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The SVS WIfI Classification System Predicts Wound Healing but Not Major Amputation in Patients with Diabetic Foot Ulcers Treated in a Multidisciplinary Setting
Caitlin W. Hicks, MD, MS, Nestoras Mathioudakis, MD, MHS, Joseph K. Canner, MHS, Ronald L. Sherman, DPM MBA, Kathryn F. Hines, PA-C, Ying W. Lum, MD, Bruce A. Perler, MD, MBA, Christopher J. Abularrage, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.

Objective(s): The SVS WIfI threatened limb classification has been shown to correlate well with risk of major amputation and time to wound healing in heterogenous diabetic and non-diabetic populations. Major amputation continues to plague the most severe Stage 4 WIfI patients with 1-year amputation rates of 40-64%. Our aim was to determine the association between WIfI class and wound healing time (WHT) and major amputation among patients with diabetic foot ulcers (DFU) treated in a multidisciplinary setting.
Methods: All patients presenting to our multidisciplinary DFU clinic from 6/2012-12/2015 were enrolled in a prospective database. Wound healing time and one-year major amputation rates were compared for patients stratified by WIfI classification.
Results: 217 DFU patients with 439 wounds (mean age 58.3±0.8 years, 58% male, 63% black) were enrolled, including 29% WIfI stage 1, 9% stage 2, 35% stage 3, and 27% stage 4. Peripheral vascular disease and dialysis were more common in patients with advanced (stage 3 or 4) wounds (P<.01). Patient demographics, socioeconomic status, and comorbidities were otherwise similar between groups. There was a trend towards an increased number of active wounds per limb at presentation with increasing WIfI stage (stage 1: 1.08±0.07 vs. stage 4: 1.39±0.12; P=.19). Mean wound area (stage 1: 3.75±1.3 vs. stage 4: 13.5±2.1cm2; P<.001) and depth (stage 1: 0.18±0.01 vs. stage 4: 0.84±0.08cm; P<.001) increased progressively with increasing wound stage. Minor amputations (stage 1: 15% vs. stage 4: 56%; P<.001) and revascularizations (stage 1: 6% vs. stage 4: 52%; P<.001) were more common with increasing WIfI stage. WIfI classification was predictive of WHT (P<.001; Figure 1A), but not major amputation rates (P=.91; Figure 1B). For stage 4 wounds, the mean WHT was 184±16 days and risk of major amputation at 1 year was 6.8±3.9%.
Conclusions: Among patients with DFU, the WIfI classification system correlated well with WHT but was not associated with risk of major amputation at 1 year. Use of a multidisciplinary approach for diabetic foot wound care reduced amputation risk and augmented healing time compared to previously published reports among patients with advanced stage 4 disease.


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