Arthroscopy opened new window into orthopedist’s world of bones and joints

Procedures done now with scopes and viewing them on TV monitors in the OR trace back to the arthroscope’s orthopedic origins.

--- Robert W. Jackson

Safely viewing organs and other structures inside the human body has long been man’s desire. Even Isaac Asimov in his 1966 science fiction novel “Fantastic Voyage” labeled the inside of the body a new frontier. Interestingly, his book gained popularity at a time when many orthopedists were poised to begin their own similar explorations.

When the arthroscope was developed about half a century ago what thrilled orthopedic surgeons worldwide was that this new frontier, the interior nooks and crannies of the human body, could at last be conquered. For them, as scientists and explorers of a sort, a slender metal tube attached to a microscope and later a camera lense opened a window into a new world.

Today investigators continue to explore and view that world in new ways, thanks to the groundwork laid by those who developed the arthroscope and used it innovatively. As a result, unique minimally invasive treatments of all kinds are emerging, ranging from cartilage repair and joint arthroplasty in orthopedics, to colonoscopies, laparoscopies and a host of other scope-based surgeries done by other medical specialists.

Overcoming obstacles

Although for years its use was met with considerable opposition, in this country practicing orthopedic surgeons started using the arthroscope in the mid-1960s. From there, its popularity grew so that by the late 1970s, a few hundred orthopedists were using it; later it was deemed a superior tool for teaching diagnosis and treatment of intra-articular pathology.

Orthopedic surgeons first used the arthroscope for diagnosing knee pathology and doing simple procedures to clean up the knee joint. Here an arthroscopist is shown placing his eye directly on the arthroscope to view inside a patient’s knee. COURTESY OF JOHN B. MCGINTY

Sports medicine as an orthopedic subspecialty advanced considerably because of introduction of arthroscopy to treat meniscal tears, anterior cruciate pathology and cartilage defects.

Over time, arthroscopists switched from working in the knee to exploring and treating the shoulder, an area pioneered by Lanny Johnson, MD, and later the elbow, wrist, ankle and even finger joints. Johnson told Orthopedics Today he was even first to use it in the tempero mandibular joint.

“The arthroscope came into being, like many other things, at a time when it was needed. I think some of our care, in terms of joints, was less than desirable and the arthroscope filled that void. … Its evolution was needed to improve surgery,” said John B. McGinty, MD, of Mobile, Ala., one of arthroscopy’s early innovators. He is past chief medical editor of Orthopedics Today.

Orthopedists in the United States led the race to adopt the arthroscope. The speed at which it developed directly corresponded to the rate at which various conditions in the knee and their treatments were identified. And then word got out about the technique.

The gradually increasing demand for arthroscopic procedures at centers in Boston, Michigan and California, to name a few, eventually impacted scope sizes, introduction of new and powered arthroscopic instruments, and the addition of better light sources. Through-the-scope visualization improved due to advances like two-channel arthroscopy, split viewing used for teaching purposes, and the ability to easily view everything done through the arthroscope on television monitors set up in the OR.

Early growth in the arthroscopy field typified a classic example of supply-and-demand, McGinty said.

Japanese import

Arthroscopy pioneer Masaki Watanabe, MD, of Tokyo, laid the groundwork in this field, developing the Watanabe No. 13 arthroscope in 1951 and several more models after that. After Robert W. Jackson, MD, visited Watanabe in 1965 and learned arthroscopy from him, Jackson returned to North America with the Watanabe No. 21 arthroscope. Now in the department of orthopedic surgery at Baylor University Medical Center in Dallas, Jackson practiced in Toronto at the time.

Acceptance was slow, Jackson said. The arthroscope was essentially used from the late-1960s to nearly the mid-1970s purely as a diagnostic tool and almost entirely in the knee, according to McGinty: “We would do a few things like biopsies and remove loose bodies, but other than that it was a diagnostic tool.”

Treating knee pathology through the arthroscope evolved in the 1970s when it was used by some clinicians, like Johnson, who mostly practiced at Ingham Medical Center, Lansing, Mich. He used it to perform meniscectomies and synovectomies and shave off loose pieces of articular cartilage.

