CLINICAL ARTICLE
Clinical utility of the modified frailty index in predicting adverse outcomes in patients undergoing lower extremity free flap reconstruction
Romina Deldar MD,
Samuel S. Huffman BS,
John D. Bovill BS,
Nisha Gupta MS,
Brian N. Truong BS,
Zoë K. Haffner BS,
Adaah A. Sayyed BS,
Kenneth L. Fan MD,
Karen K. Evans MD,
Romina Deldar MD
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorSamuel S. Huffman BS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorJohn D. Bovill BS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorNisha Gupta MS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorBrian N. Truong BS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorZoë K. Haffner BS
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorAdaah A. Sayyed BS
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorKenneth L. Fan MD
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorCorresponding Author
Karen K. Evans MD
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Correspondence
Karen K. Evans, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007, USA.
Email: [email protected]
Search for more papers by this authorRomina Deldar MD,
Samuel S. Huffman BS,
John D. Bovill BS,
Nisha Gupta MS,
Brian N. Truong BS,
Zoë K. Haffner BS,
Adaah A. Sayyed BS,
Kenneth L. Fan MD,
Karen K. Evans MD,
Romina Deldar MD
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorSamuel S. Huffman BS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorJohn D. Bovill BS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorNisha Gupta MS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorBrian N. Truong BS
Georgetown University School of Medicine, Washington, DC, USA
Search for more papers by this authorZoë K. Haffner BS
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorAdaah A. Sayyed BS
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorKenneth L. Fan MD
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Search for more papers by this authorCorresponding Author
Karen K. Evans MD
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
Correspondence
Karen K. Evans, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007, USA.
Email: [email protected]
Search for more papers by this authorFirst published: 20 December 2023
Abstract
Background
Identifying at-risk patients for complications remains challenging in patients with chronic lower extremity (LE) wounds receiving free tissue transfer (FTT) for limb salvage. The modified-5 frailty index (mFI-5) has been utilized to predict postoperative complications, yet it has not been studied in this population. The aim of this study was to determine the utility of the mFI-5 in predicting adverse postoperative outcomes.
Methods
Patients ≥60 years, who underwent LE FTT reconstruction at a single institution from 2011 to 2022, were retrospectively reviewed. Patient characteristics, mFI-5, and postoperative outcomes were collected. Cohorts were divided by an mFI-5 score of <2 or ≥2.
Results
A total of 115 patients were identified, of which 71.3% (n = 82) were male, 64.3% (n = 74) had a mFI-5 score of ≥2, and 35.7% (n = 41) had a score <2. The average age and body mass index were 67.8 years and 28.7 kg/m2, respectively. The higher mFI-5 cohort had lower baseline albumin levels (3.0 vs. 4.0 g/dL, p = .015) and higher hemoglobin A1c levels (7.4 vs. 5.8%, p < .001). The postoperative length of stay was longer in the higher mFI-5 cohort (18 vs. 13.4 days, p = .003). The overall flap success was 96.5% (n = 111), with no difference between cohorts (p = .129). Postoperative complications were comparable between cohorts (p = .294). At a mean follow-up of 19.8 months, eight patients (7.0%) underwent amputation, and 91.3% (n = 105) were ambulatory.
Conclusion
High microsurgical success rates can be achieved in comorbid patients with high frailty indexes who undergo FTT for limb salvage. A multidisciplinary team approach may effectively mitigate negative outcomes in elderly, frail patients.
