Supervisor:

1Chairman,

Prof. and 2Course-coordinator

of International Co-operation.

Co- Supervisors:

Prof. F. H. Sirazee

3(Ex. Head of the Department ),

Associate Prof. P.C Debenath

3( Head of the Department ).

1. Dept. of Medical Radiation Physics, Kreis-krankenhaus Gummersbach Teaching Hospital of the University of Cologne, 51643 Gummersbach, Germany.

2. Dept. of Medical Physics and Biomedical Engineering, GonoBishwabidyalay(Gono University), Nayarhat, Savar, Dhaka- 1344, Bangladesh.

3. Department of Orthopedic and Traumatology, ShaheedSuhrawardy Medical College Hospital, Dhaka-1207,Bangladesh.

2

3

Contents:

Optimizing the results of fracture treatment requires a holistic view of both patients and treatment.

There is a perception, not least among fracture surgeons themselves, that the mechanical issues have been over-emphasized in the past.

4

Introduction:

5

The principles of AO treatment, drummed into a generation of orthopedic trainees, were anatomical open reduction, rigid internal fixation and early rehabilitation of soft tissues without external splint.

Introduction:

6

Now the science is taking another step, further in the direction from mechanics to biology. If the mechanical environment influences bone regeneration and hence fracture healing, how, at a cellular level, does it do so.

Introduction:

Low level laser acts on biological tissues on cellular level.

The basic premise is that LLLT stimulates cell activation processes which in turn, intensify physiologic al activities.

7

Introduction:

8

Low Level Laser increases - Cellular ion-exchange, Tissue vascularization, Lymphatic circulation, Activates cytokines, Growth factors andnecessary hormonal activities for tissue healing enhancement in the proliferative stage thereby reduction of pain & inflammation.

Introduction:

9

And increases Fibroblast, Chondrocyte and osteoblast proliferation, Inhibition of osteoclast & Synthesis of bone collagen and bone matrix that activities & enhances bone regeneration.

Introduction:

Although there are no magical ways to fix a bone fracture, but there are ways to help speed up the healing process, and help fracture to heal properly/ faster.

Proper medical management. Nutritional Support. BMP/ Osteoblast cell injection Electrical stimulation. Magnetic stimulation. Ultrasound therapy. Gene-therapy Low Level Laser therapy.

10

How to Speed up

fracture healing !

Enhancement of Bone Union(Cont.)

Among the current procedures of bone fracture union enhancement, low level laser therapy is superior to others in contrast to-

Patient Compliance,

Length Of Healing Time,

Less-invasive Procedure And

Cost-effectiveness.

11

The primary (physical) mechanisms relate to the interaction between photons and molecules in the tissue, while the secondary mechanisms relate to the effect of the chemical (Bio-chemical) changes induced by primary effects.

12

Laser mechanism on biological tissues can be explained by-1. Physical mechanism2. Bio-chemical mechanism

Mechanism of action of LLLT on tissue (cont.):physical-

There are two primary forms of physical effects generated by laser irradiation on biological tissues:

Photon-absorption (the basis of photobiologicalaction, and generated by all forms of light).

Internal conversion & fluorescence of light also generates Speckle formation, which is unique to laser therapy.

13

Mechanism of action ofLLLT on tissue (cont.): Biochemical-

Bio-chemical action of laser can be explained by “Action of photon with mitochondrial respiratory chain- Cytochromecoxidase enzyme”. Cytochromecoxidase mediated increase in ATP

production. Cytochromecoxidase mediated singlet-oxygen

production. Cytochromecoxidase mediated Reactive oxygen

species (ROS) formation. Cytochromecoxidase mediated Photodiassociation

and Nitric Oxide Production.

14

Infrared laser radiation enhances bone regeneration/ formation by two consecutive phases of cellular, intra cellular and tissue modulating cascades of inter-depended process.

• 1.Directly by simulation of osteoblastformation, inhibition of osteoclastactivities, proliferation/differentiation of fibroblast and enhancement bone growth factors/ modulation of cytokines.

• 2. Indirectly by enhancing some specific bone formation modulation, and creating a friendly environment that fascinates bone formation /regeneration.

15

• Studies of bone healing response to infrared light show acceleration of osteoblast formation as well as calcium salt deposition under the influence of infrared light.

• Osteoclast Inhibition Prevents Bone Mineral Resorption .

• Bone-matrix & collagen synthesis.

16

Mechanism of action of Laser on Bone union(Direct)-

Mechanism of action of Laser on Bone union(Indirect)-

• Laser promotes cellular/tissue ion exchange / transport and enhances Bone Mineralization.

• Laser therapy increases Nitric Oxide in tissues which increases vascularity, thereby helps in tissue healing and Bone Formation.

• Laser therapy increases lymphatic circulation in bone and enhances better tissue healing & regeneration.

17

Effects Of Low Level Laser (Ga-al-as, 830nm) On Human Appendicular Bone FractureBy Assessing Parameters: Objective (Clinical) & Subjective (Radiological).

18

• Duration of study:

The duration of this study was two years (from

April- 2008 to March- 2010).

• Type of study:

• Prospective Randomized Case Control study.

• Place of study: The study was conducted at

ShaheedSuhrawardy Medical College Hospital in

the Department of Orthopedics and

Traumatology, Sher-E-Bangla Nagor, Dhaka-

1207, Bangladesh.

19

Materials: sample

• The sample was collected randomly from admitted patients with appendicular bone fracture (superior and inferior extremity) at ShaheedSuhrawardy Medical College Hospital in the Department of Orthopedics and Traumatology, Dhaka-1207, Bangladesh.

