Presented by

“Laser in
Dr. Md Nazrul islam.
Assistant Registrar,
Orthopedic
Orthopedic and Traumatology
Dep't.Shaheed Suhrawardy Sur ge ry ”
Hospital,
Sher-E-Bangla Nagor, Dhaka-1207.
Bangladesh. abbirr1@gmail.com..
(Part-4)

Interaction & effects

of Laser (UV-IR) radiation
on Biological Hard Tissues
and
its application in
07/17/09
Orthopedic Surgery.1
 “ Progress in surgical medicine is often
related to an improved technique of
performing osteotomies, i.e.bone
excisions.
Standard tools in orthopedics are saws,
milling-machines and mechanical drills. All
of them operate in contact mode and
possibly induce severe mechanical
vibrations and hemorrhage. It is thus
straightforward to ask whether lasers
might represent a considerable alternative
in orthopedic surgery”.

•
07/17/09 Markolf H. Niemz 2
 Hard tissue
Basics of Hard tissue

Basics
of
Har d
07/17/09 3
Basics of Hard tissue:
Types of Hard
Tissue:
Tis su e tha t h as be co me mi ner al ise d,
hav in g a f irm i nte rc el lul ar su bst an ce ,
e.g ., ca rti lag e and b on e.

• Co mpa ct bo ne or ( Cor ti cal bo ne ):

The hard outer layer of bones is
composed of compact bone tissue, This
tissue gives bones their smooth, white,
and solid appearance, and accounts for
80% of the total bone mass of an adult
skeleton.
• ca nce ll ous (T ra be cul ar bo ne) :
Filling the interior of the organ is
the trabecular bone tissue (an open
cell porous network also called
cancellous or spongy bone), Trabecular
bone accounts for the remaining 20% of
total bone mass but has nearly ten
07/17/09 times the surface area of compact bone 4 .
 Basics of Hard tissue

Mean composition
of Human Bone:

Matter Constituent Percentage

• Anorganic Hydroxyapatite 0 – 60%
Water 15 – 20%
Carbonates 5%
Phosphates 1%
• Organic Collagen 20%
Proteins 1–2%

07/17/09 5
 Ba si cs of
Basics of Hard tissue

Ha rd Ti ssu e:

07/17/09 6
 Basics of Hard tissue :
Ba si cs of
Ha rd
Ti ss ue:

07/17/09 7
 Ra di o A nat om y
Basics of Hard tissue of B one :

07/17/09 8
 General
View-

•Laser:
Ge ner al
07/17/09
Vi ew- 9
 Laser:
General View.
Ty pes o f las er ac t
on
Hard Tiss ue:
A. Cold Lase r:
A 100W Nd: YAG laser and
optical fibre. Cold Laser is the common term
used for a Low Level Laser
Therapy (LLLT) device. It is
considered cold laser because
it will not increase the
thermal temperature of what it
is contacting. Cold lasers
deliver power from 1mW to
500mW.
07/17/09 10
 Laser:
General View.

. Types of laser
act on Hard
Tissue:
• B. Ha rd La se r.

Most lasers used by

medical professionals on
the market are “HOT”
lasers or high powered
lasers. Hot lasers are
lasers that have an output
larger than one Watt
07/17/09 11
(1000mW).
 Types of laser
Laser:
General View. act on
Tissue:

07/17/09 12
 La se r
Laser:
General View.

