Siebert, Saunier, Gerber, Lubbers
Techniques in Orthopaedics, 10(4):309-317
Since the early 1980s, different groups of researchers have tried to develop arthroscopic
laser surgery. Laser technology may be ideal for use in arthroscopic surgery, because
laser instruments are extremely small, but remain powerful. When used properly, lasers
offer the arthroscopic surgeon the potential to decrease hemarthrosis, iatrogenic
articular damage, and postoperative morbidity.
Imhoff, Ledermann
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol. 11, No. 5 (October),
1995: pp 549-556
Because of the low level of postoperative pain, the absence of adhesions and the almost
complete lack of swelling, the patients treated with the Holmium:YAG laser and without
electrocautery were able to regain full range of shoulder motion sooner than those treated
with shaver and electrocautery.
Hayashi, Markel, Thabit, Bogdanske, Thielke
The American Journal of Sports Medicine, Vol. 23, No. 4
To evaluate the effect of laser energy at nonablative levels on the mechanical properties
of joint capsular tissues, we tested the femoropatellar joint capsules of 12 mature New
Zealand White rabbits. Specimens were divided into three treatment groups (5, 10, and 15
watts) and one control group. This study demonstrates that significant capsular shrinkage
can be achieved with the application of non ablative laser energy without detrimental
effects to the viscoelastic properties of the tissue; although at higher energy densities,
laser energy did lessen capsular stiffness properties. The results of this study should be
interpreted with caution until in vivo studies are performed.
Lowell, Errico, Fehlings, DiBartolo, Ladosi
Orthopedics, October 1995, Vol. 18, No. 10
One hundred patients who underwent microlumbar diskectomy over 5 years were
retrospectively reviewed. L4-5 and L5-S1 were compared to determine whether a patient's
post-surgical outcome is related to the level where a herniation has occurred. Overall
results included 70 excellent, 19 good, 2 fair, and 9 poor. Statistical analysis showed
that neither the level involved, length of follow-up, nor degree of manual labor predicted
outcome. Older patients and females tended to fare worse, but the trends were not
significant. Three recurrent herniations occurred, 1 in the L4-L5 group and 2 in the L5-S1
group. No variable predicted recurrence.
Shapiro, Fanton, Dillingham, Perkash
Clinical Orthopaedics and Related Research, No. 310, January 1995
A retrospective study was conducted in which several parameters of postoperative recovery
were compared between 2 groups of patients: 25 patients who had lateral retinacular
release surgery in which the Holmium:yttrium-aluminum-garnet (Ho:YAG) laser was used, and
a control group of 17 patients who had the same surgery in which electrocautery was used.
Postoperative recovery times of patients treated with the Ho:YAG laser were significantly
decreased as compared with the recovery rates of patients in the control group. Morbidity
also was reduced in the group for whom the laser was used. The results of this study
indicate that the 2.1 micron wavelength, pulsed Ho:YAG laser can be used safely and
effectively to perform lateral retinacular release surgery.
Moss
Biophotonics International, February, 1995
The Holmium LACS procedure appears to represent a unique minimally invasive treatment for
shoulder dislocation. Future applications may include malalignment between kneecap and the
femur and torn knee cartilage. The laser is also being explored in treatment of
temporomandibular joint disease, in which the jaw bone and the temporal bone of the skull
grate against each other causing extreme facial pain and headaches. The Holmium laser is a
powerful yet precise and safe tool easily adapted for use in arthroscopic surgery. Thermal
modification of capsular tissue by this procedure may be useful in treating GHI resulting
from capsular redundancy. Further study is in progress to optimize tissue shrinkage and
tissue strength.
Orthopedics Today, May 1994, Vol. 14, No. 5
A group of orthopedic surgeons is working assess the use of the Holmium:YAG laser in
correcting glenohumeral instability. By using the laser to "shrink" tissue in
the shoulder capsule, function and mobility are restored to patients. The procedure,
dubbed laser assisted capsular shift (LACS), is being described as a "potentially
promising alternative" to the variety of techniques that currently address
glenohumeral instability.
Meller, Black, Sherk, Uppal, Rhodes
ASLMS ABSTRACTS
To compare electrosurgical devices and various laser wavelengths in their acute effects on
human meniscal tissue. CO2, sapphire contact tip Nd:YAG, Ho:YAG, and excimer
laser wavelengths cause little thermal damage to meniscal tissue in vitro and appear
superior to electrosurgical devices and freebeam Nd:YAG lasers. This study shows that CO2,
contact Nd:YAG and excimer laser wavelengths can be used to cut, sculpt and ablate
fibrocartilage or hyaline cartilage safely and effectively.
