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.

Contents:

Introduction:
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.

Introduction:

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: 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.

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

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

How to Speed up fracture healing !

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.

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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.
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Laser mechanism on biological tissues can be explained by1. Physical mechanism 2. Bio-chemical mechanism

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

physicalThere are two primary forms of physical effects generated by laser irradiation on biological tissues: Photon-absorption (the basis of photobiological action, and generated by all forms of light). Internal conversion & fluorescence of light also generates Speckle formation, which is unique to laser therapy.

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Mechanism of action of LLLT on tissue (cont.): BiochemicalBio-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.
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Infrared laser radiation enhances bone regeneration/ formation by two consecutive phases of cellular, intra cellular and tissue modulating cascades of interdepended process. 1.Directly by simulation of osteoblast formation, inhibition of osteoclast activities, 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.
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Mechanism of action of Laser on Bone union(Direct) 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.
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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.
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Effects Of Low Level Laser (Ga-al-as, 830nm) On Human Appendicular Bone Fracture By Assessing Parameters: Objective (Clinical) & Subjective (Radiological).
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 Duration of study: The duration of this study was two years (from April2008 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, SherE-Bangla Nagor, Dhaka-1207, Bangladesh.

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Materials & Method (Cont.)

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).

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Materials & Method (Cont.)

Materials: Machine

Bio-Lux MD Ga- Al- As Laser (830 nm) Machine with Probe.

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Materials & Metho(Cont.)

Method:
Applied laser in the laser therapy group was continuous infrared laser with BioLux MD (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.
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Materials & Method(Cont.)

Method:
Procedure: LLLT was irradiated on the fracture- side, performed transcutaneously in 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.
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Materials & Method (Cont.)

Method: Treatment Protocol (Cont.)
Laser Treatment Protocols used in This 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 datas 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 datas 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.
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Materials & Method(Cont.) Method (Cont.) The patients were analyzed byClinical Assessment Pain & inflammation level. Stability of fracture side. Movement of fracture side. Immobilization duration. 26 Patient compliance.

Densitometer used in this work.

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.
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 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).

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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.
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Observation & Result (Cont.)

Patient on LLLT

Before starting of treatment. L1-2. Patient Name: Md DalilUddin Age: 95 Years Sex: Male Diagnosis: Fracture Lt. Humerus (Shaft) Study group: L1

At 1st week

At 2nd week

At 3rd week

At 4th week

At 6th week

At 12th week

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Observation & Result(Cont.)

C1-1.. Patient Name: Halima Begum Age: 55 Years Sex: Female Diagnosis: Fracture Rt. Shaft of Femur Study group: C1 Patient Name: Ms Halima Begum
Week 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

2.0033

1.7767

1.7567 1.43

1.0167 1.1667 1.0033 0.8333 0.87 0.8367 0.9267 0.5633 At the end of the 1st week At the end of the 2nd week

1.2267

1.8133 1.0167

1.2867 1.8233 1.1033

1.14

0.9333

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At the end of the 3rd week At the end of the 4th week At the end of the 6th week

Observation & Result(Cont.)

L1-1. Patient Name: Ms Anowara Age: 55 Years Sex: Female Diagnosis: Fracture Rt. Shaft of Radius Study group: L1
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

2.0267

0.9067 0.9667 1.1733 0.78 0.88

1.2333 1.1667

0.9033

1.1767 1.3067 0.8333 0.88 1.39

0.9033

0.8367
1.0967 0.5633

0.8967

1.0933

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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

 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.

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This study has demonstrated the potential of low level laser therapy in the treatment of Enhancement Of Human Bone Fracture Union.
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Future Recommendations(Cont.)
A large multi- centric study pointing important subjective (i.e. mechanical, biochemical and Histological , as well as objective (clinical) parameters.
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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 noninvasive method of bone stimulation applicable in medical science.
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