th eo ry:
• Biological field
theory.
• Cellular
oscillation theory.
• Bio luminescence
theory.
07/17/09 13
 Laser theor y: Bio
Laser:
General View. luminescence theory-
• Bio luminescence theory - according to
Russian researchers, DNA replication
emits light at 630 nm. Since this is
very close to the wavelength of the He
Ne-laser light, it is postulated that
laser may accelerate DNA replication
via photic stimulation. Laser
irradiation at this frequency is said
to be non mutagenic since it is not in
the range to alter the genetic program
by affecting chromosomal ultra
structure. The latter is more likely to
occur at ultra-violet light irradiation
at 300 to 400 nm.
07/17/09 14
 Laser theory:
Laser: Cellular oscillation
General View.
theory:
• Cellular oscillation theory - the laser
beam carries electromagnetic
oscillations of definite frequency.
When it reaches the tissues the
electromagnetic oscillations gradually
"swing and excite" single cells. This
is thought to eventually intensify the
bionomical processes that ultimately
regulate the performance of various
vital organs. Soviet scientists go on
to say that the cell itself begins to
emit light similar to the rays of the
laser, when the resonance sets in.
07/17/09 15
 Laser theory:
Laser: Biological field
General View.
theory.
• Biological field theory - connections
between tissues and organs in the
intact organism are not limited to
humeral effects and nervous control
mechanisms alone. Rather, there exist
unique around every cell, tissue and
organ and higher structural levels
(organism, organ) exerting a
normalizing influence on lower levels
(tissue cells). The resonance effect
of the low power laser is thought to
restore the normal energetic status of
the organism, that is, restore its
normal physiological state.
07/17/09 16
 Laser:
Tissue &
General View.
Cellular
Response:
• Red light affects all cell:
absorbed by the mitochondria
present in all cells
• Infrared light is more
selective absorbed by
specific proteins in the
cell membrane & affects
permeability directly.
07/17/09 17
 Tissue &
Laser:
General View.
Cellular Response:
• Cytochromes (respiratory chain enzymes)
within the mitochondria have been
identified as the primary biostimulation
chromophores (primary light-absorbing
molecules).
• Cytochromes function to couple the
release of energy from cellular
metabolites to the formation of high
energy phosphate bonds in adenosine
triphosphate (ATP)
• Cytochromes also can absorb energy
directly from illumination, it is
possible that during LLLT light energy
can be transferred to cell metabolism
via the synthesis of ATP.
07/17/09 18
 Laser:
Tiss ue &
General View.
Cell ul ar
Resp on se:
• ATP is used to drive cell
metabolism (maintain membrane
potentials, synthesize proteins &
power cell motility &
replication).
• Since enzymes are catalysts with
the capability of processing
thousands of substrate molecules,
they provide amplification of
initiation of a biological
response with light.
07/17/09 19
 The Phys iolog ical E ffec ts
Laser: of L ow L evel Laser Ther apy:
General View.
• Im pro ve d b lo od ci rcu la tio n & v as odi la tio n. -
In cre as es bl ood s upp ly .
• Inc rease coll agen p rodu ction:
– Dev elops coll agen & mus cle ti ssue

• Inc rease macr ophage act ivity:

– Sti mulate s im mune s yste m
• Alt er ner ve c onduct ion veloci ty:
– Sti mulate s ne rve fu ncti on.

• In cre as es AT P p ro duc ti on
• Bi ost im ula ti on –
Imp rov ed me ta bol is m, in cre as e o f cel l
me tab ol ism - Inc re ase s spe ed , q ua lit y & t en sil e
st ren gt h o f tis su e r ep air .

• An alg es ic ef fec t- Re li eve s acu te /ch ro nic p ain .

• An ti- in fla mm ato ry & ant i- ede ma tou s eff ec ts-
Re duc es in fl amm at ion .
• Sti mulati on o f woun d he aling:
– Pro motes fast er wou nd h ealing /clo t form atio n
– Hel ps gen erat e new & he althy cell s & ti ssue .

07/17/09 20
 Laser:
Laser:
General View.
Short Term Effects-
• * Production and release of beta-
endorphins (these are morphine like
substances produced by various cells in
the body that inhibit the sensation of
pain).

• * Cortisol production is increased

(cortisol is the precursor of cortisone).
This enables
the body to combat the stress
associated with trauma or the disease
process.
• * The short-term effect is significant in
5-10% of cases during or after the
conclusion of the initial treatment, but is
not as important as the long term or
07/17/09 cumulative effect. 21
 Laser:
Laser: Long Term
General View.
Or Cumulative Effect-
• * ATP (adenosine triphosphate) production is
increased resulting in improved cellular
Metabolism.
• * DNA (deoxyribonucleicacid) production;
protein building block of tissue is
substantially increased.

