Wound, Ischemia, and foot Infection (WIfI) classification

NewsBot · Apr 4, 2018

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The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification independently predicts wound healing in diabetic foot ulcers
Presented as a podium presentation at the Thirty-ninth Annual Meeting of the Canadian Society for Vascular Surgery, Banff, Alberta, Canada, September 15-16, 2017.
Caitlin W. Hicks, MD, MS et al
Journal of Vascular Surgery 3 April 2018

Objective
Previous studies have reported correlation between the Wound, Ischemia, and foot Infection (WIfI) classification system and wound healing time on unadjusted analyses. However, in the only multivariable analysis to date, WIfI stage was not predictive of wound healing. Our aim was to examine the association between WIfI classification and wound healing after risk adjustment in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting.

Methods
All patients presenting to our multidisciplinary DFU clinic from June 2012 to July 2017 were enrolled in a prospective database. A Cox proportional hazards model accounting for patients' sociodemographics, comorbidities, medication profiles, and wound characteristics was used to assess the association between WIfI classification and likelihood of wound healing at 1 year.

Results
There were 310 DFU patients enrolled (mean age, 59.0 ± 0.7 years; 60.3% male; 60.0% black) with 709 wounds, including 32.4% WIfI stage 1, 19.9% stage 2, 25.2% stage 3, and 22.4% stage 4. Mean wound healing time increased with increasing WIfI stage (stage 1, 96.9 ± 8.3 days; stage 4, 195.1 ± 10.6 days; P < .001). Likelihood of wound healing at 1 year was 94.1% ± 2.0% for stage 1 wounds vs 67.4% ± 4.4% for stage 4 (P < .001). After risk adjustment, increasing WIfI stage was independently associated with poor wound healing (stage 4 vs stage 1: hazard ratio, [HR] 0.44; 95% confidence interval, 0.33-0.59). Peripheral artery disease (HR, 0.73), increasing wound area (HR, 0.99 per square centimeter), and longer time from wound onset to first assessment (HR, 0.97 per month) also decreased the likelihood of wound healing, whereas use of clopidogrel was protective (HR, 1.39; all, P ≤ .04). The top three predictors of poor wound healing were WIfI stage 4 (z score, −5.40), increasing wound area (z score, −3.14), and WIfI stage 3 (z score, −3.11), respectively.

Conclusions
Among patients with DFU, the WIfI classification system predicts wound healing at 1 year in both crude and risk-adjusted analyses. This is the first study to validate the WIfI score as an independent predictor of wound healing using multivariable analysis.
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NewsBot · May 8, 2018

The correlation of the society for vascular surgery wound, ischemia, and foot infection threatened limb classification with amputation risk and major clinical outcomes.
Mayor JM, Mills JL.
Indian J Vasc Endovasc Surg 2018;5:83-6

The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification more comprehensively describes the extent of limb threat in patients with chronic limb-threatening ischemia than many previous classification systems. Several centers have published 1-year amputation rates stratified by WIfI clinical stage. Stage 1 limbs have the lowest amputation risk, Stage 4 limbs have the highest, and Stages 2 and 3 have an intermediate risk. As WIfI clinical stage increases, wound healing time is longer, 1-year wound healing rate is lower, and reintervention rate, hospital costs, length of stay, and readmission rate all increase.
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NewsBot · Jul 2, 2020

A Comparison Between Diabetic Foot Classifications WIfI, Saint Elian, and Texas: Description of Wounds and Clinical Outcomes
Gabriela Verónica Carro et al
Int J Low Extrem Wounds. 2020 Jun 28

Several wound classification systems are used to assess diabetic foot wounds. The recommendations for their use depend on the authors and foot associations. In this study, we compared Saint Elian score system, WIfI classification and Texas in 101 patients with foot wounds, and we followed them for a median of 149 days, finding differences both in the assigned risk and in the association with major amputation and wound healing. Saint Elian and WIfI scores match when Saint Elian is low or high risk but not when it is moderate. WIfI stages correlate with major amputation and wound healing. Saint Elian III correlates with major amputation. Prevalence of major amputations was 41% for WIfI 4 and 83% for Saint Elian III. WIfI 1 and 2 and Saint Elian I had a rate of wound healing of 80% to 85%. Stages 1 and 2 of WIfI score behave similar with regard to wound healing, 82% and 80% (P = .71), and major amputation, 0% and 10% (P = .68). Stages I and II of Saint Elian have the same rates of major amputation, 0% and 8% (P = .66), but not of wound healing, 85% and 51% (P < .05). The optimal cut point for detecting major amputation in Saint Elian is 18, with a sensitivity of 90.9 and specificity of 84.9, but there is no recommended cut point for wound healing. These classifications are validated for their use in diabetic foot wounds and to assess amputation risk, helping physicians make decisions and talk to the patients about prognosis.
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NewsBot · Jun 29, 2021

