Laser on Hard Tissue

04/11/23 1

“Laser in

Orthopedic Surgery”(Part-4)

Interaction & effects of Laser (UV-IR) radiation on Biological Hard Tissues

and its application in Orthopedic Surgery.

“Laser in

Orthopedic Surgery”(Part-4)

Interaction & effects of Laser (UV-IR) radiation on Biological Hard Tissues

and its application in Orthopedic Surgery.

Presented by

Dr. Md Nazrul islam.Assistant Registrar, Orthopedic and Traumatology Dep't.Shaheed Suhrawardy Hospital, Sher-E-Bangla Nagor, Dhaka-1207. Bangladesh. [email protected].

mailto:[email protected]

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“ 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”.

• Markolf H. Niemz Laser-Tissue Interactions,Fundamentals and

Applications.

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Basics of Hard Tissue:

Hard tissueHard tissueBasics of Hard tissueBasics of Hard tissue

http://upload.wikimedia.org/wikipedia/commons/5/51/Caput_femoris_cortex_medulla.jpg

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Types of Hard Tissue:

Types of Hard Tissue:

• Compact bone or (Cortical bone): 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.

• cancellous (Trabecular bone): 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 times the surface area of compact bone.

Tissue that has become mineralised, having a firm intercellular substance, e.g., cartilage and bone.

Basics of Hard tissue:Basics of Hard tissue:

http://en.wikipedia.org/wiki/Cortical_bone

http://en.wikipedia.org/wiki/Cancellous_bone

http://en.wikipedia.org/wiki/Cancellous_bone

http://en.wikipedia.org/wiki/Porosity

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Mean composition of Human Bone:

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%

Basics of Hard tissueBasics of Hard tissue

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Basics of Hard tissueBasics of Hard tissue

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Basics of Hard Tissue:Basics of

Hard Tissue:Basics of Hard tissueBasics of Hard tissue ::

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Radio Anatomy of Bone:

Radio Anatomy of Bone:Basics of Hard tissueBasics of Hard tissue

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•Laser: General View-

General General View-View-

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Types of laser act on

Hard Tissue:

Types of laser act on

Hard Tissue:

A. Cold Laser:

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.

A 100W Nd: YAG laser and A 100W Nd: YAG laser and optical fibre.optical fibre.

Laser:Laser: General View.General View.

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Types of laser act on Hard Tissue:

Types of laser act on Hard Tissue:

• B. Hard Laser. 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 (1000mW).


..

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Types of laser act on Tissue:

Types of laser act on Tissue:


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Laser theory:Laser theory:

• Biological field theory.

• Cellular oscillation theory.

• Bio luminescence theory.


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Laser theory: Bio luminescence theory-

Laser theory: Bio 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.


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Laser theory: Cellular oscillation

theory:

Laser theory: Cellular oscillation

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.

Laser:Laser:General View.General View.

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Laser theory:Biological field theory.

Laser theory:Biological field 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.


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Tissue & 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.

Laser:Laser:HardHardTissueTissueView.View.


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• 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.


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• 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.


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The Physiological Effects of Low Level Laser

Therapy:

The Physiological Effects of Low Level Laser

Therapy:• Improved blood circulation & vasodilation.-

Increases blood supply.• Increase collagen production:

– Develops collagen & muscle tissue

• Increase macrophage activity:– Stimulates immune system

• Alter nerve conduction velocity:– Stimulates nerve function.

• Increases ATP production• Biostimulation – Improved metabolism, increase of cell

metabolism- Increases speed, quality & tensile strength of tissue repair.

• Analgesic effect- Relieves acute/chronic pain.

• Anti-inflammatory & anti-edematous effects- Reduces inflammation.

• Stimulation of wound healing:– Promotes faster wound healing/clot formation– Helps generate new & healthy cells & tissue.


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Laser:Short Term Effects-

Laser: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 cumulative effect.


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Laser:Long Term

Or Cumulative Effect-

Laser:Long Term

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). • * Regulates cell membrane potential, essential

in Na, Cl and K ion transfer (electrolyte balance). • * Cytokines and other chemicals enhancing

cellular communications are released.


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Laser:Other Effects:

Laser: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.


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Advantages of lasersurgery vs.

traditional surgery-

Advantages of lasersurgery vs.

traditional surgery-

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.


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Advantages of laser surgery vs. traditional surgery-

Advantages of laser surgery vs. traditional surgery-

• Most laser surgeries can be performed on an outpatient basis.

• Very small / precise incision.

• No damage to surrounding areas.

• Less bleeding /"bloodless surgery," , and less swelling.

• Less time consuming procedure.

• Lower rate of local infections.