• * Neurotransmission is facilitated due to

elevated levels of serotonin and
aceytylecholine.
• * Mitochondrial activity is stimulated resulting
in cell replication etc. (i.e. replacement,
regeneration and repair of abnormal cells).
• * Modulation of macrophages, fibroblasts and
other cells .
• * Angiogenesis (formation of new blood
vessels).
07/17/09 • * Regulates cell membrane potential, 22
 Laser:
Laser:
General View. Other Effects:

• * The immune response is

stimulated.
• * Lymphatic drainage is improved.
• * The histamine response is
positively altered.
• * Production of growth hormone is
increased.
• * The body’s natural healing
processes are enhanced.
07/17/09 23
 Adv antag es of lase r
Laser: sur gery vs. t radit ional
General View.
sur gery-
1. Unique capabilities.
2. No-touch technique.
3. Dry surgical field.
4. Reduced blood loss.
5. Reduced edema.
6. Limited fibrosis/stenosis.
7. Potential reduction in spread of
metastasis.
8. Fewer instrument in the field.
9. Sterilization of the impact site.
10. Reduced postoperative pain.
11. Precision.
07/17/09 24
 Laser: Ad va nta ge s o f las er
General View. su rg ery
vs . tra di tio na l s ur ger y-
• Most laser surgeries can be
performed on an outpatient
basis.
• * Non-invasive • Very small / precise
• * Non-toxic incision.
• * Easily applied • No damage to surrounding
areas.
• * Highly effective • Less bleeding /"bloodless
• * Cure rate > 95% surgery," , and less
swelling.
• * No known negative
• Less time consuming
side effects. procedure.
• Lower rate of local
infections.
• Reduce post-operative pain.
• Reduce post operative
07/17/09
recovery period. 25
Laser:
General View.
Dis advan tages of l aser
sur gery vs. t radit ional
sur gery ?
• Cost.
• Eye hazards.
• Imprecisely aimed lasers can
burn or destroy healthy tissue.
• Needs special training/
arrangement.
• Cardiopulmonary resuscitation
(CPR) arrangement is
recommended to avoid/ manage
electrical incidence.
07/17/09 26
Laser:
General View. CONTRAINDICATIONS:
• 1. Pregnancy.
• 2. Patients with cancer.
• 3. Patients with pacemakers.
• 4. Directly looking into the light.
5. Growth plates in children10.
• 6. Over cardiac region & Vagus nerve.
• 7. Over & around thyroid gland &
endocrine glands.
• 8 .Patients who have been pre-treated
with one or more photo- sensitizers.
• 9. Organ transplantation: There is a
possibility that the laser's positive
effects on immune systems could
compromise the immune suppression,
which is critical to successful
transplantation.
07/17/09 27
Laser:
General View.
Important parameters of
laser of medical
interest:

07/17/09 28
Laser:
General View.
Important
parameters of
laser of medical
interest:

• Ultraviolet: 100–400 nm
• Visible Light: 400–700 nm
• Near infrared: 700–2500 nm
• Mid infrared: 2500 - 25000 nm
• Far infrared: 25–1000 µm

07/17/09 29
 Imp ort an t
para me ter s
of la ser o f med ical
inter est:

Laser:
General View.

07/17/09 30
 Different types of
laser used in medical
Laser: application:
General View.

07/17/09 31
Laser interaction
with Hard Tissue:

Interaction

Laser
interaction
with Hard
Tissue:
07/17/09 32
 Laser and Hard
tissue
interaction:

Laser
interaction
With
Hard Tissue:

07/17/09 33
 Inte ra cti on of
lase r wi th Ha rd
Tiss ue :

Laser
interaction
With
Hard Tissue:

07/17/09 34
 Laser-tissue
interactions:

Laser
interaction
With
Hard Tissue:

07/17/09 35
 Laser-tissue
interactions:

Laser
interaction
With
Hard Tissue:

07/17/09 36
 Laser-tissue
interactions:

Laser
interaction
With
Hard Tissue:

07/17/09 37
 Laser-tissue
interactions:

Laser interaction
with Hard Tissue:

07/17/09 38
Laser :
Interaction
with
Hard Tissue:
Laser-tissue
interactions:
• Scattering
• Penetration
• Absorption
Electromagnetic radiation
in the UV-IR spectral range
propagates into biologic
tissues until it is either
scattered or absorbed.
07/17/09 39
 Laser-tissue
Interactions:

Laser :
interaction
with
Hard Tissue:

