Since the earliest days of primitive medicine, those who practice it have longed for some ways in which to view what may be going on inside the human body. While they were quick to peer into the ear and the throat, and to investigate the lower reaches of the birth canal, access to the bladder, rectum, lungs, and digestive tract required technology and instruments that would not be developed for almost two millennia. While the first practical endoscope was developed in 1806, arthroscopy – the use of an endoscope to examine the interior of a joint – took place for the first time more than a century later.
For this achievement, the orthopaedic fraternity can thank Professor Kenji Takagi of Tokyo. In 1919, he used a modified cystoscope, normally used to examine the urinary bladder, and inserted it into a knee joint. Others quickly followed his example, modifying various other types of endoscopies to adapt them to this new application. At this stage, arthroscopy was viewed primarily as a diagnostic tool; one that offered a more detailed view of the damage to the interior structure of a diseased joint than the X-ray images that had become available a little under two decades earlier. While these shadowy, negative, black and white images were invaluable in many other situations, when examining a joint, the greater the detail, the more reliable the diagnosis.
That said, the early endoscopes that were adapted for arthroscopy were simple tubes that provided the user with an illuminated image and lacked all the added refinements of the modern instrument. Today, light is directed on to the target area by a flexible fibre optic cable that also carries the illuminated and magnified image back to be captured by a miniature TV camera from which it can then be displayed in full colour on a monitor screen, in real-time. If required, the video material can then be saved to a suitable storage device for a more in-depth review at some later stage.
Having used the findings of the arthroscopy to establish a diagnosis and determine the most appropriate intervention, where surgery was deemed necessary, the surgeon would then expose the entire joint as usual in order to perform the agreed intervention. This meant that joint surgery continued to be a highly invasive procedure and one that often meant a fairly lengthy period of post-operative recovery for the average patient.
While Takagi must be acknowledged for his role in pioneering the endoscopic examination of joints, it was another Japanese surgeon, Masaki Watanabe, that must be awarded the credit for being the first to make use of arthroscopy in order to perform an actual surgical intervention. The idea was soon adopted by a number of his peers who experimented with its use as a means to excise fragments from a torn meniscus to affect a repair.
One of the greatest improvements to the safety of surgical intervention has been the development of so-called “keyhole” procedures. The use of tiny incision and a scope serves to limit the risk of haemorrhage and infections while also serving to reduce the time needed for recovery. Already widely employed by the specialists in many other branches of surgery, it has now become common practice for orthopaedic surgeons to utilise arthroscopy while performing a number of their specialised procedures.
In addition to the small incision through which the scope is inserted, just one or two equally small incisions to accommodate the necessary surgical instruments are all that is required. The result is a far less invasive intervention than when exposing the entire joint as in the traditional approach. Even though it has proved to be a low-risk procedure with very few incidents of serious complication, it does require a lot more skill on the part of the surgeon to operate using this technique. As a result, it tends to be only the most skilled and experienced orthopaedic specialists that will undertake to employ arthroscopy to perform procedures such as partial or total joint replacements.
Hip and knee joint replacements are most frequently required in patients suffering from osteoarthritis, once a condition associated mainly with those aged 65 or older. For a number of possible reasons, the age of osteoarthritis patients has been falling and the demand for joint replacements increasing. Arthroscopy is proving invaluable both as a diagnostic tool and as the means to perform the surgical interventions needed to reduce pain and swelling and to restore normal joint mobility.