Hi Regine, thanks for the question. I wasn't able to access pictures if you sent them. There a couple of things that stand out from your description though. Based on the location of the wound and exposed bone, I wonder if this area is adequately offloaded and protected. The next area of concern is vascular supply. The toe index is low on this side and given the non healing status, I would recommend perusing vascular intervention if it is available in your area. However, the occlusion is likely in small vessels and endovascular attempts may be difficult at best. Your patient is carrying a diagnosis of osteomyelitis from ID and by default has been on antibiotics now for some months. One could make an argument that this is now chronic refractory osteomyelitis and you could seek HBO approval based on this diagnosis. If none of this provides the solution you are looking for, amputation of the toe could also be considered. However, one should still consider adequacy of blood flow at the presumptive amputation site before this is done.

Hope this helps.

Hi, thanks for the pics. The pretreatment looks a little wet around the margins. You could change the dressing more frequently or change to something more absorbent. I like Iodosorb for wounds like this. However, I think blood flow is likely the limiting factor here and changing dressing types is not likely to be the answer.