07/17/09 40
Laser :
interaction
with
Hard Tissue: Absorption of laser
into biologic tissue-

• Laser absorption in
biological tissues
( In IR-UV region of
medical interest)
predominantly depends on
wavelength.
• The absorption of laser is
highest in water molecule.
• Protein, Pigments and
Melanin has different
absorption coefficient
depending their molecular
structure.
07/17/09 41
Mode of action
of Laser on Hard Tissue:

Mode of Action:

Mo de of
ac ti on of
La se r o n
Ha rd
Ti ss ue:
07/17/09 42
Mode
of action
of Laser with
Hard Tissue: Mode of
action (Interaction
) of laser with
Hard Tissue:
a. Photochemical/ Photo-biological
Bio-stimulation, anti-
inflammatory, Analgesic
effects.
b. Thermal effects of laser-
Incision, Coagulation.
c. Mechanical effects- Tattoo
removal.
d. Photo-ablative effects-
07/17/09 Percutaneous discectomy. 43
Mode
of action
of Laser with
Hard Tissue: Photomedicine:
Photochemical
Effects-
Laser light increases cell
permeability
Light is absorbed by
mitochondria
Leading to increased ATP
production.
Cascade of metabolic effects
causes a
number of physiological
                         
Improvement in Macrophage
response
and validity - Immune system
07/17/09 boost/repair and increases in
44
Mode
of action
of Laser with
Hard Tissue:
Laser effects:
Photochemical/
Photobiological-
• Anti-inflammatory effects of
Laser.
• Analgesic effects of Laser.
• Tissue healing/ regenerative
effects of Laser.
• Biomodulative/ Biostimulative
effects of Laser.
• Osseointegration effects of Laser
on biomedical implant.
07/17/09 45
Mode Schematic
of action
of Laser with diagram of
Hard Tissue:
tissue healing
by laser:

07/17/09 46
Mode
of action
of Laser with
Hard Tissue: Las er:
Bio stimu lativ e
eff ects.
Biostimulation is believed
to occur at very low
irradiances and to belong to
the group of photochemical
interactions.
Wound healing and anti-
inflammatory properties by
red or near infrared light
Typical energy fluences lie
in the range 1–10 J/cm2.
07/17/09 47
Mode
of action
Las er:
of Laser with Red uces Heali ng Ti me
Hard Tissue:
by-
• Enhanced leukocyte
infiltration.
• Increased macrophage activity.
• Increased neovascularization.
• Increased fibroblast
proliferation.
• Keratinocyte proliferation.
• Early epithelialization.
• Growth factor increases.
• Enhanced cell proliferation
and differentiation.
• Greater healed wound tensile
07/17/09
strength. 48
 Laser:
Thermal effects-

Mode
of action
of Laser with
Hard Tissue:

07/17/09 49
 Laser:
Thermal effects-

Mode
of action
of Laser with
Hard Tissue:

07/17/09 50
 La ser :
Th erm al
ef fec ts-
Temperature Biological effect

• 37◦C Normal
Mode
• 45◦C Hyperthermia
of action
of Laser with • 50◦C Reduction in enzyme activity,
Hard Tissue: cell immobility
• 60◦C Denaturation of proteins and,
collagen,coagulation
• 80◦C Permeabilization of membranes
• 100◦C Vaporization thermal
decomposition (ablation)
• > 100◦C Carbonization
• > 300◦C Melting.
07/17/09 51
 Summary of
Thermal
Interaction:
• Main idea: achieving a certain
temperature which leads to the
desired thermal effect
Mode
of action • Observations: either coagulation,
of Laser with vaporization,carbonization or
Hard Tissue: melting
:
• Special applications: coagulation,
vaporization, melting,thermal
decomposition,treatment of retinal
detachment,laser-induced
interstitial thermotherapy.
07/17/09 52
 Summ ar y
of
Ther ma lIn te rac tio
n:
Mode
of action
of Laser with
Hard Tissue:
: • Typical lasers:
• CO2, Nd:YAG, Er:YAG, Ho:YAG,argon ion and
diode lasers.
• Typical pulse durations: 1 μs . . . 1min
• Typical power densities: 10 . 106 W/cm2.
07/17/09 53
 Application of
laser on Hard
Tissue:
The rmal effec ts-
• incision.
• Cutting of Hard Tissue
(Osteotomy).
Mode
of action • Cauterization.
of Laser with
Hard Tissue:
• Bone Coagulation.
• Tissue Vaporization.
• Angiomas, known as port-
wine stains
• Cutaneous condylomas.
07/17/09 54
Mode
of action
of Laser with Mode of action of
Hard Tissue:
laser act on Hard
Tissue:
Mechanical
effects-
• Nd:YAG lasers, a very high
intensity of luminous flux over a
small area (between 1010 and
1012 W/cm2) ionizes atoms and
creates a plasma.
• At the boundary of the ionized
region, there is a very high
pressure gradient which causes
the propagation of a shock wave.
It is the expansion of this shock
wave which causes the destructive
07/17/09 effect. 55
 Application:
Mechanical effects of
laser on Hard Tissue:

