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4th International IMLAS Congress - Kyoto, Japan. Nov. 5-7, 1997
Report by Stephen Abelow
The 4th International Congress of IMLAS held in Kyoto, Japan was a huge success. Drs. Onomura, Yonezawa and Abe were divine hosts. From the opening reception with a Japanese cuisine prepared as French cuisine (sort of a sino-ois instead of chin-ois), to the Grand Banquet serving a traditional shabu shabu dinner served at our table by geishas, to the closing reception which included another gourmet dinner and Emperor's music, the experience was a cultural wonder.
Kyoto is a city of more than 1600 Buddhist temples, 300 Shino shrines and has an ambience unlike any other place I have ever been in my life. Although prices were extraordinarily high in Japan, my wife Mary and I had a delightful time discovering this very foreign country. We were never quite sure whether the sign on the door we were entering read "restaurant" or "enter here for express vasectomy service".
The fact of the matter is that the Japanese culture is thousands of years old and in many ways we Westerners are truly barbarians. Both Mary and I felt that we have never been treated so graciously by any group of individuals in our lives as we were treated by our Japanese hosts.
When I arrived in Japan, my major objective was to try to enrich my knowledge of the use of lasers in orthopedic surgery as much as I could. I must say, however, that as soon as I got to Japan my major objective became trying to find food without suckers, tentacles or eyes on it. My second major objective became trying to find my way out of the train stations.
This meeting was an extraordinary opportunity for physicians and clinical research scientists to communicate with each other and raise our understanding of the use of laser technology in its medical applications.
Prof. Onomura asked us to put serious thought as top why the use of lasers in musculoskeletal surgery has not been widely embraced by the medical community and what parameters must be dealt with in the future.
Most importantly this congress gave us the opportunity to reunite with old friends and make new acquaintances in this most enlightening venue.
Synopsis of the Scientific Program
I felt the best paper of the meeting was presented by Jacques Saunier from Switzerland, entitled "MRI Modifications after HolmiumLaser Arthroscopy". Saunier presented 44 patients with preoperative and postoperative MRI (from 4-8 weeks postoperatively). The operative procedures consisted of meniscectomy, synovectomy, chondroplasty and plica excisions. Attention was paid to the bone signal pre- and postoperatively. 29 patients had normal preoperative and postoperative bone signal. 9 patients had edema or hyposignal preoperatively which remained identical postoperatively. 6 patients with a normal preoperative MRI had a hyposignal or edema on postoperative MRI. 5 of the 6 patients had a normal follow-up and complete recovery (during the same time period as the normal cases). The last patient went on to develop an osteoarthritis but no osteonecrosis. Dr. Saunier concluded that bone necrosis after arthroscopic treatment remains an unsolved problem and that the laser cannot be responsible for necrosis after arthroscopy.
Another good paper by Okamato, Yonezawa, Abe and Onomura from Japan gave a prospective randomized clinical study of 42 patients who underwent preoperative and postoperative MRI. Most of them had meniscectomies and/or debridement of soft tissue in the intracondylar space during ACL reconstruction. Mean laser energy was 9.539 Kjoules. Their study did not reveal any evidence that the Ho:YAG laser caused osteonecrosis. One patient who had medial meniscectomy and ACL reconstruction had a small subchondral bone change in the medial femoral condyle on the postoperative MRI done 4 months after surgery.
Werner Siebert of Kassel, Germany, presented a report of 320 arthroscopic knee procedures compared to conventional mechanical methods. Follow-up was 2 years. His study showed that chondromalacia, combined meniscal cartilage lesions and chronic rheumatoid synovitis were treated more effectively with better results with the Ho:YAG-laser in comparison to conventional arthroscopic methods. He found significant advantage to the use of laser in lateral retinacular release. No significant advantage could be found to using the laser during meniscectomy. He felt the laser was useful for treating smaller hard-to-reach places and joints and lowered the risk of iatrogenic cartilage damage.
Laser-assisted arthroscopic synovectomy of the knee in rheumatoid arthritis was presented by the Orthopedic Surgeons from the Komaki City Hospital in Japan. They had 15 knees in eight rheumatoid patients with average age being 50.3 years. Follow-up was 12.5 months. They found "significant improvement in pain and range of motion at the follow-up evaluation". There was no apparent postoperative hemarthrosis nor other significant complications noted. They felt that their study showed that laser-assisted arthroscopic synovectomy was useful and safe in the treatment of persistent rheumatoid arthritis.
117 cases of knee arthroscopy were reported on by Nishiyama, Moriya, Wada and Mitsuhashi from Chiba University, Japan. Holmium laser as well as conventional instrumentation was used. Holmium laser was found to be useful when the joint space was tight in that it diminished intraoperative and postoperative bleeding.
