LASER ON SOFT TISSUE / ORTHOPEDIC VIEW:

““Laser inLaser in Orthopedic Orthopedic Surgery”Surgery”(Part-3)(Part-3)

Interaction and effects of laser Interaction and effects of laser (UV-IR) radiation on biological (UV-IR) radiation on biological

tissue tissue and its uses in Orthopedic and its uses in Orthopedic

Surgery.Surgery.Presented by-Dr. Md Nazrul Islam.Assistant Registrar, Orthopedic and traumatology Department, Shaheed Suhrawardy Hospital, Dhaka.

Laser : Laser : Alternative/ AdjuventiveAlternative/ Adjuventive

Over 2,500 scientific studies in the National Over 2,500 scientific studies in the National Library of Medicine have identified the many Library of Medicine have identified the many benefits of laser therapy as an alterative to benefits of laser therapy as an alterative to surgical intervention for pain.   surgical intervention for pain.  

Laser therapy does not require the use of Laser therapy does not require the use of drugs or invasive treatment; there are fewer drugs or invasive treatment; there are fewer side effects and risks, and it is quick, side effects and risks, and it is quick, painless, and convenient. painless, and convenient.

It can be adjuventive to other modalities of It can be adjuventive to other modalities of treatment like- medication, surgery or other treatment like- medication, surgery or other therapeutic approach.therapeutic approach.

LaserLaserInteraction Interaction with with Biological Tissues:Biological Tissues:

Types of laser, based on Effectiveness:Types of laser, based on Effectiveness:

a. Biostimulative Laser a. Biostimulative Laserb. Bioinhibiting Laser.b. Bioinhibiting Laser.

a. a. Biostimulative Laser:Biostimulative Laser: Laser is biostimulative effect on bioligical tissues, Laser is biostimulative effect on bioligical tissues, when it is used in a targeted tissue with specific wavelength. when it is used in a targeted tissue with specific wavelength.

Different biological tissue is responsive to different wavelength.Different biological tissue is responsive to different wavelength.

b. Bioinhibiting Laser:b. Bioinhibiting Laser: Laser has bioinhibitory effect when it is used with inappropriate Laser has bioinhibitory effect when it is used with inappropriate

wavelength, that means laser can be harmful to biological tissue when wavelength, that means laser can be harmful to biological tissue when it is used with an inappropriate wavelength.it is used with an inappropriate wavelength.

Types of laser, based on power:Types of laser, based on power:a. Low power Lasera. Low power Laser b. High power Laser b. High power Laser

Low power Laser: It has long wavelength, Low power Laser: It has long wavelength, anabolic effects, and it promote rapid anabolic effects, and it promote rapid reduction of pain, accelerates healing time/ reduction of pain, accelerates healing time/ growth and reduce repair stage of healing: on growth and reduce repair stage of healing: on the other hand don't give of heat use photo the other hand don't give of heat use photo energy.energy.

High power laser: they have shorter High power laser: they have shorter wavelengths which have catabolic effects wavelengths which have catabolic effects that can deliberately destroy tissue in that can deliberately destroy tissue in cauterizing and surgical applications, are cauterizing and surgical applications, are used to through tissue and give off heat.used to through tissue and give off heat.

Interaction of laser on Interaction of laser on biologic tissuesbiologic tissues

ScatteringScattering PenetrationPenetration AbsorptionAbsorption

Electromagnetic radiation in Electromagnetic radiation in the UV-IR spectral range the UV-IR spectral range propagates into biologic tissues propagates into biologic tissues until it is either scattered or until it is either scattered or absorbed.absorbed.

Interaction of laser with biologic Interaction of laser with biologic tissue tissue

Interaction of laser with biologic Interaction of laser with biologic tissuetissue

Interaction of laser on biologic Interaction of laser on biologic tissuestissues

Interaction of laser on biologic Interaction of laser on biologic tissuestissues

Scattering of laser into Scattering of laser into biologic tissuebiologic tissue

Scattering occurs at the boundaries Scattering occurs at the boundaries

between regions having between regions having different optical different optical refractive indicesrefractive indices because of because of inhomogeniusness that is-inhomogeniusness that is-

a. Watera. Water

b. Biomolecule (Protein, lipid etc.)b. Biomolecule (Protein, lipid etc.)

c. Pigments in the tissue.c. Pigments in the tissue.

