钬激光技术在骨科的应用

二、钬激光 技术在骨科的应用

关节镜在不需切开、缝合关节，避免引起机械性损伤的情形下，诊断与治疗关节疾病。钬激光（Holmium Laser）在骨关节外科应用则优于其他激光，Smith首先使用CO2激光，不可避免地出现炭化、皮下气肿、滑膜反应，因设备笨重而难以推广。20世纪80年代中期采用以固体为介质的钕激光，也因其吸收波段较宽，不易被水吸收，穿透靶组织范围、程度不易控制，产生一个宽的坏死区和很厚的硬化层，使用受到限制。20世纪90年代初Fanton首先应用钬-钇-石榴石激光，此后，Lune使用钬激光。钬激光的应用简化了关节镜手术，目前我国也引进了钬激光系列应用于骨关节外科。

1.钬激光的特点　钬是微量元素，钬与钇- 石榴石混合后，可发出波长2 180 nm的激光。钬激光是一种脉冲式；高能量激光，具有平行性、加强性和单向性。因为其波长的浅穿透性，并可为组织中的水分迅速吸收，在单个激光脉冲之间的间隙时间里组织可发生冷却，最大限度地阻止了对组织的损害。钬激光光束只有靠近组织，通过接触、半接触的方式发挥作用。因为每一脉冲的钬激光只切割相对恒定数量的组织，所以可进行精细的手术操作。钬激光基本无炭化，但有止血作用，与其他激光的深穿透性相比，对周围组织的损伤最小，安全可靠，通过调节发射功率、频率及能量水平，可对组织实施切割、凝固、分离摘除。钬激光容易切割软骨，特别适用在髌软骨面、远端股骨髁、肱骨近端软骨成形术。

2.钬激光的传导系统　钬激光容易通过弯曲的光导纤维进行传递，特别适用于小的关节镜；如腕、踝、肩关节镜。钬激光系列由主机、光导纤维、机头、手柄和多种角度的转换杆（0°、10°、20°、30°、60°、90°）组成。光导纤维由580 lm（1 lm=1 cd·sr）的硅石英纤维构成与手柄相接。所有的钬激光机头是经久耐用的，亦可作为探针使用，其末梢渐细使其能在内镜内自主地运行、可视，进行切割和使组织雾化。内镜视野清晰。使用时手柄头端应接触被切割的组织或接近被气化的组织。如果缩回头端，可使激光束发散，降低光能量密度，有效地用于修整软骨面。转换杆的设计从0°～60°有多种，也包括一个90°侧面发射激光的手柄。膝关节常用的是20°和30°。而0°则用于稳定膝关节的半月板后角处狭窄部位的手术操作；90°侧面发射机头便于进行髌后软骨成形术，也可用于治疗髌骨软骨面不平和半月板前角撕裂或桶柄状撕裂。还可用于肩关节镜，适合进行盂唇中部撕裂的切除及肱骨软骨软化和关节挛缩症。

3.钬激光是关节镜下手术的理想工具 在关节镜下进行手动或电动器械切割、修整损伤的半月板、软骨等手术比关节切开损伤小，功能恢复快现以被公认。但由于关节腔隙狭小，有弯曲，此类手术难以掌握。易损伤周围组织（如切除半月板时伤及附近软骨）。而钬激光转换杆比关节刨削器（6mm）小得多，直径仅为1.2 mm，避免了手动器械反复进出切口引起的损伤。同时，提高了手术的精确性与速度。由于转换杆有多种角度适合关节内曲度，可在关节镜监视下对准病灶，踏动开关即可从事气化等操作，与电刨削及手动器械操作相比简单且易于掌握。由于其损伤小，止血作用强，术后很少发生关节积液。尤其在肩、腕、踝关节间隙小，角度特殊，电动、手动器械操作难度更大的部位。

钬激光自20世纪90 年代初国外应用于临床，我国也于近年开始使用，最初应用于血管成形术，但目前已适用于关节镜的应用，钬激光具有切割、凝固、气化、紧固、雕刻等多种作用，在膝关节可进行半月板切除术、软骨成形术、侧副韧带松解术、滑膜切除术、清创或清理术和前交叉韧带重建术。在肩关节可进行关节唇缘撕裂切除术、肩峰减压术、滑膜切除术、肩袖清创术。踝关节可进行清创术、软骨成形术及组织紧固操作。为骨关节外科理想的手术工具。术后制动时间短，功能恢复快，但关节周围软组织有感染、关节僵硬或明显活动受限者不适用。

（郭其勇）

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