The Evolution of Knee Surgery

Feb 1, 2021 | Articles

Given the complex structure of this joint, it is perhaps not too surprising that the first successful attempts to perform knee surgery were relatively recent. By contrast, physicians and even laypeople have been treating other orthopaedic problems such as fractured arms and legs, dislocations and spinal deformities for millennia, albeit with varying degrees of success.


While most people tend to think of tuberculosis as a disease of the lungs, the causative organism, Mycobacterium tuberculosis, can infect various parts of the body, including the joints. Here it forms painful abscesses and can affect mobility. For the longest time, physicians could only recommend the palliative option of splinting and rest. With the advent of antisepsis, knee surgery seemed like a viable option. During the late 18th and early 19th centuries, surgeons started to operate on this joint and drain the offending abscesses. Nevertheless, post-operative infections remained a problem. Unfortunately, a significant number of patients suffered crippling deformities or required amputations, and some failed to survive the procedure.


As with TB patients, those with injuries to this joint usually received palliative treatments, relying mostly on compresses and bed rest, but knee surgery attempts continued. Aided by advances such as X-rays, improved anaesthetics and aseptic techniques, surgeons became more skilled, more adventurous and, ultimately, far more successful in their endeavours.


One of the most significant developments in the field of orthopaedics was the invention of the arthroscope. Other medical disciplines had used similar instruments to explore the bowel, the stomach, the bladder and the respiratory system for decades. However, it was only in 1918 that a Tokyo University professor used a modified cystoscope to examine the interior structure of the knee. His action marked the first step towards a new type of surgery that, in the future, would provide life-changing therapy for millions of patients affected by diseased or injured joints.


Not long after Professor Kenji Takagi’s pioneering efforts, it was one of his former students who made two contributions that were to mark the dawn of a new era for the orthopaedic surgeon. Firstly, he made many improvements to the design and performance of the primitive endoscopic instruments of that time. In practice, some of his ideas helped to shape the advanced arthroscopes used today. Secondly, Dr Masaki Watanabe performed the first-ever arthroscopic knee surgery.


When treating a teenager with a torn meniscus, he decided not to avoid the usual practice of fully exposing the joint. Instead, he used an arthroscope to view his movements and miniature instruments, inserted through additional small incisions, to effect the repair. Today, orthopaedic surgeons perform arthroscopic procedures routinely on most of the body’s joints and to treat a wide range of conditions.


While meniscectomies or meniscus repairs, reconstruction of the anterior cruciate ligament (ACL) and repairs to the patellar tendon are just a few examples of knee surgery that have now become commonplace, the one orthopaedic procedure that never fails to impress is arthroplasty. In simple language, the term refers to replacing one or both of the articulating components of a joint with prosthetic ones.


The most common condition that inevitably results in the need for a patient to undergo arthroplasty is osteoarthritis. Though traditionally a problem of the elderly, it is now becoming more frequent in middle-aged and even younger subjects. Osteoarthritis results from the protective layers of cartilage that cover the articulating surfaces of a joint becoming eroded. While painkillers may suffice at first, knee surgery will eventually be the only option, as the exposed bone becomes increasingly damaged by friction, intensifying joint pain and impairing the patient’s movements.


While the early attempts at arthroplasty demonstrated that joint replacement was achievable, the prosthetic replacements proved to be problematical. Also concerned with the damage caused by the tubercle bacillus, a German professor named Themistocles Glück attempted to replace the head of a femur with one made from ivory. It lasted just a few days and most of the other materials available for decades coped no better. It was only in 1953 that a metal-on-metal prosthesis was used successfully to replace a damaged hip joint, in the process, laying the foundation for future knee replacement surgery.


Today, hip, knee and shoulder arthroplasty are seen as the most successful orthopaedic interventions of all time. Furthermore, in very few places, have they proved to be more successful than at the nationally and internationally renowned orthopaedics unit of Pretoria’s Life Wilgers Hospital.