Smiley, Wasilewski
Arthroscopy: The Journal of Arthroscopic and Related Surgery, 6(1):18-23
This study was undertaken to evaluate the efficacy of knee synovectomy with arthroscopic
technique. Nineteen patients with 25 operated knees were studied. All 25 knees had 6-month
follow-up, 21 knees had 2-year follow-up, and 14 knees were evaluated at least 4 years
after operation. After operation, patients were evaluated using clinical data including
pain relief, functional capacity, range of motion, recurrent synovitis, and presence of
effusion. Preoperative as well as follow-up weight bearing radiographs were also studied
to assess the results of this procedure. At 6 months' postoperative clinical evaluation,
96% of patients showed good results. At 2 years, 90% of patients were considered to have
good results, and at 4 years, 57% of patients continued to do well. Of those knees studied
radiographically, 81% showed no progressive radiographic changes at 2 years and 61.5%
showed no deterioration at 4 years. Clinical results correlated well with radiographic
results. Arthroscopic synovectomy yielded results similar to those previously published
for open synovectomy, with less operative and postoperative morbidity.
Garrick
At the present time, lasers offer the orthopedist little beyond what can be accomplished
by well-established mechanical means. Most unique are the arthroscopic laser delivery
systems that allow cutting or ablation in areas difficult to access with mechanical
instruments. Perhaps unique is the precision with which some lasers ablate diseased
tissue, although the sparing of one or two mm of meniscus or articular cartilage may be of
negligible clinical importance. Most disturbing, however, is the burgeoning availability
and use of lasers in orthopedics despite the paucity of scientific documentation regarding
their efficacy.
Sherk, Kollmer
Lasers in Orthopaedics, Chapter 5
The effects of lasers on cartilage, tendon, and other tissues are described in chapters on
arthroscopy (chapter 9) and tissue welding* (chapter 8) The effects of lasers on bone
tissue and laser osteotomy justify separate discussion.
* Application not cleared for use in the U.S.
Dillingham, Price, Fanton
Orthopedics, Vol. 16, No. 5, pp 563-566
This relatively new form of laser energy, with its powerful and precise ability to ablate
the dense tissues of the musculoskeletal system as well as its transmissibility in
fiberoptic cables and a fluid medium, makes this an ideal tool for use in orthopedic
surgery. Its importance as a new orthopedic modality may well lie in its unique ability to
gain access to small articular compartments while providing superior homeostatic control,
thereby decreasing postoperative morbidity. While not yet in widespread use, its
popularity is rapidly spreading and research into a variety of new applications is growing
steadily.
Timmerman, Andrews
American Journal of Sports Medicine, Vol. 22, No. 5, 1994
The histology and arthroscopic anatomy of the ulnar collateral ligament of the elbow were
studied in cadaveric specimens. The capsule consists of two layers of collagen fibers,
with two distinct ligamentous bundles corresponding to anterior and posterior portions of
the ulnar collateral ligament. The posterior bundle consists of distinct collagen bundles
within the layers of the capsule; the anterior bundle consists of a similar thickening
with the capsular layers, with an additional ligament complex superficial to the capsular
layers. With arthroscopy only the anterior 20% to 30% of the anterior bundle of the ulnar
collateral ligament could be visualized via the anterior portal. Only the posterior 30% to
50% of the posterior bundle could be seen via the posterior portals. After sectioning of
the anterior bundle, joint instability was noted arthroscopically by an increased opening
in the ulnohumeral joint with application of valgus stress.
Arthroscopic Treatment of Post-traumatic Elbow Pain and Stiffness
Timmerman, Andrews
American Journal of Sports Medicine, Vol. 22, No. 2, 1994
Nineteen consecutive cases of posttraumatic arthrofibrosis of the elbow secondary to a
fracture or fracture-dislocation and treated with arthroscopic debridement and
manipulation were retrospectively reviewed. All of the patients had pain and stiffness in
their elbows, and all had failed a conservative therapy program. all 19 patients were
followed postoperatively for an average of 29 months (range, 12 to 51). One hundred-point
scoring systems were used to evaluate subjective (pain, swelling, locking, and activities)
and objective (range of motion) results. The average preoperative subjective score of 39
improved to 91 postoperatively (P=.0001); the objective score improved from 46
preoperatively to 81 postoperatively (P=0.0001). Extension improved from a mean of 29 to
11 degrees; flexion improved from an average of 123 to 134 degrees. Fourteen patients had
limitations in their sports activity preoperatively; 11 were able to return to their
pre-injury levels of activity after surgery. This study demonstrated good-to-excellent
overall results in 79% of the patients treated with arthroscopic debridement for
posttraumatic elbow arthrofibrosis.
