What a fun night syncing our WIfI settings!
Our October 13 journal club in Pasadena took us Back to the Future, from the early days of diabetic-foot classification to the questions shaping limb preservation today.
Chia-Ding “JD” Shih led the evening’s overview, connecting the history of Wagner and Meggitt’s work at Rancho Los Amigos with the Society for Vascular Surgery’s Wound, Ischemia, and foot Infection classification. That history has particular resonance here in Southern California, with Wagner’s work rooted in Rancho and USC and how that led to the interdisciplinary “Toe and Flow” Limb Preservation Program led by Tanzim “TK” Khan and Tze Woei Tan, today .
A shared language, then and now
Revisiting the foundational WIfI paper by Joe Mills, Mike Conte, George Andros, and Tony Sidawy, (and me) was a chance to reflect on how a common language of limb threat can help teams communicate. Wound, ischemia, and foot infection each matter. Bringing them together gives us a more complete framework for discussing risk and planning care. We also traced its roots from Fontaine and Rutherford to Meggitt-Wagner, and UT and today.
The Meggitt part of Meggitt–Wagner deserves particular recognition. Bernard Meggitt’s Surgical management of the diabetic foot appeared in the British Journal of Hospital Medicine in 1976, preceding Wagner’s later publications, including the 1981 paper. In his 1999 retrospective, Wagner credited Meggitt with codifying the grading system while a fellow at Rancho Los Amigos.
The University of Texas work was another important step along that path. Lawrence Lavery, Lawrence Harkless, and I described the UT classification in 1996, separating wound depth from the presence of infection and ischemia. Our validation study appeared in Diabetes Care in May 1998. In a review of 360 patients, increasing wound grade and stage were associated with a greater prevalence of amputation at six months, reinforcing the importance of considering depth, infection, and perfusion together.
Congratulations to our vascular surgery residents Michelle Manesh and Lily Adler for their presentations and for helping make this such an engaging evening of discussion.
It was also a pleasure to welcome Ángel Ibarra, a fourth-year UC Davis medical student from Inglewood and a mentee of our friend Dr. Misty Humphries. Ángel serves as medical student co-director of UC Davis CHAMPIONS, where Misty is lead physician. CHAMPIONS was founded and piloted in the San Joaquin Valley by Dr. Leigh Ann O’Banion in 2021 and has since expanded through the Foundation to Advance Vascular Cures and partner sites. Its community-based screening, education, and connections to care bring limb-preservation efforts beyond the clinic while helping train the next generation.
What do the revascularization-benefit quartiles tell us?
Caitlin Hicks and colleagues at Johns Hopkins examined WIfI-based revascularization-benefit quartiles in 187 revascularized limbs among 136 people with diabetes and chronic limb-threatening ischemia. The estimated one-year major-amputation rate was 25.7% in the “questionable benefit” quartile, compared with 3.8% to 7.2% in the other three quartiles.
That finding makes for an important journal-club conversation about the risk that can remain after restoring blood flow. These benefit quartiles are distinct from WIfI clinical stages. And because everyone included in this observational study underwent revascularization, it describes outcomes after treatment; it cannot establish whether an individual would have done better or worse without revascularization.
The limb, the person, and the future
Kay Yee Hon, Rob Fitridge, and colleagues in Australia brought the whole person into focus. Their three-year prospective study of 100 people with diabetes-related foot disease examined handgrip strength, muscle mass, and FRAIL-scale frailty alongside WIfI. Higher handgrip strength was associated with greater odds of wound healing (OR 3.83, 95% CI 1.35–10.92) and lower mortality.
The distinction matters: FRAIL-scale frailty itself was not significantly associated with wound healing, and none of the tested markers was significantly associated with amputation-free survival. These observational findings encourage further study of whole-person reserve; they do not show that strength training or any surgical intervention improves those outcomes.
Together with Tze-Woei Tan, Miguel Manzur, and our USC colleagues, it was a terrific evening of history, science, and conversation.
Many thanks to JD, Michelle, Lily, and everyone around the table. Connecting the foundations of our field with the next generation of clinicians made Back to the Future a fitting theme. A special thank-you to Celeste Mendoza from our GME team for putting it all together.
Syncing our WIfI settings. Keeping our focus on the people we serve.
#WIfI #LimbPreservation #VascularSurgery #MedicalEducation #ActAgainstAmputation
Selected references
Joseph L. Mills Sr, Michael S. Conte, David G. Armstrong, Frank B. Pomposelli, Andres Schanzer, Anton N. Sidawy, and George Andros; Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). Journal of Vascular Surgery. 2014;59(1):220–234.e1–2.
Caitlin W. Hicks, Joseph K. Canner, Ronald L. Sherman, James H. Black III, Ying Wei Lum, and Christopher J. Abularrage. Evaluation of revascularization benefit quartiles using the Wound, Ischemia, and foot Infection classification system for diabetic patients with chronic limb-threatening ischemia. Journal of Vascular Surgery. 2021;74(4):1232–1239.e3.
Kay Yee Hon, Madeleine Bain, Suzanne Edwards, Guilherme Pena, Neil McMillan, and Robert Fitridge. The association of sarcopenia and frailty in diabetes-related foot disease: A 3-year prospective evaluation. Journal of Foot and Ankle Research. 2025;18(1):e70038.
Bernard F. Meggitt. Surgical management of the diabetic foot. British Journal of Hospital Medicine. 1976;16:227–232. Bibliographic citation in Diabetes Care.
F. William Wagner Jr. The Dysvascular Foot: A System for Diagnosis and Treatment. Foot & Ankle. 1981;2(2):64–122.
Lawrence A. Lavery, David G. Armstrong, and Lawrence B. Harkless. Classification of diabetic foot wounds. The Journal of Foot and Ankle Surgery. 1996;35(6):528–531.
David G. Armstrong, Lawrence A. Lavery, and Lawrence B. Harkless. Validation of a diabetic wound classification system: The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21(5):855–859.
F. William Wagner Jr. The Diabetic Foot: A Personal Experience of 50 Years. Foot & Ankle International. 1999;20(11):684–686.
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