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
REFERENCES
- Adams, P., Ghanem, T., Stachler, R., Hall, F., Velanovich, V., & Rubinfeld, I. (2013). Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngology. Head & Neck Surgery, 139(8), 783–789. https://doi.org/10.1001/jamaoto.2013.3969
- Bekeny, J. C., Zolper, E. G., Steinberg, J. S., Attinger, C. E., Fan, K. L., & Evans, K. K. (2021). Free tissue transfer for patients with chronic lower extremity wounds. Clinics in Plastic Surgery, 48(2), 321–329. https://doi.org/10.1016/j.cps.2021.01.004
- Bhama, P. K., Patel, S. A., Khan, U., Bhrany, A. D., & Futran, N. D. (2014). Head and neck free flap reconstruction in patients older than 80 years. Journal of Reconstructive Microsurgery, 30(8), 523–530. https://doi.org/10.1055/s-0034-1384664
- Bigdeli, A. K., Gazyakan, E., Schmidt, V. J., Bauer, C., Germann, G., Radu, C., Kneser, U., & Hirche, C. (2019). Long-term outcome after successful lower extremity free flap salvage. Journal of Reconstructive Microsurgery, 35(4), 263–269. https://doi.org/10.1055/s-0038-1675146
- Black, C. K., Zolper, E. G., Ormiston, L. D., Schwitzer, J. A., Luvisa, K., Attinger, C. E., Fan, K. L., & Evans, K. K. (2020). Free anterolateral thigh versus Vastus Lateralis muscle flaps for coverage of lower extremity defects in chronic wounds. Annals of Plastic Surgery, 85(S1 Suppl 1), S54–s59. https://doi.org/10.1097/sap.0000000000002335
- Bosse, M. J., MacKenzie, E. J., Kellam, J. F., Burgess, A. R., Webb, L. X., Swiontkowski, M. F., Sanders, R. W., Jones, A. L., McAndrew, M. P., Patterson, B. M., McCarthy, M. L., Travison, T. G., & Castillo, R. C. (2002). An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. The New England Journal of Medicine, 347(24), 1924–1931. https://doi.org/10.1056/NEJMoa012604
- Chen, H., Hara, Y., Horita, N., Saigusa, Y., Hirai, Y., & Kaneko, T. (2020). Declined functional status prolonged hospital stay for community-acquired pneumonia in seniors. Clinical Interventions in Aging, 15, 1513–1519. https://doi.org/10.2147/CIA.S267349
- Chimukangara, M., Helm, M. C., Frelich, M. J., Bosler, M. E., Rein, L. E., Szabo, A., & Gould, J. C. (2017). A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair. Surgical Endoscopy, 31(6), 2509–2519. https://doi.org/10.1007/s00464-016-5253-7
- Culliford, A. T. I., Spector, J., Blank, A., Karp, N. S., Kasabian, A., & Levine, J. P. (2007). The fate of lower extremities with failed free flaps: A single institution's experience over 25 years. Annals of Plastic Surgery, 59(1), 18–22. https://doi.org/10.1097/01.sap.0000262740.34106.1b
- Dasgupta, M., Rolfson, D. B., Stolee, P., Borrie, M. J., & Speechley, M. (2009). Frailty is associated with postoperative complications in older adults with medical problems. Archives of Gerontology and Geriatrics, 48(1), 78–83. https://doi.org/10.1016/j.archger.2007.10.007
- DeFazio, M. V., Economides, J. M., Anghel, E. L., Tefera, E. A., & Evans, K. K. (2019). Lower extremity free tissue transfer in the setting of thrombophilia: Analysis of perioperative anticoagulation protocols and predictors of flap failure. Journal of Reconstructive Microsurgery, 35(4), 270–286. https://doi.org/10.1055/s-0038-1675145
- Donato, D., Veith, J., Holoyda, K., Magno-Padron, D., Simpson, A., King, B., & Agarwal, J. (2022). Associations of discharge destination and length of stay in lower extremity free flap reconstruction. Journal of Plastic Surgery and Hand Surgery, 57, 279–284. https://doi.org/10.1080/2000656X.2022.2070175
- Doyle, D. J., Goyal, A., & Garmon, E. H. (2022). American Society of Anesthesiologists Classification. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441940/
- Ducic, I., & Attinger, C. E. (2011). Foot and ankle reconstruction: Pedicled muscle flaps versus free flaps and the role of diabetes. Plastic and Reconstructive Surgery, 128(1), 173–180. https://doi.org/10.1097/PRS.0b013e3182173d3a
- Farhat, J. S., Velanovich, V., Falvo, A. J., Horst, H. M., Swartz, A., Patton, J. H., & Rubinfeld, I. S. (2012). Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. Journal of Trauma and Acute Care Surgery, 72(6), 1526–1530; discussion 1530–1. https://doi.org/10.1097/TA.0b013e3182542fab
- Ferrari, S., Copelli, C., Bianchi, B., Ferri, A., Poli, T., Ferri, T., & Sesenna, E. (2013). Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection. Journal of Cranio-Maxillo-Facial Surgery, 41(2), 167–171. https://doi.org/10.1016/j.jcms.2012.07.005