Vangsness, Ghaderi
Orthopedics, May 1993, Vol. 16, No. 5, pp 593-598
Articles from the English literature concerning lasers and articular cartilage were
reviewed. Different experimental methods and laser systems were analyzed. Many studies
lacked scientific validity. Future investigations with sound biologic foundations are
recommended.
Jones, Savoie
Journal of Arthroscopic and Related Surgery, Arthroscopy, Vol. 9, #3, 1993, pp 277-283
Twelve patients with flexion contractures of the elbow were managed by arthroscopic
release of the proximal capsule and debridement of the olecrasnon fossa. Postoperatively
the mean flexion contracture improved from 38 to 3 degrees with supination improving from
45 to 84 degrees and pronation improving from 80 to 88 degrees. All patients reported a
decrease in pain level as well as improvement in motion. There was one severe complication
in this series, in which a patient sustained a permanent posterior interosseous nerve
palsy.
Abelow
Orthopedics, May 1993, Vol. 16, No. 5, pp 551-556
A surgical laser is a new, multipurpose tool that can cut, coagulate, and vaporize
tissues. It utilizes a low profile handpiece that allows easy access to tight places and
small joints. The Holmium laser at 2.1 µm wavelength is gaining wide acceptance among
orthopedic surgeons as a useful arthroscopic surgical tool. It has a minimal amount of
thermal necrosis and is able to cut and ablate tissues with great ease. Current
investigation with laser tissue&endash;agglutination* and tissue
welding*&endash;may make it possible to repair torn tissues with laser energy.
* Application not cleared for use in the U.S.
Basford
Orthopedics, May 1993, Vol. 16, No. 5, pp 541-547
This review first examines the 25-year history and scientific basis for laser therapy.
Clinical applications are discussed and the reasons for its relative lack of acceptance in
the US are examined. The article concludes with an overview of current research and the
impact it will have on laser therapy's role in US clinical practice.
Pollock, Bigliani
Journal of the American Academy of Orthopaedic Surgeons, 1993; 1:24-32
Glenohumeral instability encompasses a spectrum of disorders of varying degree, direction,
and etiology. The keys to accurate diagnosis are a thorough history and physical
examination. Plain radiographs are frequently negative, especially in subtle forms of
instability. Computed tomography (CT), CT arthrography, magnetic resonance imaging,
arthroscopy, and examination under anesthesia may occasionally yield important diagnostic
information. Non-operative treatment of shoulder instability consists of reduction of the
joint (when necessary), followed by immobilization and rehabilitative exercises. The
length and the value of immobilization remain controversial.
Marcacci, Buda, Zaffagnini, Visani, Iacono, Strocchi, dePasquale
Journal of Clinical Laser Medicine & Surgery, Volume 11, Number 1, 1993
The authors report their experiences using the excimer laser and Holmium:YAG laser in
arthroscopic meniscal surgery. Histologic and ultrastructural aspects caused by laser
irradiation on meniscal tissues are evaluated. Two groups of 10 patients, each suffering
from a bucket-handle lesion of the internal meniscus, were used for this study. The
histologic results of the study confirm the clinical reliability of the laser even in the
presence of different ultrastructural frames.
Cameron, Travis, Kruse
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol. 9, No. 2, 1993
A patient was found to have a tea-cup handle fragment in her elbow joint. The fragment was
removed arthroscopically. Interestingly, the patient was unaware of its presence and was
asymptomatic for >29 years.
Sherk
Journal of Bone and Joint Surgery, Vol. 75-A, No. 5, May 1993
This article explains history of laser including basic laser physics, arthroscopy,
discectomy, removal of polymethylmethacrylate*, tissue welding*, biostimulation* and
treatment of tissue defects, photodynamic treatment of tumors with lasers, and safety and
credentialing.
* Application not cleared for use in the U.S.
Siebert
Orthopade, (1992) 21:273-288
Arthroscopic surgery has become a routine procedure, thanks to the availability of
excellent video systems and the development of new and efficient instruments. Since early
1980 several groups have been developing arthroscopic laser surgery. Laser technology is
ideal for use in endoscopic surgery because lasers are potentially extremely small but
nevertheless powerful tools with many advantages. Lasers are used in arthroscopy not only
to divide tissue but also to smoothen cartilage, for hemostasis, for percutaneous lumbar
and cervical disc surgery, for photodynamic therapy, for tumor therapy and in diagnosis.
Lasers must now show, in prospective clinical studies, that their theoretical advantages
are matched in practice.