Mode
of action
of Laser with
Hard Tissue:

07/17/09 56
Laser:
Mode action on
Hard on Tissue: Laser ablation
Ablation
Micro Cutting
Laser Scissors
Nano
Dissection

Surgery

07/17/09 57
 Pr in cip le s o f
ph ot oab la tio n:
• Absorption of high-energy UV photons
• ⇓
Mode
of action • Promotion to repulsive excited states
of Laser with • ⇓
Hard Tissue:
• Dissociation
• ⇓
• Ejection of fragments (no necrosis)
• ⇓
• Ablation.
07/17/09 58
 Su mma ry of
Ph oto abl at ion :
• Main idea: direct breaking of molecular
bonds by highenergy UV photons
Mode • Observations: very clean ablation,
of action associated with audible report and
of Laser with
Hard Tissue:
visible fluorescence
• Typical lasers: excimer lasers, e.g.
ArF, KrF, XeCl, XeF
• Typical pulse durations: 10 . . 100 ns
• Typical power densities:107 .1010 W/cm2
• Special applications: Prolapsed Disc
decompression, refractive corneal
07/17/09 surgery. 59
 Ab lation cur ves of fre sh and
dr ied bo ne o btaine d wi th a
CO 2 lase r.
Ablation curves of fresh and dried bone obtained with a CO2
laser (pulse duration: 250 μs, wavelength: 10.6 μm). Due to
its higher water content, freshbone is ablated more
efficiently. Data according to Forrer et al. (1993).

Mode
of action
of Laser with
Hard Tissue:

07/17/09 60
 Ab latio n cur ve of fres h
bo ne ob taine d wit h an
Er :YAG laser -
(b) Ablation curve of bone obtained with an Er:YAG laser
(pulse duration: 180 μs, wavelength:2.94 μm). Data
according to Scholz and Grothves-Spork (1992).

Mode
of action
of Laser with
Hard Tissue:

07/17/09 61
 Application:
Pho toabl ative Effe cts-

a. Bone Tumor excision-

Mode Benign – bony exoxtosis/
of action osteoid osteoma.
of Laser with
Hard Tissue: Malignant, no operation
induced metastasis.
b. Bony tissue Biopsy.
c. Herniated disc removal/ laser
decompression.
d. Arthroscopy-meniscectomy.
07/17/09 62
 Ap pl ica tio n

Orthopedic
Application
of Laser:
07/17/09 63
Orthopedic
Application of Laser.
Mo dal it ies
of Ha rd
Ti ssu e
•
ma nag em ent :
Conservative management.
General conservative
procedure.
Laser conservative
management.
• Surgical management.
General operative
management.
Laser operative
07/17/09 management. 64
Orthopedic
Application of Laser.

Orthopedic
Application of
Laser:
Nono pera tive-
• Pain management.
• Fractures: enhancement of
union.
• Burn healing
• Wound care.
• Healing Heel fissures.
• Verrucae mnagement.
• Plantar fascitis mnagement.
• Fungal nail correction.
• Arthoscopy(all types)
07/17/09 o 65
Orthopedic
Application of Laser.
Orthopedic
Application
of Laser:
No no pe rat ive -

• Ne uro ge ni c P ain
• Herpes Zoster
(Shingles)
• Fibromyalgia
• Post Traumatic Injury
• Diabetic Neuropathy
• Trigeminal Neuralgia
• Radiculitis
• Sciatica
• Management of gout.
07/17/09 66
 Orthopedic

Orthopedic
Application of Laser.