- Fitzgerald O'Connor, E. J., Vesely, M., Holt, P. J., Jones, K. G., Thompson, M. M., & Hinchliffe, R. J. (2011). A systematic review of free tissue transfer in the management of non-traumatic lower extremity wounds in patients with diabetes. European Journal of Vascular and Endovascular Surgery, 41(3), 391–399. https://doi.org/10.1016/j.ejvs.2010.11.013
- Fried, L. P., Xue, Q. L., Cappola, A. R., Ferrucci, L., Chaves, P., Varadhan, R., Guralnik, J. M., Leng, S. X., Semba, R. D., Walston, J. D., Blaum, C. S., & Bandeen-Roche, K. (2009). Nonlinear multisystem physiological dysregulation associated with frailty in older women: Implications for etiology and treatment. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 64(10), 1049–1057. https://doi.org/10.1093/gerona/glp076
- Hackett, N. J., de Oliveira, G. S., Jain, U. K., & Kim, J. Y. S. (2015). ASA class is a reliable independentpredictor of medical complications and mortality following surgery. International Journal of Surgery, 18, 184–190. https://doi.org/10.1016/J.IJSU.2015.04.079
- Jain, N. S., Vuong, L. N., Hickman, L. B., Chin, P., Hill, E. J. R., Buck, D., II, & Festekjian, J. H. (2021). Using the modified frailty index to predict negative outcomes in free-flap breast reconstruction: A National Surgical Quality Improvement Project-based study. Microsurgery, 41(8), 709–715. https://doi.org/10.1002/micr.30810
- Järbrink, K., Ni, G., Sönnergren, H., Schmidtchen, A., Pang, C., Bajpai, R., & Car, J. (2016). Prevalence and incidence of chronic wounds and related complications: A protocol for a systematic review. Systematic Reviews, 5(1), 152. https://doi.org/10.1186/s13643-016-0329-y
- Jubbal, K. T., Zavlin, D., & Suliman, A. (2017). The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases. Microsurgery, 37(8), 858–864. https://doi.org/10.1002/micr.30189
- Khouri, R. K., Cooley, B. C., Kunselman, A. R., Landis, R. J., Yeramian, P., Ingram, D., Natarajan, N., Benes, C. O., & Wallemark, C. (1998). A prospective study of microvascular free-flap surgery and outcome. Plastic and Reconstructive Surgery, 102(3), 711–721. https://doi.org/10.1097/00006534-199809030-00015
- Kim, P. J., Attinger, C. E., Steinberg, J. S., Evans, K. K., Akbari, C., Mitnick, C. D. B., Johnson-Arbor, K. K., & Singh, B. (2016). Building a multidisciplinary hospital-based wound care center: Nuts and bolts. Plastic and Reconstructive Surgery, 138(3 Suppl), 241s–247s. https://doi.org/10.1097/prs.0000000000002648
- Kim, S., Brooks, A. K., & Groban, L. (2015). Preoperative assessment of the older surgical patient: Honing in on geriatric syndromes. Clinical Interventions in Aging, 10, 13–27. https://doi.org/10.2147/cia.S75285
- Lee, J., Alfonso, A. R., Kantar, R. S., Diep, G. K., Berman, Z. P., Ramly, E. P., Daar, D. A., Levine, J. P., & Ceradini, D. J. (2020). Modified frailty index predicts postoperative complications following Panniculectomy in the elderly. Plastic and Reconstructive Surgery. Global Open, 8(7), e2987. https://doi.org/10.1097/gox.0000000000002987
- Lee, Z. H., Daar, D. A., Stranix, J. T., Anzai, L., Levine, J. P., Saadeh, P. B., & Thanik, V. D. (2020). Free-flap reconstruction for diabetic lower extremity limb salvage. The Journal of Surgical Research, 248, 165–170. https://doi.org/10.1016/j.jss.2019.12.008
- Levy-Lambert, D., Ramly, E., Kantar, R., Alfonso, A., & Levine, J. (2020). Congestive heart failure predicts major complications and increased length of stay in lower extremity Pedicled flap reconstruction. Plastic and Reconstructive Surgery, 146, 790e–795e. https://doi.org/10.1097/PRS.0000000000007363
- Maddox, S. S., Palines, P. A., Hoffman, R. D., Danos, D. M., Womac, D. J., Tuggle, C. T., & Stalder, M. W. (2021). A novel technique for radiographic diagnosis of sarcopenia that accurately predicts postoperative complications in lower extremity free flap patients. Journal of Reconstructive Microsurgery, 37(9), 744–752. https://doi.org/10.1055/s-0041-1726396
- Magno-Pardon, D. A., Luo, J., Carter, G. C., Agarwal, J. P., & Kwok, A. C. (2022). An analysis of the modified five-item frailty index for predicting complications following free flap breast reconstruction. Plastic and Reconstructive Surgery, 149(1), 41–47. https://doi.org/10.1097/prs.0000000000008634
