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The early days of arthroscopy in the United States
Arthroscopy: The Journal of Arthroscopic and Related Surgery 3(2):71-73 Published by Raven Press © 1987 Arthroscopy Association of North America
The Early Days of Arthroscopy in the United States S. Ward Casscells
senting the American Orthopaedic Association. There was brief mention of the scientific program and the fact that a Japanese professor, Masaki Watanabe, had presented his findings and early experience with arthroscopy of the knee. The thought occurred to me that perhaps an arthroscope might be clinically applicable in furthering my investigation of chondromalacia of the patella. I wrote to Dr. Watanabe in early 1967 to inquire about the possibility and the feasibility of obtaining an arthroscope. After many delays, some correspondence, and many more delays, the arthroscope arrived in the fall of 1967. It included a right-angle scope as well as an end-viewing telescope, a light source, and all the necessary equipment including a half-frame 35 mm Olympus camera. When the import duty was added to the cost of the arthroscope, the total was -$700. The instructions were written in Japanese. I had great difficulty assembling this scope, and my first attempt to introduce it into a knee joint was unsuccessful. This was true despite the fact that some months previously while I was at "Expo 67" in Montreal I had taken a side trip to Toronto to watch Dr. Robert Jackson perform one arthroscopy. As I recall, the patient had arthritis, and visualization was not very good, but I was assured by Dr. J a c k s o n that a r t h r o s c o p y was a worthwhile endeavor. Progress in learning arthroscopy was painfully slow, and often I dispaired of ever learning this new orthopaedic operation. Although I thought of giving up entirely, I was motivated to continue largely by the fact that I had $700 invested in the scope, and the market for used arthroscopes in 1967 and 1968 was nonexistent. Initially, all my patients that were arthroscoped were also subjected to arthrotomy so that I could confirm what I had or had not seen through the arthroscope. By the time I had arthroscoped 50 knees, I was feeling a little more encouraged. Thirty of these cases were analyzed and presented at a meeting of the South Carolina Orthopaedic Association in the summer of 1968. At that time,
Arthroscopic surgery is being performed with such frequency and enthusiasm at the present time, that it is difficult to believe that when first reintroduced into the United States 20 years ago, it was greeted with skepticism, indifference, and neglect. Unfortunately, we have no way of knowing if there was a similar reaction to the efforts of Burman and Kreuscher who were the real pioneers in arthroscopy in the United States. Although the work of Burman, Mayer, and Finkelstein was successful enough that their paper was published in the Journal of Bone and Joint Surgery in 1931, they abandoned their efforts to establish arthroscopy on a firmer footing, and we do not know why. Both Burman and Mayer lived for more than 40 years after their paper was published. A part of our early history is lost. Fortunately, the modern pioneers are still with us and can provide an interesting historical background to the development of present-day arthroscopy. In previous issues we published Professor Masaki Watanabe's account of the problems he encountered in the early 1950s and 1960s. We also have Dr. Robert Jackson's history of his introduction to arthroscopy in Japan at Dr. Watanabe's clinic and his early efforts to establish arthroscopy in Canada. Somewhat later, arthroscopy spread to the United States. To these two earlier sketches, the editor of Arthroscopy adds his version of the early days of arthroscopy in the United States. My first interest and introduction to arthroscopy was serendipitous--it was the proximate result of dissecting cadaver knees in an attempt to learn something about chondromalacia of the patella. In the course of reading the literature in an effort to familiarize myself with the subject, I chanced on a paragraph in the Proceedings of the Journal of Bone and Joint Surgery which described the visit to Japan of a group of orthopaedic surgeons repreAddress correspondence and reprint requests to Dr. S. W. Casscells at 1205 Gilpin Avenue, Wilmington, Delaware 19806, U.S.A.
7/
S. W. C A S S C E L L S
scarcely anyone had even heard of an arthroscope. If I had given the paper in a foreign language, it could not have been less understood. A similar reaction followed a presentation of this subject at the sports medicine meeting in Oklahoma City in 1969. An exception to this indifference was an expression of interest on the part of Dr. Don O'Donohue who asked where he could obtain an arthroscope. He did purchase an arthroscope, but I learned subsequently from his residents and fellows that it lay on a shelf accumulating dust. From time to time, he did state that he wanted to come to Wilmington to learn more about this new operative technique, but he never did. My next effort to explain arthroscopy to an uninterested and skeptical group of orthopaedic surgeons was at the 1969 Quad-City Orthopaedic meeting in Washington, D.C. One person who saw some merit in arthroscopy was Goren Bauer who at that time was working at the Hospital for Special Surgery in New York. He asked me to repeat the talk a few weeks later at that hospital. I did this and, during the "question and answer period" that followed, someone in the audience asked me to compare the relative merits of arthroscopy and arthrography. Despite the fact that the New York Hospital for Special Surgery at Cornell Medical School had pioneered and developed arthrography, I ventured the opinion that in the future, when arthroscopy itself was well established, it would perhaps supplant arthrography. I was unaware of the fact that Dr. Robert Friberger, the father of arthrography, was in the audience. He promptly jumped to his feet and assured me and the audience that arthrography was a well-developed and highly accurate means of diagnosing intraarticular pathology and that it was very unlikely that it would be supplanted by this new technique of arthroscopy now or in the future. I had a c c u m u l a t e d 150 cases by the time of the Academy meeting in 1970, and the results were presented at that meeting. The discussant warned about the dangers of infection with this new technique but said little else. If my paper impressed anyone in that large audience, I was unaware of it, and this was also true of the reaction of the Sports Medicine Society to a presentation I gave in San Francisco a few months later. The discussor, who shall be nameless but who was a well-known figure in the Sports Medicine Society, was even less kind, and predicted a dismal future for arthroscopy and said it was just another way to make money. He Arthroscopy, Vol. 3, No. 2, 1987