Better instrumentation

Among the arthroscope’s early evolutionary changes in terms of the instruments were these developments:

1. Richard L. O’Connor, MD, introduced the operating scope in 1971.
   
   
2. Johnson and McGinty connected it to black-and-white, and later color, TV cameras and monitors for enhanced visualization in about 1972.
   
   
3. Johnson developed motorized shavers, burrs and other instruments working with Dyonics. This helped make operating through the arthroscope easier.
   
   
4. The original light source in the No. 21 model — a bulb on the end of the scope — gave way to fiber optic illumination.
   
   
5. More portals were added through which surgeons could operate. The concept of triangulation, although originally introduced by Watanabe in 1955, started to catch on.
   
   
6. Scopes were adapted with beam splitters enabling a “teacher” to see one part of the image during surgery and the student followed along on the other. Flexible beam splitters followed, along with teaching attachments.

Less morbidity

“With the arthroscope, it was not what they couldn’t do otherwise, but they could do it with a lot smaller incisions, cutting much less tissue and causing much lower morbidity, so that it ultimately became an outpatient procedure,” McGinty told Orthopedics Today. Patients returned to work faster, in as few as one or two days depending on their type of employment.

“The morbidity was much less. Initially when we took out a meniscus it would mean four, five days in the hospital and about six weeks on crutches, as opposed to arthroscopy, when there was no time in the hospital and maybe two or three days on crutches at the most.”

The advent of ambulatory care also occurred in the late 1970s, at about the time these developments in minimally invasive surgery (MIS) got underway. “I think arthroscopy was one of the pioneers in that,” McGinty said.

Changes to the arthroscope improved teaching methods, including fixed beam splitters (top left), teaching attachments (top right), early use of large TV cameras (bottom left) and miniaturized cameras (bottom right). COURTESY OF ROBERT W. JACKSON

Impacted sports

Another field in which arthroscopy played a pioneering role was sports medicine. When the sports medicine subspecialty was new, so was the arthroscope. “We were in a period of time when we were ‘growing’ weekend athletes and everybody was getting involved in sports, and professional sports was growing at a great rate. And the arthroscope got publicized through professional sports and commercial television to the point where everybody who had a problem with their knees wanted it. And I think that accounts for some of its growth,” McGinty said.

Nothing indicates better how important the arthroscope was to sports than when Sports Illustrated named Jackson in 1994 among the top contributors to the field since the magazine was established. According to Jackson that occurred as part of the publication’s 40th anniversary. “They chose 40 people, individuals who made the biggest contributions to sports and I was the only doctor,” he said.

For his work involving the arthroscope Jackson ended up being listed among the ranks of such sports greats as Henry “Hank” Aaron, Muhammad Ali, Peggy Fleming and Pelé. That was fitting, because when Jackson first started using the scope he said it complemented and enhanced what he already considered a sports medicine practice. He regularly operated on some high-level athletes, like hockey player Bobby Orr, Wes Unseld, who played basketball with Washington/Baltimore teams, even O.J. Simpson and a lot of other football players. “I was getting some top-level athletes coming for examination and treatment, so that promoted it largely in the sports field,” Jackson told Orthopedics Today.

What’s the diagnosis?

Diagnosing joint diseases and conditions reached new heights with the arthroscope, helping surgeons do a better job in this area. In fact, many say that in the knee it eventually replaced using the arthrogram.

Physicians like Johnson started out using it solely to diagnose ailments in patients sent to him, sending a report to the referring physician, much like radiologists read a radiograph or MRI today. “I was doing them maybe 20 in a day in 1972 or 1973 … Later on we started developing surgical approaches and, of course, the surgery changed [its use],” according to Johnson. “Bob Metcalf was calling himself an arthroscopic surgeon around 1975 or 1976 and I thought, ‘Who would want to be that?’ ” For Johnson, that was too limiting.

He was self-taught on arthroscope usage, and he may have been the first to perform such procedures under local anesthesia. “It made more sense to me than just making a big cut on a person’s knee. The first arthroscopy I ever saw I did under local,” said Johnson, who first operated with the needlescope, the ultra-thin forerunner of the arthroscope.

Take another look

Johnson also advanced the concept of performing second-look arthroscopies to confirm postoperative healing status. From 1978 until he retired in 1994 he videotaped all his cases and still has the tapes. They show amazing uses of the arthroscope, he said. “One of the things that helped surgeons understand it value was opportunistic second looks. … We could show doctors befores and afters, which they had never seen before.”

