New perspectives on the treatment of the diabetic foot

Wolfgang Best (editor „foot&shoe“),  Dr. Gerald Engels Dr. Dirk Hochlenert Annette Switala(editor „Orthopädieschuhtechnik“) Herbert Türk, Jürgen Stumpf (from left).

Which treatment concept is effective with wounds at the diabetic foot? This was the central issue at a symposium in Cologne, Germany, where a newly developed therapy concept was introduced and discussed.

In order to treat wounds at the diabetic foot in a sustainable way it is decisive to find out the biomechanic reasons that caused them – and to treat them as well. In case of pressure ulcers the localization indicates the specific disturbance of the biomechanics.

Based on this insight, Dr. Dirk Hochlenert and Dr. Gerald Engels together with Dr. Stephan Morbach and Pedorthist Peter Brümmer developed the so-called “Entity-Concept”. The localization of the ulcerations and the identification of the typically harmful triggers were developed with the help of more than 10 000 case documentations. 50 spots on the foot that preferably develop ulcerations could be determined this way. This limited amount of wounds at very special spots on the foot they call “entities”.  The concept of entities facilitates the understanding of the complex biomechanic background and uses the systematic connection between the localization and the causes of the diabetic foot syndrome for the standardization of the resulting therapy options and for the specification of the prognosis. Often also here a surgical approach is recommended with the help of which specific, small interventions can lead to a foot that can be loaded again.

This concept used to be presented only in medicine, but now in Cologne on 5 November two designers of the concept, Dr. Gerald Engels and Dr. Dirk Hochlenert, discussed with pedortists how this new perception can be implemented in practice. Pedorthist Herbert Türk and OSM Jürgen Stumpf had already done some pioneer work for this symposium by elaborating and further developing the entity concept for pedorthics. 55 participants took the opportunity the learn more about this concept.

The most frequent eight entities that pedorthists have to deal with were topic of this event. Whether lesions beneath various metatarsal heads, beneath the points of the toe, torsion lesions of the big toe or lateroplantar lesions at the metatarsal head 5 with the pes cavus: Hochlenert and Stumpf explained the biomechanical background of all entities, before they dealt with pedorthic and surgical treatment options.

When should which therapy carried out? This was the question in focus. Dr. Gerald Engels thrilled the audience with understandable and humorous remarks about the surgical options and clarified that some entities, such as lesions at the points of the toes in case of hammer toes and claw toes, can easier be treated surgically than with the help of pedorthics – and that surgery at the diabetic foot nowadays offers much more than just amputation techniques. But not always is surgery the solution. Unloading concepts with orthoses and shoes are still in demand – always with the perspective to address the biomechanical cause of the wound.

There was a lot of consent between physicians and pedorthists concerning therapy, but also there were different views as to what makes sense in a concrete case. But the most important result was that this symposium initiated a new chapter within the interdisciplinary cooperation on the diabetic foot.

The next symposium on this topic will be held in Berlin, Germany, March 25, 2017.

Literature: Das diabetische Fußsyndrom - Über die Entität zur Therapie, Hochlenert, Dirk, Engels, Gerald, Morbach, Stephan, Springer 2014.