- THIS MATERIAL IS PUBLISHED AND PROTECTED BY U.S. COPYRIGHT LAW - REPRODUCTION PROHIBITED UNLESS FOR PERSONAL USE, EXCEPTING AUTHOR PERMISSION - Peter F. Kelly, D.P.M., F.A.C.F.A.S. Diplomate, American Board of Podiatric Surgery Fellow, American College of Foot and Ankle Surgeons APPLICATIONS OF THE Nd:YAG LASER TO PODIATRIC SURGERY An article in three parts: PART I: THE LIGHT SCALPEL - Nd:YAG LASER CONTACT TIP PART II: THE Nd:YAG LASER FOR THE PODIATRIC SURGEON PART III: QUANTITATIVE STUDIES - THE Nd:YAG VS. CONVENTIONAL SURGERY PART III: QUANTITATIVE STUDIES - THE Nd:YAG VS. CONVENTIONAL SURGERY In a comparative study of 185 podiatric patients treated for structural foot and ankle deformities in the rearfoot, metatarsal, and digital regions, the author found that a novel approach to surgery using the contact Nd:YAG resulted in significant reductions in pain, bleeding, edema, and recovery time. To establish the database, the author standardized and quantified clinical parameters and compared these resultants against similar surgeries using the contact Nd:YAG and conventional cold steel instrumentation. Of 185 patients, 103 were treated with the contact Nd:YAG technique while a parallel group of 82 patients were treated via conventional instrumentation. A significant patient volume was essential to minimize data variations and achieve scientific validity. Patient populations were simultaneously monitored in this study and results recorded concurrently. This employed method of measuring both groups concomitantly greatly minimized retrospective bias. Thus no retrospective analysis was necessary. Uniform surgical protocol was followed. Postoperative followup was similarly consistent. All subjects were healthy. Patients affected by peripheral or systemic medical complications were excluded from the study. The majority of treatments, 55.1%, were performed in the metatarsal region; 19.3% of the cases were digital; 15.4% were in the rearfoot region; and 10.2% were pure soft-tissue treatments. After surgery, the patients were followed very carefully by conducting hundreds of postoperative examinations. The advantages that emerged for laser treatment appeared more divergent with the larger surgical cases. Comparative differences in postoperative pain, edema, and disability were not as significant for the smaller (ie: digital) cases. Most notable in the data was the comparative reduction of pain by nearly one-half (41%) in the laser group. This was ascertained by quantifying the amount of similar oral narcotic medications consumed postoperatively in each group. However, many patient responses were unexpected. Many patients offered spontaneous declarations that they had never experienced any need to consume postoperative pain medication when interviewed at the 72-hour and two-week postoperative examinations. In considering the physiology of laser tissue interaction, apparently the Nd:YAG laser scalpel seals microscopic nerves and lymphatics during the surgical dissection. This is compared with the steel scalpel microscopically crushing and dragging axonal and microtubules through the tissue producing spontaneous depolarizations which explains the clinical effects from its microtraumatic nature. The laser patients also exhibited 23% faster recovery time. Typically, patients who had undergone laser surgery returned to work 11.4 days following surgery, while patients treated with a steel scalpel averaged 14.9 days. Some limitations of this parameter involved the necessity of postoperative casting and this work restriction was imposed by O.S.H.A. regulations. The reductions in laser macroscopic bleeding was 8%, which the author felt was not significant. This could result from reflex hyperemia secondary to ankle tourniquet use. However, postoperative edema was significantly reduced in the laser group by 37%. This was contributed largely to laser hemostasis of small vessels which reduced microscopic bleeding. Restoration of adequate joint function in reconstructive cases was not quantified, but was observed to be restored at much earlier postoperative dates, a likely consequence of this factor. There was no change in measurable infection rates. Neither group of patients experienced any infections. Within the scope of this study it remains unproven that any chance of infection theoretically would be decreased, however the premise is that the temperature of the laser tip is bacteriocidal. In conclusion, within the author's practice there is little question that the neodynium-YAG contact-tip laser has achieved a significant impact in the reduction of pain and swelling for Podiatric foot and ankle surgery, most importantly decreasing the tissue remodeling time which results in shorter term disability. The patient study of this size is statistically significant, yet it is motivating to see the repetition of these results as the patients are seen on a daily basis One caution is that the Nd:YAG laser scalpel is not an instrument rapidly acquired by the casual surgeon. The surgical techniques described herein require training at professional courses including adequate hands-on involvement and in consultation with an experienced laser faculty. Even the most experienced surgeons should approach this new modality with the attitude that this is a radical alteration of their surgical technique. To achieve the results discussed in these articles, a steep learning curve should be realized. The author emphasizes the importance of the adequacy of conventional surgical training as a prerequisite for the laser scalpel applications. With the appropriate training and application of the instrument, significant improvements in surgical results can be achieved with the Nd:YAG laser scalpel. Database of 185 Patients remains on file.