Application of
Laser:
Non- opera tive
Pain
management-
•
Acute & Chronic Joint
Problems:
– Osteoarthritis
– Rheumatoid Arthritis
– Ligament & Tendon injuries
– Chondromalacail Patella.
07/17/09 67
Orthopedic
Application of Laser.
Orthopedic
Application of
Laser:
Pain No nop er at ive :
management-
• Chronic Back & Neck Pain
Reduction of Inflammation:

• Metatarsalgia.
• Trigeminal Neuralgia.
• Brachial Neuralgia.
• Plantar Fascia.
• Frozen Shoulder.
07/17/09 • Carpal Tunnel syndrom. 68
Orthopedic
Application of Laser. Orthopedic Application
of Laser: Nonoperative-

Laser
healing:

Researchers at Massachusetts General

Hospital are developing a method to
heal surgical incisions with laser
light. Surgeons Ying Wang and Min Yao
position a metal frame that directs a
green surgical laser over the
incision. The frame keeps the
instrument steady and at a measured
distance from the skin. They shine the
light onto the cut to activate the
dye, leaving it on for three minutes.
Credit: Porter Gifford
07/17/09 69
Orthopedic
Application of Laser.

Orthopedic
Application of
Laser:
Wound
Management Nonoperative-

Open /Unhealthy wounds

o
Pressure/Bed Sores
o
Post Surgical Healing
o
Burns.

07/17/09 70
Orthopedic
Application of Laser.
Orthopedic Application
of Laser:
Wound
Management:
Partial tear of Tendoachilis
(Approximately 50 percent) Nonoperative:

07/17/09 71
Orthopedic
Application of Laser.

Orthopedic
Application of Laser:
Burn Nonoperative-
Management:

Laser application in
burn is very promising
and effective, It
subsides burn pain,
inflammation and
promotes faster tissue
healing without any
07/17/09 scar. 72
Orthopedic
Application of Laser.
Orthopedic
Application of
Laser:
Op erati ve
General-
• Sc ar ex cis ion .
• Ex cis io n o f c ys ts , c or ns,
Ca llu s.
• Ex cis io n o f N eu ro ma.
• Ex cis io n o f H ee l Spu rs .
• Su bun gu al hea mo to ma
ma nag em ent .
• He ama ng iom a m an ag eme nt .
07/17/09 • Ma tri xe cto my. 73
Orthopedic
Application of Laser.
Orthopedic
Application of
Laser:

Operative-

Li mbs-
Endoscopic nerve compression
release- (carpal tunnel relese).
o
PMMA vaporization(joint
revisions).
o
Enhancement of bone
union/Regeneration.
07/17/09 74
Orthopedic
Application of Laser. Orthopedic
Application of Laser:
Spine-

07/17/09 75
Orthopedic
Application of Laser. Orthopedic
Application of
Laser:
Ope rativ e-
Spine-
• He rni ate d Di sc
• Bu lgi ng Di sc
• De gen era ti ve Di sc
Di sea se
• Ar thr iti s of th e S pi ne
• Sp ina l Ste no sis
• Sc iat ica
• Bo ne Spu rs
• Pi nch ed Ne rv e
07/17/09 • Sc ar Tis su e 76
Orthopedic
Application of Laser.
Orthopedic
Application of Laser:
Operative-
Spine-
a.C erv ica l (N eck ) S ur ge ry:
Cervical Endoscopic Discectomy (CED)
Anterior Cervical Discectomy (ACD)
Anterior Cervical Fusion (ACF).
b.Lumbar (Back) Surgery Procedures:
Lumbar Endoscopic Discectomy(LED/TA)
Disc prolapse/Disc degeneration-
Percutaneous L. Disc
Decompression.
Interspinous Process Decompression
(X-STOP)
Micro discectomy (MD)
07/17/09 77
Thermal Annuloplasty(TA).
 Thanks
everyone for
patience,
Bye.
See you next day with-
“Laser in Orthopedic
Surgery”
(Part-5)
“Do uble bl ind
noninva si ve
ap pli ca tion of La ser to
Enhan ce Bon e Un ion ”.
07/17/09 78