• Reduce post-operative pain.

• Reduce post operative recovery period.


• * Non-invasive• * Non-toxic• * Easily applied• * Highly effective• * Cure rate > 95%• * No known negative side effects.

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Disadvantages of laser surgery vs. traditional

surgery?

Disadvantages of laser surgery vs. traditional

surgery?• 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.


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CONTRAINDICATIONS: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.


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Important parameters of laser of medical

interest:

Important parameters of laser of medical

interest:


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Important parameters of laser

of medical interest:

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


http://en.wikipedia.org/wiki/Ultraviolet

http://en.wikipedia.org/wiki/Visible_Light

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Important parameters

of laser of medical interest:

Important parameters

of laser of medical interest:


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Different types of laser used in medical application:

Different types of laser used in medical application:


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InteractionInteraction Laser interaction with Hard Tissue:

Laser interaction Laser interaction with Hard Tissue:with Hard Tissue:

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Laser and Hard tissue interaction:

Laser and Hard tissue interaction:

Laser Laser interaction interaction WithWithHard Tissue:Hard Tissue:

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Interaction of laser with Hard Tissue:



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Laser-tissue interactions:Laser-tissue interactions:


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Laser-tissue interactions:Laser-tissue interactions:


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Interaction of laser with Hard Tissue:Interaction of laser with Hard Tissue:

Laser interaction Laser interaction with Hard Tissue:with Hard Tissue:

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Interaction of laser with biologic tissues:


• Scattering• Penetration• Absorption

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

Laser :Laser :InteractionInteraction with with Hard Tissue:Hard Tissue:

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Laser :Laser :interaction interaction with with Hard Tissue:Hard Tissue:

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Absorption of laser into biologic 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.

Laser :Laser :interaction interaction with with Hard Tissue:Hard Tissue:

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Mode of action of Laser on Hard Tissue:

Mode of Action:Mode of Action:

Mode of actionMode of actionof Laser on Hard Tissue:of Laser on Hard Tissue:

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Mode of action(Interaction) 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- Percutaneous discectomy.

Mode Mode of actionof actionof Laser with of Laser with Hard Tissue:Hard Tissue:

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Photomedicine:Photochemical

Effects-

Photomedicine:Photochemical

Effects-Laser light increases cell permeabilityLight 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 boost/repair and increases in cellular proliferation.


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Laser Effects: Photochemical/

Photobiological-

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.


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Schematic diagram of tissue healing

by laser:

Schematic diagram of tissue healing

by laser:


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Laser:Biostimulative

effects.

Laser:Biostimulative

effects.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 lightTypical energy fluences lie in the range 1–10 J/cm2.


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Laser:Reduces Healing Time

by-

Laser:Reduces Healing Time

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 strength.


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Laser:Thermal effects-



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Temperature Biological effect• 37◦C Normal• 45◦C Hyperthermia• 50◦C Reduction in enzyme

activity, 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.


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Summary of Thermal

Interaction:

Summary of Thermal

Interaction:• Main idea: achieving a certain temperature which leads to the desired thermal effect

• Observations: either coagulation, vaporization,carbonization or melting

• Special applications: coagulation, vaporization, melting,thermal decomposition,treatment of retinal detachment,laser-induced interstitial thermotherapy.

Mode Mode of actionof actionof Laser with of Laser with Hard Tissue:Hard Tissue:::

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Summary of Thermal

Interaction:

Summary of Thermal

Interaction:

• 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.

Mode Mode of actionof actionof Laser with of Laser with Hard Tissue:Hard Tissue:::

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Application of laser on Hard Tissue: Thermal effects-

Application of laser on Hard Tissue: Thermal effects-

a. incision.b. Cutting of Hard Tissue

(Osteotomy).c. Cauterization.d. Bone Coagulation.e. Tissue Vaporization.f. Angiomas, known as port-

wine stains

g. Cutaneous condylomas.


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Mode of action of laser act on Hard

Tissue: Mechanical effects-

Mode of action of 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 effect.


http://www.tootoo.com/d-p16415498-Laser_cutting_machine/

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Application:Mechanical effects of laser on Hard Tissue:

Application:Mechanical effects of laser on Hard Tissue:


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Laser ablationLaser ablation

Laser

Micro

Nano

Ablation

Cutting

Dissection

Surgery

Scissors

Laser:Laser: Mode action on Mode action on Hard on Tissue:Hard on Tissue:

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Principles of photoablation:Principles of photoablation:

• Absorption of high-energy UV photons

• ⇓• Promotion to repulsive excited states

• ⇓• Dissociation• ⇓• Ejection of fragments (no necrosis)

• ⇓• Ablation.