Penetration of laser into Penetration of laser into biologic tissuebiologic tissue

Penetration of laser in the Penetration of laser in the biological tissues is biological tissues is supposed to be occurred in supposed to be occurred in an exponential decrease an exponential decrease (Bears Law) if there had (Bears Law) if there had been no scattering or been no scattering or absorption. absorption.

Absorption of laser into Absorption of laser into biologic tissuebiologic tissue

Laser absorption in biological Laser absorption in biological tissuestissues

( In IR-UV region of medical ( In IR-UV region of medical interest) predominantly depends interest) predominantly depends on wavelength.on wavelength.

The absorption of laser is highest The absorption of laser is highest in water molecule.in water molecule.

Protein, Pigments and Melanin Protein, Pigments and Melanin has different absorption has different absorption coefficient depending their coefficient depending their molecular structure.molecular structure.

Absorption of laser into Absorption of laser into biologic tissuebiologic tissue

Absorption of laser into biologic Absorption of laser into biologic tissuetissue

Absorption of laser into Absorption of laser into biologic tissuebiologic tissue

Absorbed energy from laser Absorbed energy from laser releases from water/ releases from water/ biomolecule by-biomolecule by-FluorescenceFluorescenceResonant electronic energy Resonant electronic energy transfertransfer

andandThermal vibration.Thermal vibration.

Application of Fluorescence Application of Fluorescence effect of laser:effect of laser:

Laser-induced fluorescence

(LIF) is a spectroscopic method used for studying structure of molecules, detection of selective species and flow visualization and measurement.

Resonant electronic energy Resonant electronic energy transfer.transfer.

Resonance energy transfer (RET) or electronic energy transfer (EET), is a mechanism describing energy transfer between two chromospheres.

FRET has been applied in an experimental method for the detection of phosgene.

Application of absorption Application of absorption effects of laser:effects of laser:

Thermal Heating of tissues has two Thermal Heating of tissues has two effects - effects - – Coagulation/cauterizing of tissues,Coagulation/cauterizing of tissues,– Tissue vaporization for incising or Tissue vaporization for incising or

excising.excising.

Ionizing Ablation of the molecules in the target tissue.

This form of photodisruption is used primarily in ophthalmic / Orthopedic practice.

Phototherapy Photochemical effects Phototherapy Photochemical effects include photoablation, include photoablation, photodynamic therapy (necrosis of photodynamic therapy (necrosis of tumors in cancer), and tumors in cancer), and photoradiation to enhance woundphotoradiation to enhance wound

healing.healing.

Stages of tissue healing by Stages of tissue healing by laser therapy:laser therapy:

Haemostasis; the arrest of bleeding by involving the physiological processes of blood coagulation and contraction of blood vessels. Haemostasis lasts several minutes. Inflammatory phase; triggers neutrophils and macrophage migration into the wound. This phase lasts several days.

Stages of tissue healing by laser Stages of tissue healing by laser therapy:therapy: (Continues)(Continues)

Granulation; the formation of a multicellular mass of tissue which can last up to three weeks. Re-epithelization; basement proteins reappear in a very ordered sequence from the wound inward in a zipper like-fashion closing the epidermal defect. Wound contraction and tissue remodeling; growth factors and other peptides provide stimuli for wound contraction.

Laser Laser application in application in Tissues:Tissues:

General view-General view-

Laser Therapy Laser Therapy promotespromotes

Improved circulationImproved circulation

Improved nerve functionImproved nerve function

Accelerated tissue repairAccelerated tissue repair

Increased mobility and muscle Increased mobility and muscle functionfunction

Laser Therapy helpsLaser Therapy helps

Reduce inflammationReduce inflammation

Decrease swellingDecrease swelling

Heal soft tissue injuriesHeal soft tissue injuries

Diminish or eliminate acute painDiminish or eliminate acute pain

Reduce chronic pain and Reduce chronic pain and discomfortdiscomfort

Laser Therapy Laser Therapy successfully treatssuccessfully treats

Acute and chronic painAcute and chronic pain Arthritis (osteoarthritis and rheumatoid Arthritis (osteoarthritis and rheumatoid arthritis)arthritis) Soft tissue injuries, including sprains Soft tissue injuries, including sprains and strainsand strains Tendonitis and bursitisTendonitis and bursitis Muscle spasm and tensionMuscle spasm and tension Vertebral disc conditionsVertebral disc conditions Sciatica, neuralgia, fibromyalgiaSciatica, neuralgia, fibromyalgia Post operative orthopedic, implants, Post operative orthopedic, implants, fracturesfractures Swelling and edemaSwelling and edema

