There are many valid reasons why a physician or surgeon might wish to inspect the interior of a body cavity and, over the centuries, there have been numerous attempts to develop some means to facilitate this type of inspection. However, although it is a relatively simple task to examine the mouth and the throat, given sufficient daylight, in other cases, it was the lack of sufficient light that was the main obstacle to be overcome. Long before arthroscopy became a routine orthopaedic procedure, physicians were experimenting with simple devices with which to perform internal examinations. Over time, their efforts resulted in a whole family of similar instruments, collectively known as endoscopes.
It seems that the first such instrument was developed in 1806 by a German doctor named Philipp Bozzini who called it a “lichtleiter” or “light conductor” with which to examine the bladder. However, while the name may suggest a fibre-optic cable such as those used in modern arthroscopy, it was nothing quite as sophisticated. In practice, his invention was dismissed by members of the Rome Academy of Science as of interest but of little significance.
Widely considered to be the father of endoscopy, it was a French physician named Antonin Jean Desormeaux who, in 1853, used mirrors and lenses to intensify and focus the light from a gas lamp along a tube which could be inserted into the bladder. Not only did Desormeaux use his primitive cystoscope as a diagnostic tool, but he is also credited with undertaking the first surgical procedures known to have been performed endoscopically – a routine application of arthroscopy today.
Further refinements to these early instruments were focused on increasing the intensity of the light source and the big breakthrough came with the invention of the incandescent light bulb by Thomas Edison. In 1910, this enabled a Swedish physician named Hans Christian Jacobaeus to develop an improved endoscope which he used first to examine the abdominal cavity and later to treat adhesions of the pleural cavity – a common complication among those suffering from TB.
Two years later, the Swede’s design was modified and used to perform arthroscopy by a Danish surgeon named Severin Nordentoft. It is, however, the Tokyo-born Professor Kenji Takagi who, in 1918, adapted a cystoscope to examine tuberculous knee joints and is widely considered to be the true founder of this orthopaedic speciality.
Since the pioneering work of Takagi, a succession of advances in technology has seen these primitive endoscopes evolve almost beyond recognition. Today, for example, the source of illumination is provided by cold light generated by means of light-emitting diodes (LED) and directed on to the target area with the aid of a fibre-optic cable. However, the biggest single advance and one that has revolutionised arthroscopy was, without doubt, the development of the video camera. Today, a surgeon no longer needs to rely on the direct and somewhat restricted view available to the unaided eye. Instead, a miniature video camera fitted to the scope provides a magnified, full-colour image of the interior structure of a hip, knee, or shoulder joint, which can be related to a screen monitor where it can then be viewed by theatre staff.
It is this ability, in particular, that has allowed the role of the arthroscope to develop beyond that of a predominately diagnostic tool. It has enabled the application of arthroscopy as a means to perform a variety of minimally invasive surgical procedures. The earliest efforts were confined to simple repairs, such as the irrigation of a joint to remove detached particles of bone and cartilage, as well as to perform repairs to a torn meniscus or anterior cruciate ligament.
The first successful replacement of a knee joint took place in 1968 and involved the total exposure of the affected joint and thus carried the associated risks of excessive blood loss and infections. Since then, surgeons have perfected techniques that enable them to use a pair of tiny keyhole incisions through which to insert the necessary instruments, while using arthroscopy to guide their actions via a third keyhole incision. This minimally invasive technique is now frequently used for both total and partial knee replacements, and even to perform hip and shoulder arthroplasty.
These are highly specialised procedures that demand a high level of skill and experience from the surgeons who undertake them. Although not suitable for all patients, the use of arthroscopy to perform joint replacements has been growing in popularity and has been helping many arthroplasty patients to reduce their post-operative recovery times.