You have a sad and difficult situation. You did not indicate etiology other than diabetes, thus my thoughts first went to arterial insufficiency, but then the cause may have been trauma. Thus, several options.

First, you might trial a petrolatum based silver dressing (Silver Sulfadiazine in the US). If no improvement after daily dressing changes for two weeks, the most viable approach would be debridement. This is only an option in patients with no prognosis of walking in the future.

Another option is vacuum assisted closure (VAC is US brand but is also commonly referenced). There are many manufacturers globally of vacuum assisted closure. 

If the cause is limited to diabetes, then trialing a vacuum assisted closure device would be  a viable first step.

Hi. Would be helpful to know what you have tried so far and for how long. We would do a surgical debridement, bacterial cultures and the start advanced wound management with a vacuum assisted closure device (which you can also fabricate if you don´t the commercial device). When you a better wound bed then you´ll have more options, such a skin graft to partially solve the problem, a dermal matrix such as Integra to help manage tendon exposure or a free flap depending on age, prognosis and potential rehabilitation. Good luck and patience cause it will take some time to help this patient. 

Patient presented with an infected wound on June 07, 2016 and picture is of June 24th. that makes around 17th Post operative days, so far multiple episodes of debridement (surgical ) followed by Honey dressing ( for desloughing). Patient is young 35 years with poor diabetes control. He is on Insulin for the last 5 years.

This was the picture on June 7th

I think it is a very good case for a vacuum assisted closure device. Also complete bed rest is very important. Please if you have any questions on how to do this let us know.

I had a patient who presented with a similar wound some years ago. We did a workup to identify osteomyelitis, ruled out arterial insufficiency. She was negative for osteo and AI, but her sed rate and inflammatory markers were the highest results I have ever seen. Her WBC was though

To echo Dr Arriagada's comment, if a vacuum assisted closure device is not available to you, constructing one specific to your patient is not difficult (in fact- that how the VAC was actually invented in the 1970's!)

I know that in the US, this has been a problem (creating your own device), hopefully it would not be a problem in our country.

I go with vacuum assisted closure as well

Hi Dr Qureshi,

I would try with a short cycle of VAC therapy and then applying on the wound Integra .

Three weeks later a split thickness skin graft.

Regards.

Alessandro Borgognone 

Based on the picture provided, the wound bed adjacent to the exposed tendons is nice and granular. My next thought would be to not allow the exposed tendons to desiccate. I have had great success with Integra (it has a new version Omnigraft), or other topical dressings (Primatrix, Graft Jacket, Aquacel Ag). 

VAC or other negative pressure therapy device can help stimulate angioneogenesis.

Monitor the wound bed serially and debride devitalized and nonviable tissue as needed.

When the wound bed is granular and ready to accept a graft without exposed tendon, then I would do a split thickness skin graft. Using a VAC over the STSG instead of a bolster dressing has completely eliminated seroma/hematoma related graft failure. After applying and securing the STSG, apply a fenestrated non-adherent layer, then the VAC.

Thank you .

would keep you all posted . A few further clarifications

what does SSD stands for ?

What is short cycle of VAC Dressing

what is the appropriate pressure to be maintained in custom built VAC dressings?

Dear, if this is the only factor for retarded healing, so 

1- Local fascio-cutanous flap (if feasible) with split thickness skin graft cover to the new raw area.   or

2- wound debridement with tendon excision is also a solution after discussing with the patient.

but please first be sure that all other factors are managed properly, as blood quality and quantity , bone factor and others.  you can review that here:

http://onlinelibrary.wiley.com/doi/10.1111/jdi.12425/abstract

Dear Dr Quareshi,

I would recommend infection control, negative pressure therapy(VAC), and when the tendons covered split thickness grafting.

Wound bed monitoring and debridement of nonviable and necrotic tissues is also vital.

Good luck.

Co2 scanning laser would be a great option for debridement. 

Focused CO2 scanning laser  for debridement is not an alternatuve solution to negative pressure therapy, they can be both used, to cure wounds. CO2 laser  is a very effective method for debridement, with several advantages.

According to our experience the excision of the tendons is required in such a case. The tendons which was exposed (especially for long time) loose their function and viability and, moreover, can serve as a way for spreading of infection.

We've managed to "Clean" part of the exposed tendon with SmartXide2 CO2 scanning laser. In this way we've managed to preserve the tendon.