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
Contents:

3
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.

4
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.

5
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.

6
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:
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.

8
Introduction:

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

9
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.
10
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
Laser mechanism on biological
tissues can be explained by-
1. 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.

12
 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 photobiological
action, 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 of
LLLT 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 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.
15
 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.

16
 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 Fracture
By
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 & 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).

20
Materials & Method (Cont.)
Materials: Machine

Bio-Lux MD Ga- Al- As Laser

(830 nm) Machine with Probe. 21
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.
22
 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.
23
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 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
Densitometer
used in this Radiological Assessment
work.

 Radiographic Scoring System (by

Lane and Sandhu) of fracture
site, done weekly.
 Densitometer assessment of Callus in
the radiograph of fracture site, taken
weekly.
27
• 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.) 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 30

 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
1.2267 1.8133
1.1667
1.0167
1.0033
1.2867
0.8333
1.14
0.87 1.8233
0.8367
1.1033
0.9267 0.9333
0.5633
31
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
 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 0.9033
1.2333
0.9667
1.1667
1.1733 1.1767

1.3067
0.78
0.8333
0.88 0.88
0.9033
1.39 0.8367
1.0933 1.0967
0.8967
0.5633

32
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.

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