WIfI classification: the Society for Vascular Surgery lower extremity threatened limb classification system, a literature review
Lorena de Oliveira Cerqueira et al
J Vasc Bras. 2020 May 8

The Society for Vascular Surgery has proposed a new classification system for the threatened lower limb, based on the three main factors that have an impact on limb amputation risk: Wound (W), Ischemia (I) and foot Infection ("fI") - the WIfI classification. The system also covers diabetic patients, previously excluded from the concept of critical limb ischemia because of their complex clinical condition. The classification's purpose is to provide accurate and early risk stratification for patients with threatened lower limbs; assisting with clinical management, enabling comparison of alternative therapies; and predicting risk of amputation at 1 year and the need for limb revascularization. The objective of this study is to collect together the main points about the WIfI classification that have been discussed in the scientific literature. Most of the studies conducted for validation of this classification system prove its association with factors related to limb salvage, such as amputation rates, amputation-free survival, prediction of reintervention, amputation, and stenosis (RAS) events, and wound healing.
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NewsBot · May 17, 2022

WIfI scoring: a reliable tool for risk stratification in
the diabetic foot clinic
Williams P, Bakewell Z, Akinlade B, Russell DA
J.Vasc.Soc.G.B.Irel. 2022;

Background: The prevalence of diabetes is estimated to be over 5 million adults in the UK.
Diabetic foot care is estimated to cost the NHS ~£1 billion per annum, meaning that diabetic
foot ulcers (DFUs) are an increasing topic of discussion. It is estimated that reducing the
prevalence of DFUs by a third could save the NHS up to £250 million annually. The Society of
Vascular Surgery Wound, Ischaemia, foot Infection (WIfI) stage stratifies the risk of amputation
and benefit of revascularisation in patients with threatened lower limbs and has been
extensively validated in patients with chronic limb-threatening ischaemia, yet data on cohorts
with diabetic foot ulcers in the UK remain scarce. The aim of this project was to compare the
WIfI stage with the currently used Site, Ischaemia, Neuropathy, Bacterial infection and Depth
(SINBAD) score in order to stratify risk in patients with DFUs.
Methods: The electronic case record (ECR) of eligible cases was reviewed retrospectively
between February 2016 and March 2018. All patients with a recorded opening toe pressure
were included. SINBAD score was taken from an ECR proforma and WIfI stage was calculated
from ECR notes. The patients were followed up using electronic case notes.
Results: 119 patients with 129 foot wounds were included. WIfI stages predicted time to ulcer
healing (p=0.04) whereas the trend for SINBAD severity did not reach significance (p=0.08).
WIfI stages correlated with the proportion of patients with any minor/major ipsilateral lower limb
amputation at 1 year (p=0.03) and minor amputation at 1 year (p=0.04), whilst SINBAD
severity did not (p=0.95 and p=0.90, respectively).
Conclusions: WIfI more accurately predicts time to healing than SINBAD severity. WIfI
predicted amputation risk at 1 year but SINBAD did not. WIfI more accurately predicts risk of
minor amputation.
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NewsBot · Feb 16, 2023

A Prospective Analysis of the SVS WIfI Classification System to Stratify Immediate and One-Year Patient Outcomes
Michael D. Liette, DPM et al
February 14, 2023

The purpose of this study was to prospectively enroll patients that presented to the emergency department with a lower extremity infection, stratify risk and record outcomes. Risk stratification was performed based on the Society of Vascular Surgery Wound, foot Infection, and Ischemia (WIfI) classification system. This study aimed to establish the efficacy and validity of this classification in predicting patient outcomes during immediate hospitalization and throughout a one year follow up. A total of 152 patients were enrolled in the study and of these, 116 met the inclusion criteria and had at least one year of follow up for analysis. Each patient was assigned a WIfI score based on wound, ischemia, and foot infection severity according to the classification guidelines. Patient demographics as well as all podiatric and vascular procedures were recorded. The major end points of the study were rates of proximal amputation, time to wound healing, surgical procedures, surgical dehiscence, readmission rates, and mortality. A difference in rates of healing (P=0.04), surgical dehiscence (P<0.01), and one year mortality (P=0.01) with increasing WIfI stage as well as across the individual component scores was noted. This analysis further supports the application of the WIfI classification system early during patient care to stratify risk and identify the need for early intervention and a multi-specialty team approach to potentially improve outcomes in the severe multi-comorbid patient.
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NewsBot · Mar 5, 2023

Risk Factors for Major Amputation in Chronic Limb-Threatening Ischemia Patients classified as Wound, Ischemia, and foot Infection (WIfI) Stage 4 following Infrainguinal Revascularization
Koichi Morisaki et al
Ann Vasc Surg. 2023 Mar 2;S0890-5096(23)00110-3

Objective: To evaluate limb salvage outcomes and risk factors for major amputation in chronic limb-threatening ischemia (CLTI) patients classified as Stage 4 per the Wound, Ischemia, and foot Infection (WIfI) classification following infrainguinal revascularization.