Post-Operative HealingPost-Operative Healing Clinical studies have shown that laser therapy is Clinical studies have shown that laser therapy is especially beneficial for post-op patients. It works especially beneficial for post-op patients. It works to accelerate tissue repair and cell growth, heal to accelerate tissue repair and cell growth, heal wounds faster, reduce the formation of scar wounds faster, reduce the formation of scar tissue, reduce swelling and pain, improve tissue, reduce swelling and pain, improve vascular and metabolic activity and boosts the vascular and metabolic activity and boosts the function of the immune system. function of the immune system.

The energy produced by the laser stimulates the The energy produced by the laser stimulates the production of collagen and ATP (a DNA-related production of collagen and ATP (a DNA-related enzyme that serves as a source of energy to enzyme that serves as a source of energy to cells), promotes blood circulation, and stimulates cells), promotes blood circulation, and stimulates the regeneration of nerves. The non-invasive the regeneration of nerves. The non-invasive treatment speeds recovery and accelerates bone treatment speeds recovery and accelerates bone and wound healing, which means significantly and wound healing, which means significantly less down time for the patient.less down time for the patient.

Advantages of laser Advantages of laser surgery vs. traditional surgery vs. traditional

surgery?surgery?

Most laser surgeries can be performed Most laser surgeries can be performed on an outpatient basis.on an outpatient basis.Very small / precise incision.Very small / precise incision.No damage to surrounding areasNo damage to surrounding areasLess bleeding /"bloodless surgery," , Less bleeding /"bloodless surgery," , and less swelling.and less swelling.Less time consuming procedure.Less time consuming procedure.Lower rate of local infections.Lower rate of local infections.Reduce post-operative pain.Reduce post-operative pain.Reduce post operative recovery period.Reduce post operative recovery period.

Disadvantages of laser Disadvantages of laser surgery vs. traditional surgery?surgery vs. traditional surgery?

Cost.Cost.Eye hazards.Eye hazards.Imprecisely aimed lasers can burn or Imprecisely aimed lasers can burn or destroy healthy tissue.destroy healthy tissue.Needs special training/ arrangement.Needs special training/ arrangement.Cardiopulmonary resuscitation (CPR) Cardiopulmonary resuscitation (CPR) arrangement is recommended to avoid/ arrangement is recommended to avoid/ manage electrical incidence.manage electrical incidence.

RisksRisks

Like traditional surgery, laser Like traditional surgery, laser Surgery can be complicated by:Surgery can be complicated by:

HemorrhageHemorrhage

InfectionInfection

Perforation (piercing) of an Perforation (piercing) of an organ or tissue.organ or tissue.

Diagrammatic comparison graph to show muscle healing by Diagrammatic comparison graph to show muscle healing by laser therapy, to non-laser treated patients, assessing laser therapy, to non-laser treated patients, assessing

creatinine kinase level.creatinine kinase level.

Laser Laser application application

in Orthopedics: in Orthopedics:

Application of laser in Application of laser in orthopedic surgery:orthopedic surgery:

Musculoskeletal Wound HealingNerve Regeneration

a.a. To reduce pain.To reduce pain.b.b. To reduce inflammation To reduce inflammation c.c. Increased tissue tensile Increased tissue tensile

strengthstrengthd.d. Increased collagen productionIncreased collagen productione.e. To enhance and reduce healing To enhance and reduce healing

time.time.f.f. In surgical procedure.In surgical procedure.

