History

Seventy-seven-year-old Ms. G was admitted to Manor Oak Life Center, Buffalo, NY, on July 24, 2000 with a diagnosis of sacral pressure ulcer, anemia, reflex sympathetic dystrophy, hypertension, and fractured left forearm. She had fallen at home and remained in a decubitus position for a prolonged period until she was hospitalized June 15, 2000 through July 24, 2000. The acute injuries were treated (including surgical debridement of the Stage IV pressure ulcer) in the hospital through July 24 by her attending physician and various consulting specialists.

When she was admitted to the Life Center, Ms. G was ambulating with a walker and assistance for short distances. She was able to understand and comply with instructions and wanted to return home as quickly as possible. A single mother of an adult mentally retarded son, she was concerned because her son had required social service intervention for temporary placement when she was hospitalized and he would continue to require placement until her return home. These circumstances and the location of the wound dictated that the wound be completely healed before she returned home.

Wound Description

A sacral pressure ulcer was located 9.0-cm superior and slightly lateral to the anus over the sacral base. On July 24, the wound measured 3.0 cm x 4.0 cm x 3.0 cm. Undermining of 1.0 cm to 3.0 cm was present on the inferior margins from 9 o'clock to 3 o'clock, which rendered a thick (4.0 mm) epibole (rolled edges) (see Figure 1). The wound bed was pale with a ceiling of yellow hydrated fibrous tissue. The peripheral margins were hyperpigmented and indurated. A scant amount of sanguineous drainage was noted and no signs of infection were observed. Ms. G did not complain of pain at the time of examination, yet was perceptive to tactile stimulation.

Diagnosis

The sacral pressure ulcer was classified as Stage IV, using the National Pressure Ulcer Advisory Panel (NPUAP) staging system, where a Stage IV pressure ulcer is defined as a full-thickness skin loss with extensive destruction, tissue necrosis or damage to the muscle, bone, or supporting structures (ie, tendon, joint capsule).

Epibole, also clinically referred to as rolled-over edges, is often seen in chronic wounds with poor healing dynamics, especially inadequate granulation.¹ The migrating front of epithelial cells is unable to cover the cavity so they descend down and curl under at the edges. Wound edges that roll over will ultimately cease in migration secondary to contact inhibition once epithelial cells of the leading edge come in contact with other epithelial cells. Continued tissue trauma will result in thickening, rolling inward of the epidermis, fibrosis, and scarring.

In a case where reepithelialization has ceased, "knocking down the edges" may be necessary so the normal process of epithelialization can continue once the proliferation phase (granulation) of repair has caught up. Various methods are used clinically to reduce the edges, including the application of chemical pharmaceuticals (ie, silver nitrate) and sharp and surgical debridement. Each method poses a risk of inflammation, setback, and infection.

Management

The nursing staff treated the sacral pressure ulcer using topical hyperbaric oxygen (THBO) via a disposable sacral unit (Advanced Hyperbaric Technologies, Inc., Farmingdale, NJ) for 60 minutes, twice daily, seven times per week. A licensed physical therapist treated the wound using high-volt, pulsed current electrical stimulation (ES), (Rich-Mar Corp., Inola, Okla.), for 30 minutes each day, five times per week. Before each treatment, the wound was irrigated and cleansed using sterile saline and gauze. Following each treatment, the wound was packed with sterile saline soaked gauze and covered with Allevyn (Smith and Nephew, Inc., Largo, Fla.). The parameters for the THBO was 3L/min, with 22 mm Hg; the ES parameters were 150 volts, 120 pulses per second at 255 pulse pair intervals (time between each pair of pulses). The wound was assessed on a daily basis and photographs were taken using a Polaroid Health Cam (Polaroid Corporation, Cambridge, Mass.) on a weekly basis. The treatment duration from initial examination (July 25, see Figure 1) to discharge (October 30, see Figure 2) was 13 weeks. The epibole was reduced while full granulation and reepithelialization proceeded to complete closure and the wound was 100% healed.

Ms. G's diet was developed and directed by a registered dietitian. Vitamin supplements and a balanced nutritional intake were closely monitored to address the nutritional needs of her healing wound as well as her anemia and other medical conditions. At all times, staff addressed and cared for this patient in a compassionate and professional manner. Positive psychosocial interrelations significantly enhance and contribute to the success of wound management -- as demonstrated by Ms. G's progress and healing.

Overall, the treatment response and outcome was excellent. The wound was 100% healed, which is defined as full granulation and complete epithelialization. The patient was pleased with the rate of closure and success of treatment. During the treatment phase, Ms. G did not complain of any discomfort or pain -- in fact, she applauded the treatment and care she received during her stay at Manor Oak Life Center.

Patient Education

Ms. G was given a preliminary introduction to the rationale and methodology associated with our wound team approach before she received wound care at Manor Oak Life Center. She was educated in the areas of nutrition and hydration and their importance relative to wound healing and anemia. Also, she was instructed in the necessity of pressure relief, the role of nursing (including the application of THBO), physical therapy (including electrical stimulation) and functional rehabilitative aspects, the roles and responsibilities of each team member, and the need for her compliance. Ms. G was conscientious and concerned with her son's living situation and happiness; thus, she was compliant and had a positive attitude while working toward healing her wound. Her interest and compliance with the overall team approach and treatment objectives facilitated this positive outcome.

Associated Perspectives

Complete reduction of the epibole in this case also was observed in a second case involving Ms. H, an 82-year-old female with a diagnosis of Stage IV sacral pressure ulcer and cancer of the bladder with metastasis to the right hip, left shoulder, and lungs. She also had severe degenerative joint disease, was nonambulatory, had severe breakthrough pain, and was unable to eat or drink during her terminal period. The epibole associated with her wound was extensive and thick at the time of initial examination (see Figure 3). Like Ms. G, Ms. H was treated with THBO, ES, and Allevyn, and demonstrated impressive progress against great odds. The epibole reduced completely as in the above case and was nearing full granulation and beginning reepithelialization (see Figure 4) at the time of her death. The combination of THBO, ES, and a well-established, dedicated wound care approach offers a conservative and successful treatment approach to Stage IV pressure ulcers complicated by epibole. - OWM