- Mascarella, M. A., Gardiner, L., Patel, T., Vendra, V., Khan, N., Kergoat, M. J., Kubik, M. W., Solari, M. G., Snyderman, C. H., Traylor, K. S., & Sridharan, S. S. (2022). Cervical paraspinal skeletal muscle index outperforms frailty indices to predict postoperative adverse events in operable head and neck cancer with microvascular reconstruction. Microsurgery, 42(3), 209–216. https://doi.org/10.1002/micr.30848
- Meshkin, D. H., Zolper, E. G., Chang, K., Bryant, M., Bekeny, J. C., Evans, K. K., Attinger, C. E., & Fan, K. L. (2021). Long-term mortality after nontraumatic major lower extremity amputation: A systematic review and meta-analysis. The Journal of Foot and Ankle Surgery, 60(3), 567–576. https://doi.org/10.1053/j.jfas.2020.06.027
- Mitnitski, A. B., Mogilner, A. J., & Rockwood, K. (2001). Accumulation of deficits as a proxy measure of aging. TheScientificWorldJOURNAL, 1, 321027. https://doi.org/10.1100/tsw.2001.58
10.1100/tsw.2001.58 Google Scholar
- Offodile, A. C., 2nd, Aherrera, A., & Guo, L. (2014). Risk factors associated with prolonged postoperative stay following free tissue transfer: An analysis of 2425 patients from the American College of Surgeons National Surgical Quality Improvement Program database. Plastic and Reconstructive Surgery, 134(6), 1323–1332. https://doi.org/10.1097/prs.0000000000000735
- Patel, R. S., McCluskey, S. A., Goldstein, D. P., Minkovich, L., Irish, J. C., Brown, D. H., Gullane, P. J., Lipa, J. E., & Gilbert, R. W. (2010). Clinicopathologic and therapeutic risk factors for perioperative complications and prolonged hospital stay in free flap reconstruction of the head and neck. Head & Neck, 32(10), 1345–1353. https://doi.org/10.1002/hed.21331
- Piwnica-Worms, W., Stranix, J. T., Othman, S., Kozak, G. M., Moyer, I., Spencer, A., Azoury, S. C., Levin, L. S., & Kovach, S. J. (2020). Risk factors for lower extremity amputation following attempted free flap limb salvage. Journal of Reconstructive Microsurgery, 36(7), 528–533. https://doi.org/10.1055/s-0040-1710358
- Poh, A. W. Y., & Teo, S. P. (2020). Utility of frailty screening tools in older surgical patients. Annals of Geriatric Medicine and Research, 24(2), 75–82. https://doi.org/10.4235/agmr.20.0023
- Roh, D. S., Panayi, A. C., Bhasin, S., Orgill, D. P., & Sinha, I. (2019). Implications of aging in plastic surgery. Plastic and Reconstructive Surgery. Global Open, 7(1), e2085. https://doi.org/10.1097/gox.0000000000002085
- Saçak, B., Akdeniz, Z. D., Certel, F., Kocaaslan, F. N., Tuncer, B., & Çelebiler, Ö. (2015). Risk assessment for free tissue transfers: Is old age a determining factor? The Journal of Craniofacial Surgery, 26(3), 856–859. https://doi.org/10.1097/scs.0000000000001667
- Segal, D. N., Wilson, J. M., Staley, C., & Michael, K. W. (2018). The 5-item modified frailty index is predictive of 30-day postoperative complications in patients undergoing Kyphoplasty vertebral augmentation. World Neurosurgery, 116, e225–e231. https://doi.org/10.1016/j.wneu.2018.04.172
- Selber, J. C., Bergey, M., Sonnad, S. S., Kovach, S., Wu, L., & Serletti, J. M. (2009). Free flap breast reconstruction in advanced age: Is it safe? Plastic and Reconstructive Surgery, 124(4), 1015–1022. https://doi.org/10.1097/PRS.0b013e3181b453fd
- Serletti, J. M., Higgins, J. P., Moran, S., & Orlando, G. S. (2000). Factors affecting outcome in free-tissue transfer in the elderly. Plastic and Reconstructive Surgery, 106(1), 66–70. https://doi.org/10.1097/00006534-200007000-00012
- Sierakowski, A., Nawar, A., Parker, M., & Mathur, B. (2017). Free flap surgery in the elderly: Experience with 110 cases aged ≥70 years. Journal of Plastic, Reconstructive & Aesthetic Surgery, 70(2), 189–195. https://doi.org/10.1016/j.bjps.2016.11.008
- Song, X., Mitnitski, A., & Rockwood, K. (2010). Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. Journal of the American Geriatrics Society, 58(4), 681–687. https://doi.org/10.1111/j.1532-5415.2010.02764.x
- Star, A. (2018). Differentiating lower extremity wounds: Arterial, venous, neurotrophic. Seminars in Interventional Radiology, 35(5), 399–405. https://doi.org/10.1055/s-0038-1676362
- Subramaniam, S., Aalberg, J. J., Soriano, R. P., & Divino, C. M. (2018). New 5-factor modified frailty index using American College of Surgeons NSQIP data. Journal of the American College of Surgeons, 226(2), 173–181.e8.