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Summary of Photoablation:Summary of

Photoablation:• Main idea: direct breaking of molecular bonds by highenergy UV photons

• Observations: very clean ablation, associated with audible report and 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 surgery.


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Ablation curves of fresh and dried bone obtained with a

CO2 laser.

Ablation curves of fresh and dried bone obtained with a

CO2 laser.

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).


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Ablation curve of fresh bone obtained with an

Er:YAG laser-

Ablation curve of fresh bone obtained with 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).


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Application: Photoablative

Effects-

Application: Photoablative

Effects-

a. Bone Tumor excision- Benign – bony exoxtosis/

osteoid osteoma. Malignant, no operation

induced metastasis.b. Bony tissue Biopsy.c. Herniated disc removal/ laser

decompression.d. Arthroscopy-meniscectomy.


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Application

Application

Orthopedic Application of Laser.

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Modalities of Hard Tissue management:

Modalities of Hard Tissue management:

• Conservative management. General conservative procedure.

Laser conservative management.

• Surgical management. General operative management.

Laser operative management.

Orthopedic Orthopedic Application of Laser.Application of Laser.

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Orthopedic Application of

Laser:Nonoperative-


Laser:Nonoperative-

• Pain management.• Fractures: enhancement of union.• Burn healing• Wound care.• Healing Heel fissures.• Verrucae mnagement. • Plantar fascitis

mnagement.• Fungal nail correction. • Arthoscopy(all types)o

OrthopedicOrthopedic Application of Laser.Application of Laser.

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Laser:Nonoperative-


Laser:Nonoperative-

• Neurogenic Pain• Herpes Zoster (Shingles)

• Fibromyalgia • Post Traumatic Injury

• Diabetic Neuropathy • Trigeminal Neuralgia • Radiculitis • Sciatica • Management of gout.

OrthopedicOrthopedicApplication of Laser.Application of Laser.

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Laser:Non-operative


Laser:Non-operative

Acute & Chronic Joint Problems:– Osteoarthritis – Rheumatoid Arthritis – Ligament & Tendon

injuries – Chondromalacail

Patella.

Pain management-


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Laser: Nonoperative:


Laser: Nonoperative: Chronic Back & Neck

Pain Reduction of Inflammation:

• Metatarsalgia • Trigeminal

Neuralgia • Brachial Neuralgia • Plantar Fascia • Frozen Shoulder • Carpal Tunnel

Pain management-


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Laser: Nonoperative-


Laser: Nonoperative-

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


Laser healing:

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Open /Unhealthy wounds

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

Orthopedic Application of Laser: Nonoperative-


WoundWoundManagementManagement

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Orthopedic Application of Laser:

Nonoperative:


Nonoperative:WoundWoundManagement: Management: Partial tear of Tendoachilis Partial tear of Tendoachilis (Approximately 50 percent)(Approximately 50 percent)


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Nonoperative-


Nonoperative-

Laser application in burn is very promising and effective, It subsides burn pain, inflammation and promotes faster tissue healing without any scar.


Burn Management:

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Laser: Operative General-


Laser: Operative General-

• Scar excision.• Excision of cysts, corns,

Callus.• Excision of Neuroma.• Excision of Heel Spurs.• Subungual heamotoma

management.• Heamangioma management. • Matrixectomy.• Removal of tattoo.


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Laser: Operative-


Laser: Operative-

Limbs- Endoscopic nerve compression release- (carpal tunnel relese).

o PMMA vaporization(joint revisions).

o Enhancement of bone union/Regeneration.


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Orthopedic Orthopedic Application of LaserApplication of Laser.. Orthopedic Orthopedic

Application of Laser:Application of Laser: Spine-Spine-

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Laser: Operative-

Spine-


Laser: Operative-

Spine-• Herniated Disc • Bulging Disc • Degenerative Disc

Disease • Arthritis of the Spine • Spinal Stenosis • Sciatica • Bone Spurs • Pinched Nerve • Scar Tissue • Foraminal Stenosis


http://laserspinetreatment.com/disc-treatment.php

http://laserspinetreatment.com/spinal-stenosis.php

http://laserspinetreatment.com/spinal-stenosis.php

http://laserspinetreatment.com/bone-spurs.php

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Operative-


Operative-

Spine-

a.Cervical (Neck) Surgery: 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)Thermal Annuloplasty(TA).


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See you next day with-

“Laser in Orthopedic Surgery”(Part-5)

“Double blind noninvasive application of Laser to Enhance Bone Union”.

Thankseveryone for patience,Bye.

Laser on Hard Tissue

Health & Medicine

Transcript of Laser on Hard Tissue