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Section I: Symposium: History of Orthopaedics in North America

The Introduction of Arthroscopy to North America

Jackson, Robert W. MD

Editor(s): Peltier, Leonard F. MD, PhD

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Clinical Orthopaedics and Related Research: May 2000 - Volume 374 - Issue - p 183-186
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Abstract

Curiosity regarding body cavities can be traced back to the early days of Pompeii. However, the earliest known instrument designed to look into the bladder, which was called a lichtleiter, was presented by Bozzini to the Rome Academy of Science in 1806. The instrument was regarded with curiosity, but was not accepted in the scientific community.10 Almost 50 years later, in 1853, Désormaux developed his gazogene cystoscope, which consisted of a gasoline and turpentine fuel source, a combustion chamber, and a mirror to reflect the burning light directly into the bladder through a long cannula. This instrument is considered to mark the beginning of endoscopy. At that time, other investigators were trying to detect bladder stones by transillumination of the bladder, by inserting glowing hot wires encased in goose quills into the rectum.10

A significant advance in endoscopic instrumentation occurred in 1879, when Edison developed the incandescent light bulb. A few years later, a cystoscope, in which an incandescent bulb was used for illumination, was developed by Leiter and Nitze in Germany.10 From that time, cystoscopy became a reasonable science, and improved techniques and better instrumentation were developed slowly.

In 1918, the first use of a cystoscope to examine a knee was recorded.23 Kawashima17 and Takagi were concerned about tuberculosis of the knee and its end result, which usually was an ankylosed knee. A stiff knee was a serious social and physical disability to the patients in Japan. Takagi wanted to diagnose tuberculosis early and perhaps prevent ankylosis by early treatment. Therefore he was motivated to use a cystoscope to look inside knees. Eventually he developed instruments specifically for this purpose, and in 1931, he produced the first arthroscope. He subsequently produced 12 different models of arthroscopes, until this developmental process was halted by the start of World War II.24

At approximately the same time, on the opposite side of the world, Eugen Bircher in Switzerland was using a Jacobaeus Laparoscope to look inside knees. He did not pursue arthroendoscopy, as he termed it, for very long, but he published the first articles regarding arthroscopy of the knee.1,2

In 1925, Philip Kreuscher published an article in the Illinois Medical Journal, entitled A Plea for the Early Diagnosis of Semilunar Cartilage Disease by Arthroscopy.18 Kreuscher is thought to be the first American pioneer in arthroscopy, and the first author to publish a study on arthroscopy in the English literature.

In 1930, Michael Burman went to Berlin on a 1-year fellowship in endoscopy. He returned to the New York Hospital for Joint Diseases and worked with his colleagues, Finkelstein, Mayer, and Sutro, in examining every joint in the body with an endoscope. Burman and colleagues wrote several classic articles from 1931 to 1936.3-5 A text for an atlas of arthroscopy also was prepared but never published. I had the pleasure of meeting Burman in 1969. He became excited to think that after 30 years, someone finally was expressing an interest in arthroscopy. He showed me some of his early work on intravital staining of articular cartilage lesions,5 a subject that was obviously far in advance of its time.

Several other authors, primarily European, published reports in the years just before World War II.11,22,25 But when World War II began, progress in the biologic sciences was restricted. It was approximately 16 years later that reports regarding arthroscopy of the knee were being published.12-14,21

Dr. Masaki Wantanabe of Tokyo is credited as being the modern "father of arthroscopy." Watanabe returned from the Japanese army after World War II and resumed his career in medicine. He continued the work of Takagi and developed arthroscopes using the modern techniques involving electronics and optics, which became prevalent in Japan in the era after World War II.26 Watanabe produced several arthroscopes, and the Number 21, developed in 1959, was considered good enough to become a production model.27 He also published the first Atlas of Arthroscopy in 195728 and a second edition was published in 1969.29

In 1964, I had the opportunity to work in Tokyo on a McLaughlin Scholarship before returning to the University of Toronto. While in Tokyo I contacted Watanabe and realized that the ability to look inside a joint was truly something special. During the next few months, I repeatedly attended his operating sessions and he, with the help of Dr. Hiroshi Ikeuchi (who spoke English well), tried to teach me the techniques of arthroscopy.

I returned to Toronto in 1965 with a Number 21 arthroscope. There were many technical problems in the early days, such as breakage of the light bulb, electrical short circuits causing tetaniclike contractions of the quadriceps, and nurses mistakenly autoclaving the scope instead of sterilizing it in formalin vapor. Heat sterilization melted the lens seals and the electric cords, and destroyed the arthroscope. Component parts were hard to get and had to be shipped from Japan. There also was significant ridicule and skepticism about the procedure and colleagues expressed the opinions such as "if you need an arthroscope to treat knee problems, you should not be treating knee problems" and "why peek through the keyhole, when you can open the door!"

