016/demo/P95-16-1.html
• 2 Kalyani RR, Golden SH, Cefalu WT. Diabetes and aging: unique considerations and goals of care. Diabetes Care 2017; 40 (04) 440-443
• 3 King DE, Xiang J, Kulshreshtha A. Cardiovascular health status in baby boomers with diabetes mellitus. South Med J 2016; 109 (06) 346-350
• 4 González-Consuegra RV, Verdú J. Quality of life in people with venous leg ulcers: an integrative review. J Adv Nurs 2011; 67 (05) 926-944
• 5 Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J 2016; 13 (05) 892-903
• 6 Nussbaum SR, Carter MJ, Fife CE. et al. An economic evaluation of the impact, cost, and medicare policy implications of chronic nonhealing wounds. Value Health 2018; 21 (01) 27-32
• 7 Sen CK. Human wounds and its burden: an updated compendium of estimates. Adv Wound Care (New Rochelle) 2019; 8 (02) 39-48
• 8 ADA. Economics of wound care. 2015 https://www.brhmedical.com/healthcare-proessionals/#economics
• 9 Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Am Podiatr Med Assoc 2010; 100 (05) 335-341
• 10 Lu J, DeFazio MV, Lakhiani C. et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg 2019; 35 (02) 117-123
• 11 Falola RA, Lakhiani C, Green J. et al. Assessment of function after free tissue transfer to the lower extremity for chronic wounds using the lower extremity functional scale. J Reconstr Microsurg 2018; 34 (05) 327-333
• 12 Sato T, Yana Y, Ichioka S. Free flap reconstruction for diabetic foot limb salvage. J Plast Surg Hand Surg 2017; 51 (06) 399-404
• 13 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
• 14 Robinson TN, Eiseman B, Wallace JI. et al. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg 2009; 250 (03) 449-455
• 15 Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001; 1: 323-336
• 16 Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr 2008; 8: 24
• 17 Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. J Surg Res 2013; 183 (01) 104-110
• 18 Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index using American College of Surgeons NSQIP Data. J Am Coll Surg 2018; 226 (02) 173-181.e8
• 19 Adams P, Ghanem T, Stachler R, Hall F, Velanovich V, Rubinfeld I. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg 2013; 139 (08) 783-789
• 20 Yagi M, Michikawa T, Hosogane N. et al. The 5-Item Modified Frailty Index is predictive of severe adverse events in patients undergoing surgery for adult spinal deformity. Spine 2019; 44 (18) E1083-E1091
• 21 Panayi AC, Haug V, Kauke-Navarro M, Foroutanjazi S, Diehm YF, Pomahac B. The modified 5-item frailty index is a predictor of perioperative risk in head and neck microvascular reconstruction: an analysis of 3795 cases. Am J Otolaryngol 2021; 42 (06) 103121
• 22 Ehlert BA, Najafian A, Orion KC, Malas MB, Black III JH, Abularrage CJ. Validation of a modified Frailty Index to predict mortality in vascular surgery patients. J Vasc Surg 2016; 63 (06) 1595-1601.e2
• 23 Chow AL, Karius AK, Broderick KP, Cooney CM. Frailty is the new age: a retrospective study of modified frailty index for preoperative risk assessment in autologous breast reconstruction. J Reconstr Microsurg 2023; 39 (02) 81-91
• 24 ACS NSQIP Participant Use Data File. ACS. Accessed July 27, 2022 at: https://www.facs.org/quality-programs/data-and-registries/acs-nsqip/participant-use-data-file/
• 25 Birkmeyer JD, Shahian DM, Dimick JB. et al. Blueprint for a new American College of Surgeons: National Surgical Quality Improvement Program. J Am Coll Surg 2008; 207 (05) 777-782
• 26 Rege RM, Runner RP, Staley CA, Vu CCL, Arora SS, Schenker ML. Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries. Injury 2018; 49 (12) 2234-2238
• 27 Tracy BM, Wilson JM, Smith RN, Schenker ML, Gelbard RB. The 5-Item Modified Frailty Index predicts adverse outcomes in trauma. J Surg Res 2020; 253: 167-172
• 28 Cuccolo NG, Sparenberg S, Ibrahim AMS, Crystal DT, Blankensteijn LL, Lin SJ. Does age or frailty have more predictive effect on outcomes following pedicled flap reconstruction? An analysis of 44,986 cases^† . J Plast Surg Hand Surg 2020; 54 (02) 67-76
• 29 Fitzgerald O'Connor EJ, Vesely M, Holt PJ, Jones KG, Thompson MM, Hinchliffe RJ. A systematic review of free tissue transfer in the management of non-traumatic lower extremity wounds in patients with diabetes. Eur J Vasc Endovasc Surg 2011; 41 (03) 391-399
• 30 Xiong L, Gazyakan E, Wähmann M. et al. Microsurgical reconstruction for post-traumatic defects of lower leg in the elderly: a comparative study. Injury 2016; 47 (11) 2558-2564
• 31 Piwnica-Worms W, Stranix JT, Othman S. et al. Risk factors for lower extremity amputation following attempted free flap limb salvage. J Reconstr Microsurg 2020; 36 (07) 528-533
• 32 Kotha VS, Fan KL, Schwitzer JA. et al. Amputation versus free flap: long-term outcomes of microsurgical limb salvage and risk factors for amputation in the diabetic population. Plast Reconstr Surg 2021; 147 (03) 742-750
• 33 Innocenti M, Menichini G, Baldrighi C, Delcroix L, Vignini L, Tos P. Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction?. Clin Orthop Relat Res 2014; 472 (07) 2276-2286
• 34 Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg 2008; 61 (07) 772-776
• 35 Luo J, Carter GC, Agarwal JP, Kwok AC. The 5-Factor Modified Frailty Index as a predictor of 30-day complications in pressure ulcer repair. J Surg Res 2021; 265: 21-26
• 36 Wilson RJ, Davies S, Yates D, Redman J, Stone M. Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery. Br J Anaesth 2010; 105 (03) 297-303
• 37 Mayo NE, Feldman L, Scott S. et al. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery 2011; 150 (03) 505-514
• 38 Jain NS, Vuong LN, Hickman LB. et al. Using the modified frailty index to predict negative outcomes in free-flap breast reconstruction: a National Surgical Quality Improvement Project-based study. Microsurgery 2021; 41 (08) 709-715