Methods: We retrospectively analyzed multicenter data of patients who had undergone infrainguinal revascularization for CLTI between 2015 and 2020. The endpoint was secondary major amputation defined as an above- or below-knee amputation following infrainguinal revascularization.

Results: We analyzed 243 patients with CLTI and 267 limbs. Bypass surgery was performed in 14 (25.5%) and 120 (56.6%) limbs from the secondary major amputation and limb salvage groups, respectively (P < .01). Endovascular therapy (EVT) was performed in 41 limbs (74.5%) in the secondary major amputation group and 92 limbs (43.4%) in the limb salvage group (P < .01). The average serum albumin levels were 3.0 ± 0.6 and 3.4 ± 0.5 g/dL in the secondary major amputation and limb salvage groups, respectively (P < .01). The percentage of congestive heart failure (CHF) was 36.4% and 14.2% in secondary major amputation and limb salvage groups, respectively (P < .01). The number of limbs with infra-malleolar (IM) P0, P1, and P2 were 4 (7.3%), 37 (67.3%), and 14 (25.5%), respectively, in the secondary major amputation group and 58 (27.4%), 140 (66.0%), and 14 (6.6%), respectively, in the limb salvage group (P < .01). Limb salvage rates at 1-year were 91.0% and 68.6% in the bypass and EVT groups, respectively (P < .01). Limb salvage rates at 1-year in patients with IM P0, P1, and P2 were 91.8%, 79.9%, and 53.1%, respectively (P < .01) Multivariate analysis revealed that serum albumin level [Hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.36-0.89; P = .01], hypertension (HR, 0.39; 95% CI, 0.21-0.75; P < .01), CHF (HR, 2.10; 95% CI, 1.09-4.05; P = .03), wound grade (HR, 1.72; 95% CI, 1.03-2.88; P = .04), IM P (HR, 2.08; 95% CI, 1.27-3.42; P < .01), and EVT (HR, 3.31; 95% CI, 1.77-6.18; P < .01) as independent risk factors for secondary major amputation being required.

Conclusions: Among CLTI patients with WIfI stage 4, the limb salvage rate was poor in those with IM P1-2 following infrainguinal EVT. Low serum albumin levels, CHF, high wound grade, IM P1-2, and EVT were independent risk factors for CLTI patients requiring major amputation.
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NewsBot · Sep 21, 2023

Clinical characteristics of patients with diabetic foot using WIfI classification—A pilot study in VietnamCaracterísticas clínicas de pacientes con pie diabético utilizando la clasificación WIfI. Un estudio piloto en Vietnam
Huynh Le Thai Bao , Nguyen Hai Thuy
Endocrinología, Diabetes y Nutrición; 15 September 2023

Background
Due to its effect on patient health and healthcare resources, the study of diabetic foot is essential. Despite the existence of classification and grading systems, further evidence is required. Current systems are prone to a lack of validation in specific populations, inadequate consideration of regional variations, and an incomplete evaluation of risk factors and outcomes. The prevalence and complications of diabetes, such as diabetic foot, are on the rise worldwide, necessitating regionally specific research. To fill these gaps, this study focuses on a Southeast Asian subpopulation.

Objective
The study aims to evaluate the clinical characteristics of diabetic foot patients using the WIfI classification system, and to develop a risk calculator for patients to predict and evaluate potential outcomes.

Methods
A retrospective analysis was conducted on the medical records of patients with diabetic foot who visited a tertiary hospital in Vietnam between December 2021 and July 2022. Demographic data, clinical characteristics, and outcomes were collected and classified according to the WIfI (Wound, Ischemia, and foot Infection) classification system. Descriptive statistics were used to analyze the data, and a multivariable logistic regression model was employed to develop a risk calculator.

Results
The study included 60 patients with diabetic foot. Gender distribution was similar (56.7% male), with a mean age of 44 years. Most patients had ulcers of varying degrees, while ischemia contributed to higher grades, placing 43.3% at moderate-to-high risk of amputation (stages 3 and 4). HbA1c positively correlated with amputation risk (p < 0.05), while ABI, TBI, and TP showed inverse correlations (p < 0.001). The amputation risk equation based on the WIfI scale was: risk = 3.701 − 0.788ABI − 1.260TP. A risk calculator was developed using these predictors to estimate adverse outcomes.

Conclusion
In diabetic foot patients, early identification and management of risk factors are crucial. The findings of this study highlight the importance of ischemia and its association with amputation risk. Incorporating HbA1c, ABI, and TP, the risk calculator enables personalized assessments of amputation risk, thereby assisting healthcare professionals in treatment planning. Further validation and refinement of the risk calculator is required for broader clinical application.
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