Slowly, I gained experience, and in 1967, my first paper on arthroscopy was presented at the inaugural meeting of the Association of Academic Surgeons in Toronto. In 1970, I gave the first of many instructional courses in diagnostic arthroscopy at the American Academy of Orthopaedic Surgeons annual meetings. The first course attracted only approximately 24 people. In 1967 and 1968, numerous visitors came to Toronto because word was spreading that the technique of arthroscopy was possible. Dr. John Joyce, III, Dr. Ward Casscells, and Dr. Jack McGinty were among the first surgeons from America to learn about arthroscopy. In 1968, Dr. Leonard Peltier, then professor of orthopaedics at the University of Kansas, was the first surgeon to order a Number 21 arthroscope in the United States. Many European surgeons also came. To some it was a curiosity, to others it became an increasingly useful adjunct to practice.15

In 1968, I was able to show the interior of a knee on a black and white television monitor. Later, color television cameras were used, which soon were miniaturized and attached directly to the arthroscope. The ability to view the joint from an enlarged image on the television monitor was a great advance because it enabled everyone in the operating room to be involved in the procedure.

Other notable events in those early years included Dr. Dick O'Connor's visit to Watanabe in 1969, and the subsequent help of the Richard Wolf Instrument Company (Rosemont, IL) in developing instruments and arthroscopes to enable O'Connor to do the first partial meniscectomies in patients in North America.19 In 1972, Dr. Lanny Johnson introduced the needlescope and later taught the comprehensive examination of the knee.16 Interest and activity in Europe also was increasing, and several significant contributions were published.8,9,20 Also in 1972, Dr. John Joyce organized the first course in arthroscopy in Philadelphia. In 1974, the course was repeated, and the International Arthroscopy Association was founded. Watanabe was named president and I was named vice president.

North America and Japan were the founding chapters of the International Arthroscopy Association.

In 1975, the first meeting of the International Arthroscopy Association was held in conjunction with the Societe Internationale de Chirurgie, Orthopedique et de Traumatologie in Copenhagen, Denmark. O'Connor, who was the Treasurer of the International Arthroscopy Association, had converted the small amount of money obtained through the founding member's dues into gold coins. He carried these coins, which were purchased at $40 an ounce, with him to Europe, and after the meeting in Copenhagen, he went to Zurich and deposited the gold into a numbered Swiss bank account. His foresight was exceptional in that, in December 1975, the price of gold was unpegged and rapidly rose to more than $600 an ounce. The International Arthroscopy Association sold its gold approximately 2 years later at $800 an ounce and made a profit of approximately $60,000. With this money, appropriate office space and administrative help was obtained and Tom Nelson was hired as the Executive Director of the Association.

In 1982, the Arthroscopy Association of North America formally was established as a distinct and separate entity. At this point, there were many excellent arthroscopic surgeons and many textbooks had been published on the subject. Dr. Lanny Johnson pioneered the development of techniques and instrumentation. Dr. Robert Metcalf was one of the pioneers in education, conducting yearly courses that were unparalleled in their teaching value. Dr. Jack McGinty organized courses through the American Academy of Orthopaedic Surgeons, and many other surgeons were busy giving lectures.

Many courses were held in universities and in private institutions. In 1984, the first satellite television course was held, which was sponsored by a manufacturing company. It was telecast to 29 stations in North America, and featured lectures and live surgery.

With the advent of arthroscopic surgical procedures, the companies that manufactured instruments became more interested in arthroscopy. Before the early 1980s, arthroscopy was primarily a diagnostic tool. It now became a useful therapeutic tool, and with the help of the manufacturers of the instruments, appropriate instrumentation was developed to fulfill my personal credo that if you could see pathology, you should be able to deal with it. By the mid-1980s, courses were being held on anterior cruciate ligament reconstruction and on shoulder arthroscopy, and advanced concepts such as meniscal repair were being explored.

The initial benefits of minimally invasive surgery, such as fewer complications, less downtime, and an earlier and often more effective treatment, were obvious. By the mid-1980s, data were being collected to show that the treatment methods actually were superior to the open operative procedures that were taught previously. Therefore, the success of arthroscopic surgery can be considered as the catalyst of a true revolution in surgery, with techniques for minimally invasive surgery developed for almost all subspecialities. General surgeons began to do laparoscopic cholecystectomies, appendectomies, and small bowel resections, Gynecologic surgeons were doing tubal ligations and other procedures, and thoracic surgeons began to do partial resections of lung.

It can be said that arthroscopy, an offshoot of cystoscopy, has evolved to a major tool in the armamentarium of the orthopaedic surgeon during the past 80 years. It has been an honor and a privilege to be part of something that now is recognized as one of the three most significant advances in orthopaedics in the past century, the other two advances being the development of total joint arthroplasties and open reduction and internal fixation of fractures.

References

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