USC multidisciplinary health care team, including division faculty member Stephanie Woelfel, propose adding new metric to risk stratification used when considering amputation.

WHEN, AS A HEALTHCARE PROFESSIONAL, DO YOU KNOW YOU’VE DONE ALL YOU CAN, and the only option left for your patient with that severely wounded foot is to amputate it?

To help medical professionals, a risk-stratification tool was developed called the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System, which assesses amputation risk based on the extent of a patient’s wound, the extent of ischemia (blood supply) and the severity of the foot infection (or WIfI, for short).

In a new Journal of Vascular Surgery article, a group of USC healthcare professionals have made the case for adding one additional consideration: a patient’s ambulatory functional status — or ability to get around in the world, post-amputation.

“The overarching goal is for each patient to be as active and engaged in their world as possible,” said Stephanie Woelfel, a certified wound specialist physical therapist who treats patients at the Keck Medical Center of USC. “In some scenarios, that does mean that the patient will undergo some level of amputation, but it is typically much more distal here at USC than what would be offered at outside institutions, which gives patients a better chance of remaining active.”

When We Save Limbs, We Save Lives

The idea of incorporating ambulatory functional status was born out of a meeting of the Southwestern Academic Limb Salvage Alliance, a group of healthcare professionals that meets twice a month to discuss patient cases and research.

“A lot of the limb salvage case discussions we were having would start with the patient’s WIfI score, and inevitably we would always end up discussing the patient’s pre-morbid functional status and rehab potential, so we decided it would be a good adjunct measure to consider,” Woelfel said.

This measure would be scored, from a range of 0 (the patient was walking outside the home with or without an assistive device) to 3 (the patient was completely bedbound). The overall goal of incorporating this measure into a WIfI score would be to further individualize attempts at limb salvage, based on the patient’s functional abilities.

But, Woelfel pointed out, it could have additional benefits.

“In patients with diabetes, 28-51 percent get a second amputation within five years of their first amputation,” she said. “And the five-year survival rate after amputation is only 27 percent. These are pretty bleak numbers, so when we save limbs, we are quite literally saving lives.”

The Team Approach to Healthcare

Woelfel first became interested in wound care during her physical therapy studies at Marquette University, which dedicated a full semester to wound management. At Marquette, Woelfel studied under Luther Kloth, an expert in wound management physical therapy, who made a lasting impression on Woelfel.

“I felt like I got a really strong sense of what PTs could bring to this practice area early on,” she said. “My first job out of PT school was in long-term acute care, which was primarily patients with wounds or on ventilators. They wanted PTs performing wound care there, and honestly, I just never looked back after that.”

Woelfel said this Journal of Vascular Surgery study opened up a lot of exciting avenues for further study, including

• Do patients at a specific functional level recover better following amputations?
• Are there patient populations that might have a window for “pre-habilitation” prior to surgery for better outcomes?
• Are there specific physical therapy interventions that promote more limb salvage versus amputation?
• Are there physical therapy interventions that could help these patients remain in remission (wound free) for longer periods of time?

“I think this study is a true testament to our interdisciplinary approach here at USC,” Woelfel said. “I love the fact that I get to work in an interdisciplinary clinic every week with amazing physician colleagues. I’ve seen firsthand how much of an impact that team approach makes for patients, and I think continuing that team approach in research makes a lot of sense.”