An interesting paper from the Dept. of Orthopedic Surgery of Osaka Medical College, Japan showed the microscopic changes in canine meniscus after Ho:YAG laser irradiation. Inflammation was observed at one and two weeks after irradiation. At four weeks, the effects of the laser decreased, although thermal degeneration persisted. At eight weeks, the irradiated edges of the meniscus have almost been repaired, although there was still some evidence of thermal degeneration.
Hartmut Pelinka from Vienna, Austria compared 100 consecutive cases of arthroscopic laser knee surgery to mechanical knee surgery. They used a 60 Watt Holmium laser with 5.37 Kjoules of energy. Time for laser surgery was 24 minutes. Time for mechanical arthroscopy was 28 minutes. A tourniquet was used; laser tourniquet time was 28 minutes, 30 minutes for mechanical surgery. What was most interesting to me about this paper was that the patient treated with the laser required 2.36 days hospitalization compared to 3.04 days for patients treated with mechanical arthroscopy.
Bruno Gerber, from Neuch_tel, Switzerland, gave an excellent paper on laser-assisted arthroscopy of small joints. He concluded that the Holmium laser was an excellent instrument to use in the wrist and the ankle and seemed to have less indications in the hip and the elbow. He presented 28 cases of ankle arthroscopy with follow-up of one year: 89% indicated total pain relief; 86% improved range of motion; and 93% recovered full working capacity. He compared this with a mechanical series with pain relief in 75%; range of motion improvement in 75%; and only 25% recovered full work capacity. He feels that arthroscopy is indicated routinely prior to osteosynthesis of ankle fractures (ORIF).
Drs. Abe, Saito, Hoteya and Fukushima from the Nihon University School of Medicine in Japan presented a study on laser-assisted arthroscopic elbow surgery in 32 baseball players with a follow-up of at least one year. They reported that pain, function and range of motion of the elbow improved after Holmium laser arthroscopy. They were able to reduce the size of loose bodies, ablate osteophytes and help with hemostasis during synovectomy. They felt that with the use of the laser they could start rehabilitation earlier.
Drs. Negishi, Saito, Fukushima Hoteya and Funami from the Nihon University School of Medicine in Japan reported on 49 patients undergoing Ho:YAG laser assisted shoulder arthroscopy; follow-up was at least one year. The procedures performed were LACS in 15 patients; arthroscopic subacromial decompression in 23 patients and both LACS and ASD in 11 patients. Of their patients with combined laser surgery (n = 11), 3 were good, 3 were fair and 5 were poor. Of 23 patients with ASD, 18 were good, 5 were fair and 0 were poor. Of the LACS procedure alone, 4 were good, 6 were fair and 5 were poor. Several LACS patients were not able to return to their sports activities. Werner Siebert commented that in his study of 60 cases comparing Suretac stabilization to Suretac combined with laser-assisted capsular shift, he had a very low rate of redislocation in the group of patients treated with the laser-assisted procedure.
An interesting paper was presented by Johannes Hellinger from Munich, Germany, where he used a C-arm, Ho:YAG laser and "nonendoscopic Ho:YAG laser decompression in cases of subacromial impingement". Essentially he did a percutaneous subacromial decompression using a Holmium YAG laser and C-arm on 46 patients. 41 patients were satisfied and 5 patients unsatisfied. Essentially, it appears that Dr. Hellinger took a Holmium laser and just lased around the subacromial space and undersurface of the clavicle and acromion (under C-arm imagine intensification) and was able to achieve some successful results.This appears to be kind of a Ho:YAG laser corticosteroid injection into the subacromial region. It occurred to me that there was really no way to control what exactly was happening in the subacromial space.
More than half the congress was involved with use of lasers in spinal surgery.
There were presentations on endoscopic percutaneous laser disc decompression (PLDD), KTP PLDD, endoscopic laser discectomy and endoscopic transforaminal surgery Most interesting was a paper presented by Werner Siebert on endoscopic transforaminal surgery of the lumbar discs. This is a rather new minimally invasive percutaneous technique for the surgical therapy of prolapsed lumbar discs. 56 patients were treated with herniated lumbar discs from L3-S1 with a follow-up time from 3 to 22 months. 76% had improved their sciatic symptoms; 77% had improved back pain symptoms; and 83% of the patients stated that they would accept having this treatment again if therapy was necessary. The Holmium laser was used in these cases for its hemostatic and tissue ablative effects.
It seems that papers were presented using the Ho:YAG laser, Neodymium:YAG laser and KTP laser, but I really could not figure out whether there was any inclination to defining which laser could conceivably be better for these procedures.