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 ACS-NSQIP database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on CPT and ICD 9/10 codes. Demographic and clinical variables were extracted. The 5-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: 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, mFI-5 score remained the best predictor of all-cause complications - with high frailty associated with 1.74 increased adjusted odds when compared to no frailty (95% CI 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.

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