How Arthroscopy Has Transformed Orthopaedics

Oct 21, 2019 | Articles

It would appear that physicians have been constructing and using instruments to explore the body’s cavities since the time of the ancient Greeks and Romans. In fact, a device that is widely thought of as an early prototype of the endoscope was recovered from the ruins of Pompeii. However, the first recognisable step on the journey that would, one day, make possible the technique of arthroscopy was taken only in 1805. It was then that one Philip Bozzini created an instrument that became known as a Lichtleiter (light guide) and used it to examine the pharynx, the urinary tract, and the rectum.

Some 48 years later, a Frenchman named Antoine Desormeaux produced a more refined version of this instrument designed to inspect the bladder and urinary tract. He named it an endoscope and the term has since been applied as a catchall to describe a whole range of similar instruments with which to explore each of the body’s various cavities, including that used for arthroscopy.

Progress continued throughout the 19th century and into the 20th. The early years of the latter saw the previously rigid, tubular design of these early scopes replaced in 1932 by a more flexible structure for use in applications such as gastroscopy in which a degree of flexion is essential to conduct a complete exploration of the stomach. The physician’s view was aided by the inclusion of lenses at various points within the tube and a small torch bulb to provide illumination.

These units were designed for direct viewing, unlike those used in arthroscopy today and which are equipped with a video camera capable of relaying a magnified, real-time, full-colour image to a remote monitor screen. That said, it was only in 1950, that the first black and white images of the interior of the stomach were taken by means of a camera fitted to a gastroscope.

This refinement, however, came almost twenty years after a Japanese surgeon named Kenji Takagi first hit on the idea of modifying a cystoscope, normally used to examine the bladder, in order to view the interior structure of a joint and, in the process, gave birth to the procedure known as arthroscopy.

When, in time, these instruments were upgraded to provide the video images mentioned earlier, orthopaedic surgeons were quick to embrace what was seen, primarily, as an invaluable diagnostic tool. Instead of depending on the content of X-ray films in their multiple shades of grey, the surgeon could now inspect the bones of a joint and the surrounding soft tissue directly and, for the first time, make an accurate assessment of the extent of any damage and the measures required to repair it. However, even Kenji had seen the potential of arthroscopy as a surgical tool and, at the time, this prompted the design of instruments small enough to be inserted through a specially designed sheath and that would allow a surgeon to perform minor interventions during the exploratory process.

The techniques of arthroscopic surgery have since been refined, as have the various instruments employed in the many orthopaedic procedures that are now routinely performed in this fashion. Among the procedures most commonly performed in this way are repairs to a torn meniscus or to the anterior cruciate ligament, but the minimally invasive approach of arthroscopy is now also being applied by some surgeons to perform a rather more specialised type of intervention.

The earliest recorded attempt to replace a severely damaged hip joint with a prosthesis, a process known as hip arthroplasty, dates back to 1891 when a german Professor named Glück used ivory to replace the head of a femur that was damaged by TB. The ivory proved to be insufficiently strong and although the experiment ultimately ended in failure, the principle had been established. With the development of tough new materials, including stainless steel, titanium, polyethylene, and ceramics, the procedure has not only become routine but some surgeons are now performing joint replacements with the aid of arthroscopy.

Other joints routinely replaced, either partially or totally, are those of the knee, the shoulder, the elbow, and the ankle, and in many cases, the arthroscope is offering patients a far less invasive option with fewer risks than when resorting to older techniques that require the complete exposure of the joint and associated soft tissues.

Arthroplasty has been widely hailed as the most successful orthopaedic intervention of all time and there is no doubt that arthroscopy has played a significant role in contributing to that success.