- Üstün, G. G., Aksu, A. E., Uzun, H., & Bitik, O. (2017). The systematic review and meta-analysis of free flap safety in the elderly patients. Microsurgery, 37(5), 442–450. https://doi.org/10.1002/micr.30156
- Vaz, J. A., Côté, D. W., Harris, J. R., & Seikaly, H. (2013). Outcomes of free flap reconstruction in the elderly. Head & Neck, 35(6), 884–888. https://doi.org/10.1002/hed.23057
- Walston, J. D. (2012). Sarcopenia in older adults. Current Opinion in Rheumatology, 24(6), 623–627. https://doi.org/10.1097/BOR.0b013e328358d59b
- Weaver, D. J., Malik, A. T., Jain, N., Yu, E., Kim, J., & Khan, S. N. (2019). The modified 5-item frailty index: A concise and useful tool for assessing the impact of frailty on postoperative morbidity following elective posterior lumbar fusions. World Neurosurgery, 124, e626–e632. https://doi.org/10.1016/j.wneu.2018.12.168
- Xiong, L., Gazyakan, E., Kremer, T., Hernekamp, F. J., Harhaus, L., Saint-Cyr, M., Kneser, U., & Hirche, C. (2016). Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety. Microsurgery, 36(6), 511–524. https://doi.org/10.1002/micr.30020
- Xiong, L., Gazyakan, E., Wähmann, M., Bigdeli, A., Kremer, T., Harhaus, L., Sun, J., Kneser, U., & Hirche, C. (2016). Microsurgical reconstruction for post-traumatic defects of lower leg in the elderly: A comparative study. Injury, 47(11), 2558–2564. https://doi.org/10.1016/j.injury.2016.09.010
- Xue, Q. L. (2011). The frailty syndrome: Definition and natural history. Clinics in Geriatric Medicine, 27(1), 1–15. https://doi.org/10.1016/j.cger.2010.08.009
- Yagi, M., Michikawa, T., Hosogane, N., Fujita, N., Okada, E., Suzuki, S., Tsuji, O., Nagoshi, N., Asazuma, T., Tsuji, T., Nakamura, M., Matsumoto, M., & Watanabe, K. (2019). The 5-item modified frailty index is predictive of severe adverse events in patients undergoing surgery for adult spinal deformity. Spine, 44(18), E1083–E1091. https://doi.org/10.1097/brs.0000000000003063
- Yu, J., Hong, J. P., Suh, H. P., Park, J. Y., Kim, D. H., Ha, S., Lee, J., Hwang, J. H., & Kim, Y. K. (2020). Prognostic nutritional index is a predictor of free flap failure in extremity reconstruction. Nutrients, 12(2), 562. https://doi.org/10.3390/nu12020562
- Zolper, E. G., Bekeny, J. C., Ormiston, L. D., Walters, E. T., Fortman, E., Kotha, V. S., Fan, K. L., & Evans, K. K. (2021). Day-of-free tissue transfer qualitative cultures do not predict limb salvage outcomes. Plastic and Reconstructive Surgery, 147(2), 492–499. https://doi.org/10.1097/prs.0000000000007575
