The SVS WIfI Classification Does Not Predict Successful Healing Following Transmetatarsal Amputation
Jake F. Hemingway, MD, Deion Sims, BS, Sam Schwarz, BS, Amit Pujari, MD, Joseph Fiorito, DPM, Niten Singh, MD.
University of Washington, Seattle, WA, USA.
OBJECTIVES: The Society for Vascular Surgery WIfI (wound, ischemia, foot infection) classification system has been shown to accurately predict limb salvage among patients with chronic limb threatening ischemia (CLTI) undergoing initial revascularization. However, its ability to predict limb salvage following transmetatarsal amputation (TMA) is unknown.
METHODS: A retrospective review of all CLTI patients undergoing TMAs at a single quaternary referral center between 1/2014 and 12/2019 was conducted. Our multidisciplinary limb preservation service includes a single surgical podiatrist who performs all TMAs within our institution. Baseline demographics including vascular disease history, procedural details, and outcomes were recorded. P values were calculated using Chi-Square testing.
RESULTS: During the study period, 51 patients underwent 55 TMAs. The mean age was 62.7 (range 38-81), and 78% (40) of patients were male. The median WIfI stage was 4 on presentation. Endovascular revascularization alone was performed in 42% of patients, versus open revascularization in 11%, both in 38%, and neither in 9%. The 12-month major amputation rate was 33% (12 below knee, 6 above knee). Neither the WIfI stage (P=.66) on presentation, nor the ischemia score post-revascularization (p=.29), were associated with subsequent major amputation. Additionally, there was no association seen between the need for major amputation following TMA and either the type of revascularization (P=.87), or the use of an endovascular-first approach (P=.15). An improvement in WIfI score following revascularization also did not predict TMA healing (P=.74).
CONCLUSIONS: The WIfI stage on presentation did not predict limb salvage following TMA. Excellent wound healing can be achieved following TMA despite advanced CLTI and a high WIfI stage, and therefore patients should not be precluded from attempted limb salvage based on the WIfI stage alone. Importantly, ischemia scores post-revascularization do not predict successful TMA healing, highlighting the need for further investigation into alternative non-invasive studies that may better predict TMA success.
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