Fanton, Dillingham
Seminars in Orthopaedics, Vol. 7, No. 2, June, 1992
The Holmium laser has been found to be a safe, effective arthroscopic tool for peripheral
joint surgery. Its multiple applications, small probe size, fiberoptic capability, and
fluid medium transmissibility with pulsed, freebeam delivery offer significant advantages
over electrocautery and laser systems developed for other biomedical applications. The 2.1
µm wavelength appears to ideally suited for arthroscopic use, and the recent development
of improved delivery devices and the new high power output 32W system will continue to
provide greater versatility and speed of use and will broaden an already seemingly
limitless scope of applications.
Lane, Sherk, Mooar, Lee, Black
Seminars in Orthopaedics, Vol 7, No. 2, June 1992
Regardless of the method used, the time required for a patient to return to function was
approximately 4 weeks. With all factors being considered, this study lends support to the
use of Ho:YAG or CO2 lasers as an effective means for arthroscopic partial
meniscetomy or chondroplasty. It is unlikely that lasers will completely replace
mechanical instrumentation in arthroscopy; however, they are quickly becoming a useful
addition to the armamentarium of arthroscopists.
O'Brien, Fealy, Miller Seminars in Orthopaedics, Vol. 7, No. 2, June 1992
Biomedical Technology and the corresponding development of surgical instrumentation has
played an integral role in the evolution of orthopaedic surgery. Advances in orthopaedic
surgical instrumentation have made the orthopaedist's job much easier, efficient, and
effective. The trend has been toward minimally invasive therapeutic interventions that
achieve identical or superior clinical results as prior techniques.
Bradrick, Eckhauser, Indresano J Oral Maxillofac Surg, 50:835-842, 1992
A Neodymium yittrium aluminum garnet (Nd:YAG) laser inserted through an operating
arthroscope was used to introduce applied energy to synovial tissues, articular discs, and
bone in the temporomandibular joint of mongrel dogs. Arthroscopic inspection of the wounds
was performed at 1 and 2 weeks postoperatively. The animals were killed and the
temporomandibular joints were examined grossly and histologically to determine the extent
of injury and healing. The results show that laser wounds of bone and articular disc
undergo no repair, whereas laser wounds of synovium show rapid repair. Laser damage to
condylar marrow under an articular disc wound was unexpectedly found.
Smith, Johansen, Vangsness, Marshall, Sutter, Bonavelet Seminars in
Orthopaedics, Vol. 7, No. 2, June 1992
The gas bubble technique is a technique for use in arthroscopic laser surgery. The CO2
laser is an efficient energy delivery system in gas arthroscopy and has been highly
successful. However, most arthroscopic surgeons in the United States prefer saline
arthroscopy. The passage of CO2 gas through the CO2 energy delivery
system allows for a microenvironment of CO2 between the tool and the target
with a macroenvironment of saline to allow saline arthroscopy. No complications have been
encountered to date with the gas bubble technique.
Sherk, Lane, Black
Orthopaedic Review, September 1992
Lasers have become widely used in several medical and surgical disciplines. In
ophthalmology and plastic surgery, their use has permitted the development of therapeutic
modalities that would have been otherwise impossible. In such specialties as gynecology
and general surgery, lasers provide advantages that make certain procedures more
convenient and easier to perform. In contrast, orthopaedic surgeons have, to date, been
slow to accept these devices into the therapeutic armentarium. The purpose of this paper
is to describe the status of laser use in the orthopaedic subspecialty of arthroscopy.
Owens, Zacherl
Laser Nursing, Volume 5, Number 3, 1991
Remarkable advances in laser surgery have been made in the past decade. Surgeries that
previously required major incisions and recovery periods of days or weeks have become
outpatient procedures with significantly shorter recovery times. As concern over the high
cost of health care increases, the medical profession is adopting the least traumatic and
most cost-effective procedures available. To the patient, laser surgery can mean a shorter
hospital stay, a more rapid recovery period, and a faster return to normal daily
activities.
Lord, Maltry, Shall
Arthroscopy ,1/1/91
This article reports three cases of full thickness thermal burns of the skin in the 85
cases of arthroscopic lateral retinacular release we performed using electrocautery. To
our knowledge, this complication has not previously been reported.