• A total of 40 patients randomly collected; among which 20 were in the Laser group (L1,L2) and 20 were in the control group (C1,C2).

20

Materials & Method (Cont.)

Materials: Machine

21Bio-Lux MD Ga- Al- As Laser

(830 nm) Machine with Probe.

Materials & Method (Cont.)

Method:

22

Applied laser in the laser therapy group was continuous infrared laser with BioLuxMD (Ga-Al-As-830nm).The first session was started on the 5th day after surgery/ incidence; based on previous research work which proved that laser works best on the proliferative stage of tissue healing.

Materials & Metho(Cont.)

Method:

• Procedure: LLLT was irradiated on the fracture- side, performed transcutaneouslyin pointing method, in 4 anatomical locations at 500 mW; 0.5 centimeter away from fracture line and, two points in each site of line/ day.

• Dose and duration: @ 8J/cm2 dose (energy) of total dose 8*4*9 J/cm2 for adult &@ 4 J/cm2 dose (energy) of total dose 4*4*9 J/cm2 for child.

23

Materials & Method(Cont.)

Method:

Treatment Protocol (Cont.) Laser Treatment Protocols used inThis work:

• 4- 8 joules /cm2• 4 points/ session• Power-500mw• Point spacing is every 2-4 sq. cm.• Treatment schedule: daily for the first

week, followed by alternate day in the second week (9 days total). 24

Materials & Method (Cont.)

Method (Cont.)

• The data’s were routinely processed, by measuring the callus/ new bone formation. The best sets of weekly x-ray images of each patient from each group were selected for this analysis, and data’s are also shown in datasheets and graphs .

• Efficacies of treatment were evaluated with

pain questionnaire,

clinical assessment and

serial weekly radiograph assessment starting from 1st week up to 4th week and on the 6th week.

25

Materials & Method(Cont.)

Method (Cont.)

The patients were analyzed by-Clinical Assessment Pain & inflammation level. Stability of fracture side. Movement of fracture side. Immobilization duration. Patient compliance. 26

Materials & Method(Cont.)

27

Radiological Assessment

Radiographic Scoring System (by Lane and Sandhu) of fracture site, done weekly. Densitometer assessment of Callus in the radiograph of fracture site, taken weekly.

Densitometer used in this work.

• Clinically the laser group showed better stable fracture site, earlier movement of limb and removal of cast/plaster was performed.

• Pain & inflammation also subsided much earlier in the laser group

(L1 & L2) than the control group (C1 & C2).

28

Observation &

Result(Cont.)

• Radio-logically, this study compared degree of callus formation, callus density changes by weeks, and assessment of bone/ callus formation/ union, pain & inflammation parameters changes, with and without laser radiation (LLLT) in the post laser therapy period, starting from 1st week up to 4th week and on 6th.

29

Observation

& Result (Cont.)

Before starting

of treatment.

30

Patient on

LLLT

At 1st week At 2nd week At 3rd week

At 4th week At 6th week At 12th week

L1-2. Patient Name: Md DalilUddinAge: 95 YearsSex: MaleDiagnosis: Fracture Lt. Humerus (Shaft)Study group: L1

Observation & Result(Cont.)

0.9267

0.5633

1.1033

1.8233

0.9333

0.87

0.8367

1.2867

1.8133

1.14

1.0033

0.8333

1.2267

1.7567

1.0167

1.0167

1.1667

1.7767

2.0033

1.43

At the end of the 1st week At the end of the 2nd week At the end of the 3rd week At the end of the 4th week At the end of the 6th week

Patient Name: Ms Halima BegumWeek Vs Bone Density: Non-fracture side(Cortex, Medulla) & fracture Side

( Cortex, Medulla).

Non-fracture site, Medulla fracture site, Medulla Non-fracture site, Cortex fracture site,Cortex

31

C1-1.. Patient Name: Halima Begum

Age: 55 Years

Sex: Female

Diagnosis: Fracture Rt. Shaft of Femur

Study group: C1

Observation & Result(Cont.)

0.89671.0933

1.39

0.5633

1.0967

0.90330.88

1.3067

0.8367

0.88

0.78

1.1733

1.2333

0.8333

1.1767

0.9667

0.9067

2.0267

1.1667

0.9033

At the end of the 1st week At the end of the 2nd week At the end of the 3rd week At the end of the 4th week At the end of the 6th week

Patient Name: Ms Anowara

Week Vs Bone Density Change: Non-fracture side (Cortex, Medulla) & fracture side ( Cortex, Medulla)

Non-fracture site, Medulla fracture site, Medulla Non-fracture site, Cortex fracture site, Cortex

32

L1-1. Patient Name: Ms AnowaraAge: 55 YearsSex: FemaleDiagnosis: Fracture Rt. Shaft of RadiusStudy group: L1

• The result of this study reveals a better bone healing after irradiation with 830nm diode laser (Ga-Al-As).

• This study result also concludes that better bone healing after irradiation with Ga-Al-As, 830nm diode laser in human model as an adjunctive to regular fracture management that accelerates bone union significantly and enhances patient compliances.

33

This study has demonstrated the potential of low level laser therapy in the treatment of –

“ Enhancement Of Human Bone Fracture Union”.

34

Future Recommendations(Cont.)

A large multi- centric study pointing important subjective (i.e.

• mechanical,

• biochemical and

• Histological , as well as objective(clinical) parameters.

35

Future Recommendations (Cont.)

Including - laser protocol (dose, duration, type of laser

& mode of operation),

patient selection criteria and

procedure of therapy,

is highly desirable to make this non-invasive method of bone stimulation applicable in medical science.

36