Different than viewing open surgery, the arthroscope provided an exact, targeted viewing field. “Opportunistic second looks were very important in establishing the value of the repairs that we were doing,” Johnson said. This made the arthroscope a teaching tool “like no other.”

Many took teaching arthroscopy on as a personal mission, including John Joyce, MD, Jackson and McGinty.

Minimally invasive treatment

Richard L. O’Connor, MD, is credited with developing the operative arthroscope, which was self-named. “Dick was the person that I think should get most of the credit for doing partial meniscectomies, because he developed with the Richard Wolfe Co. the in-line type of arthroscope, so that he could actually look down, but the lense was brought off to the side,” Jackson explained. This design enabled surgeons to use a long instrument and approach the pathology, particularly the meniscus, more directly.

Johnson said “the orthopedic surgeons, Bob Jackson and myself, and the other people who were advocating this, really were the forerunners of MIS. For instance, in 1980 I tried to convince the doctors in my hospital that I could do a gall bladder by arthroscopy, [using] these methods. And of course they thought I was nuts and they refused me.” Yet today gall bladders are frequently and safely removed endoscopically.

The arthroscope’s greatest impact goes beyond orthopedics. “The things that we developed in orthopedics as arthroscopists are all the fundamentals that are used now in all MIS, no matter whether it’s in the lung or the abdomen, appendix, gall bladder or brain,” Johnson said. “We developed the fundamental surgical environment and most of the instrumentation for all those other disciplines. That came from what we learned.”

Ongoing innovation

Lanny Johnson found abrasion arthroplasty to be effective for cartilage repair. Here he takes a second look at the fibrocartilage that formed on the medial femoral condyles and tibial surface at one year postop. COURTESY OF LANNY JOHNSON

Today’s arthroscopes closely resemble ones used 10 to 15 years ago. “We reached a certain level of goodness, I guess, and I don’t think there’s been much improvement since then,” Jackson said.

But, those who spoke with Orthopedics Today for this article agreed that more arthroscopic updates are ahead. “The biggest advances have been in the shoulder because shoulder surgeons were very quick to pick up on arthroscopy and started to devise ways of suturing rotator cuff tears, of anchoring things to bones, like the bone screws, suture anchors; [performing] decompression; and excising the distal end of the clavicle, the so-called Mumford procedure. These are all good innovations in the past few years and very common now,” Jackson said.

Ankle arthroscopy is gaining popularity now, he noted.

Microdiscectomy and laser discectomy benefited directly from arthroscopic developments. “We tried hard to use laser as a surgical tool in relation to arthroscopy and it just didn’t work out that well for most things. But, laser discectomy seems to be doing pretty good,” Jackson said. Microdiscectomies to remove disc fragments with a burst of laser energy are gaining popularity, as well, although this technique is not widely used in America. However, in Japan and Korea “they’re doing a lot of it,” he noted.

Computer-controlled surgery

McGinty sees computer control being applied to arthroscopy as a next step, noting that its time has come since arthroscopy is the most common orthopedic operation done today. In fact, many procedures done through scopes probably constitute the most common surgery type, overall, he said.

“I think you’re going to see smaller and smaller incisions and slicker ways of doing things through small incisions, with computer control.”

Biologics are next

Johnson called arthroscopy “nothing more than a delivery system now. What are you going to deliver: grafts or ligaments or sutures or whatever?” He predicted biologics would be the next thing delivered through an arthroscope.

And, since cartilage repair alone is such a burgeoning field, chondro-nutritive, -reparative or -restorative treatments may all one day be arthroscopically delivered. “Instead of having a total joint, you’ll have it done a lot by arthroscopy,” Johnson said, citing procedures now done in the elbow this way by Shawn W. O’Driscoll, MD, at the Mayo Clinic in Rochester, Minn. O’Driscoll carefully reshapes the elbow bones in lieu of arthroplasty.

“Delivery of biologics and the move forward to arthroplasty in combination with biologics done arthroscopically, that’s the future,” Johnson said.

For more information:

• Jackson RW. The introduction of arthroscopy to North America. Clin Orth. 2000;374:183-186.