Application of laser in Application of laser in orthopedic surgery:orthopedic surgery: Pain Pain

Management:Management:

• • FibromyalgiaFibromyalgia

• • Myofascial painMyofascial pain

• • Cervical neck painCervical neck pain

• • Low back painLow back pain

• • Joint painJoint pain

• • Trigeminal neuralgiaTrigeminal neuralgia

Application of laser in orthopedic Application of laser in orthopedic surgery: Inflammatory Conditions:surgery: Inflammatory Conditions:

• • Rheumatoid ArthritisRheumatoid Arthritis

• • Carpal Tunnel SyndromeCarpal Tunnel Syndrome

• • TendonitisTendonitis

• • Plantar fasciitisPlantar fasciitis

• • BursitisBursitis

Application of laser in Application of laser in orthopedic surgery: orthopedic surgery:

Connective Tissue Injury / Connective Tissue Injury / Disorders: Disorders:

• • SprainsSprains

• • StrainsStrains

• • TendonitisTendonitis

• • Tendon rupturesTendon ruptures

Application of laser in orthopedic Application of laser in orthopedic surgery: Joint Injuries / surgery: Joint Injuries /

Disorders:Disorders:

• • TMJ disordersTMJ disorders

• • OsteoarthritisOsteoarthritis

• • DislocationsDislocations

• • Ligament injuryLigament injury

Application of laser in orthopedic Application of laser in orthopedic surgery:surgery:

Muscle Injuries / Disorders:Muscle Injuries / Disorders:

• • Muscle bruises, contusionsMuscle bruises, contusions

• • Muscle rupturesMuscle ruptures

• • Muscle trigger points.Muscle trigger points.

Application of laser in Application of laser in orthopedic surgery: orthopedic surgery:

Neurological injury / disorders:Neurological injury / disorders:

• • Prolapsed diskProlapsed disk

• • Ruptured diskRuptured disk

• • Crush injuriesCrush injuries

• • NeuritisNeuritis

• • Trigeminal neuralgiaTrigeminal neuralgia

• • TinnitusTinnitus

Application of laser in orthopedic Application of laser in orthopedic surgery: Skin injuries / conditions:surgery: Skin injuries / conditions:

• • Surgical incisionsSurgical incisions

• • Skin ulcersSkin ulcers

• • BurnsBurns

• • Skin graftsSkin grafts

Application of laser in Application of laser in orthopedic surgery: Diagnostic-orthopedic surgery: Diagnostic-

Arthroscopy.Bony tissue Biopsy.AngioplastyTumor imaging and visualizationSelective caries removalBlood flow cytometryLaser induced fluorescence imagingPhotoacoustic imagingTMR

Application of laser in Application of laser in OrthopedicOrthopedic

Surgery:Surgery:

TherapeuticTherapeutic

PhysiotherapyPhysiotherapy

Degenerative Conditions:Degenerative Conditions:Rheumatoid Arthritis Rheumatoid Arthritis OsteoarthritisOsteoarthritisSoft Tissue Injuries:Soft Tissue Injuries:Arthritis Pain• Tendinitis• Tennis Elbow• Arthritis Pain• Tendinitis• Tennis Elbow• Acute Pain • Chronic Pain • Wound Healing• Acute Pain • Chronic Pain • Wound Healing• Carpal Tunnel• Strains/ Sprains• Frozen Carpal Tunnel• Strains/ Sprains• Frozen Shoulder• Plantar Fasciitis• Fibromyalgia • Shoulder• Plantar Fasciitis• Fibromyalgia • Knee Pain• Neck & Back Pain• WhiplashKnee Pain• Neck & Back Pain• Whiplash

Therapeutic Therapeutic nonoperative-nonoperative-

Application of laser in OrthopedicApplication of laser in OrthopedicSurgery:Surgery:

TherapeuticTherapeutic

Therapeutic Therapeutic

operative-operative-

Reconstructive surgery: kneeReconstructive surgery: knee

Spine surgery: PLDDSpine surgery: PLDD

Removal of soft tissue mass.Removal of soft tissue mass.

Amputation:Amputation:

Biopsy: Bone/Soft tissue.Biopsy: Bone/Soft tissue.

Important parameters

Laser parameters : Wavelength, Power density, exposure time, pulse duration, focused spot size, repetition rate.Optical properties of the tissue :absorption and scattering coefficientsThermal properties of the tissue: thermal capacity and thermal conductivity.

ThanksThanksevery one for every one for

patience,patience,

Bye.Bye.

See you next day with-See you next day with- ““Laser in Orthopedic Laser in Orthopedic Surgery”Surgery”(Part-4)(Part-4)

Laser on Hard TissueLaser on Hard Tissue