Shapshay, Maretz, Setzer
Otol. - Head and Neck Surgery, 1/1/90
A Holmium-yttrium scandium gallium garnet laser is a pulsed midinfrared crystalline laser
(wavelength, 2.1 µm ), which is easily transmissible through flexible quartz fibers. With
use of a 300 µm fiber delivery system, this laser was applied in the canine trachea to
create a standard 5-mm diameter lesion through mucosa and submucosa. Power settings of 400
mJ and 600 mJ per pulse at 2 pulses per second were used, and wound healing was studied
over a 2-week period. Excellent control of depth of tissue ablation was noted, with
uncomplicated wound repair. Although healing was somewhat slower compared with healing
when the CO2 laser was used, less granulation and fewer inflammatory changes
were noted.
Johnson, Oz, Chuck, Treat
Surg Endosc, 1989
Alternative methods have been considered for treating cholelithiasis. The three devices
used for cholecystolithotripsy were the ultrasonic lithotriptor (UL), the electrohydraulic
lithotriptor (EHL), and the Thulium-Holmium-Chromium:YAG laser (THC:YAG). The UL
effectively fragmented all types of stones studied, although it is necessary to hold the
stone against the tip of the probe. The EHL quickly fragmented noncalcified and pigment
stones simply by placing the tip in the vicinity of the stone, but calcified stones had to
be held in position near the electrode. The THC:YAG was effective at fragmenting each type
of stone, but the number of pulses required was quite large, corresponding to 7 min for
some stones. Because of the specific advantages and disadvantages of each device, a
combination of devices may be required for successful clinical cholecystolithotripsy.
Siebert, Wirth
Percutaneous Lumbar Discectomy, 1989
The search for a less invasive method of treatment which hardly burdens the patient has
become important not least in view of studies which criticize the effectiveness of
chemonucleolysis (9, 11). The fundamental idea of nucleus pulposus vaporization was to
reduce by direct vaporization the optically very homogeneous properties of the nucleus
pulposus, which differ substantially from the annulus fibrosis at least in healthy person,
and thus to attain decompression in the intervertebral disc concerned. At the same time,
it was hoped that this technique would disturb the stability of the movement segments as
little as possible owing to the small operation and the selective technique.
Schultz, Krishnamurthy, Thelmo, Rodriguez, Harvey
Lasers in Surgery and Medicine, 1985, Vol. 5
The effects of laser energy on articular cartilage were studied utilizing the
Neodymium:Yag laser. Animals were killed at weekly intervals from 1 to 6 weeks, the knees
exposed to 25 and 75 J demonstrated a reparative process with chondral proliferation. The
knees exposed to 125 J demonstrated fiberoptic tissue and tissue necrosis that resulted in
fibrosis. In the knees not exposed to laser and tissue necrosis that resulted in fibrosis.
In the knees not exposed to laser energy, numerous foci of granulation tissue were present
at all stages with the end point of healing being one of fibrosis with disorganized patchy
cartilage islands.
Whipple, Caspari, Meyers
Orthopedics, September 1983, Vol. 6, No. 9
Rationale and technique are discussed for performing arthroscopic meniscectomy with a
carbon dioxide laser, including presentation of findings in limited rabbit and human
studies.
Carter R Rowe, M.D., Dinesh Patel, M.D.William W. Southmayd, M.D. The Journal of Bone and Joint Surgery January 1978, Volume 60-A, No. Of 161 patients with 162 shoulders operated on during a thirty-year period (1946 to 1976), 124 were re-examined and 21 answered a questionnaire. The lesions found at surgery were separation of the capsule from the anterior glenoid rim in 85%, a Hill-Sachs lesion of the humeral head in 77%, and damage to the anterior glenoid rim (including fracture) in 73%. There were five recurrences (3.5%) after repair by the method described in the 145 shoulders that were followed. Only one of the 46 patients with dislocation on the dominant side and one of the 31 with dislocation on the non-dominant side failed to return to the competitive athletic activities in which they had participated prior to injury. We concluded that with the meticulous technique of the Bankart repair as described, postoperative immobilization is not necessary, early return of motion and function can be expected, and resumption of athletic activities with no limitation of shoulder motion is possible for most patients.
Norman, Baker Diagnostic Radiology, December 1978
Several factors may play a role in the etiology of spontaneous osteonecrosis of the medial
femoral condyle. Corticosteroids are unknown to induce osteonecrosis, and 45% of the
patients in this study received steroids parenterally or by intra-articular injection.
Another factor, heretofore given little attention, is the association of medial meniscal
tears and spontaneous osteonecrosis. Twenty-one (78%) of 27 knees examined by arthrography
demonstrated meniscal tears. Stress concentration over the edge of the meniscal fragment
may result in ischemic necrosis of the femoral condyle. Early detection of a medial
meniscal tear by arthrography in older patients and prompt treatment may be important in
avoiding the late changes of spontaneous osteonecrosis.