was partially right in that arthroscopy did make a great deal of money for many people, but, at that time, it seemed to be a preposterous statement, as my early charge for diagnostic arthroscopy was $40. By the early 1970s, those of us who were involved in arthroscopy thought that there was a definite future for this new technique. However, there were very few in the country who agreed, and the prevailing mood was one of indifference, skepticism, and even ridicule. Strangely enough, arthroscopy had very little appeal to those in academic centers, at least in the United States. This may be the main reason why it took so many years for arthroscopy to become established. In looking through my files I discovered a 1968 worldwide list of all those who owned arthroscopes apart from those in Japan. There were 20 people on this list, 10 of whom resided in the United States and three of whom were in Canada. From a standpoint of contributions to arthroscopic surgery, the only name on this list that I now recognize is that of Dr. Robert Jackson. Presumably, the others lost interest, including one who went on to become president of the American A c a d e m y of Orthopaedic Surgeons. The combined meeting of the English-speaking nations was held in Sydney, Australia, in the spring of 1970. Dr. Robert Jackson of Toronto presented his paper outlining his experience with 200 cases. Although it was a fine paper, I do not recall that it g e n e r a t e d much e n t h u s i a s m for a r t h r o s c o p y perhaps, in part, due to the fact that Dr. Don O'Donohue, who had never arthroscoped a patient himself, was the discussant. There was nothing derogatory in his discussion, but it is difficult to be enthusiastic about a surgical procedure that you never have attempted. It is my recollection that Dr. William McAusland, former president of the Academy, was the first one to suggest to me that we should have courses to teach arthroscopy to others. After some delay and much discussion with Dr. John Joyce, who had become one of the early supporters of arthroscopy, the first course in the United States, and perhaps anywhere in the world, was given at the University of Pennsylvania in 1973. At this first course, attended by 75 people, there were five faculty members, one of whom was a professor of radiology at the University of Pennsylvania and the other, Dr. Michael Harty, a professor of anatomy, who spoke on the gross anatomy of the k n e e . The
E A R L Y D A Y S OF A R THR OSCOP Y I N THE U.S.A.
arthroscopic presentations were made by Dr. John J. Joyce, Dr. Robert W. Jackson, and by me. In addition to the presentations, there was a laboratory dissection of cadaver knees. The course lasted 1 day. The second course in arthroscopy was given in April 1974, again at the University of Pennsylvania. This was a 2-day course with a slightly enlarged faculty that included Dr. Lanny Johnson and Dr. Masaki Watanabe who, at that meeting, was elected the first president of the newly formed International Arthroscopy Association. At this meeting, an audiovisual presentation was tried for the first time, using closed-circuit television during an actual arthroscopic procedure. As might be imagined, there were some technical difficulties encountered, but it is interesting to think that even at this early stage of development, plans were being made to teach this new technique by audiovisual means. Dr. John McGinty attended this meeting to prepare himself for launching the first Academy course in arthroscopy the following year in Boston. Although he was not on the faculty, Dr. Richard
73
O'Connor also attended this 1974 meeting in Philadelphia. Largely through his efforts in the ensuing years, arthroscopic meniscectomy and many other surgical procedures performed through the arthroscope became possible. That arthroscopy had the potential for being something other than a diagnostic procedure stimulated the imagination of orthopaedists, and it soon became the most exciting and challenging operation of the decade. Here again, we have lost part of our valuable arthroscopic history with the untimely and tragic death of Dr. Richard O'Connor in November 1980. Arthroscopy is still evolving quite rapidly and, although there have been problems with overuse and serious complications that were not foreseen, it is certainly one of the major contributions to the field of orthopaedics. This is true not only because of the technique involved, which obviates the need for more major surgery, but also because it has increased our knowledge of intraarticular pathology and has a marvelous future as a research tool, although, unfortunately thus far, this has not been realized.
Arthroscopy, Vol. 3, No. 2, 1987
The Early Days of Arthroscopy in the United States S. Ward Casscells
senting the American Orthopaedic Association. There was brief mention of the scientific program and the fact that a Japanese professor, Masaki Watanabe, had presented his findings and early experience with arthroscopy of the knee. The thought occurred to me that perhaps an arthroscope might be clinically applicable in furthering my investigation of chondromalacia of the patella. I wrote to Dr. Watanabe in early 1967 to inquire about the possibility and the feasibility of obtaining an arthroscope. After many delays, some correspondence, and many more delays, the arthroscope arrived in the fall of 1967. It included a right-angle scope as well as an end-viewing telescope, a light source, and all the necessary equipment including a half-frame 35 mm Olympus camera. When the import duty was added to the cost of the arthroscope, the total was -$700. The instructions were written in Japanese. I had great difficulty assembling this scope, and my first attempt to introduce it into a knee joint was unsuccessful. This was true despite the fact that some months previously while I was at "Expo 67" in Montreal I had taken a side trip to Toronto to watch Dr. Robert Jackson perform one arthroscopy. As I recall, the patient had arthritis, and visualization was not very good, but I was assured by Dr. J a c k s o n that a r t h r o s c o p y was a worthwhile endeavor. Progress in learning arthroscopy was painfully slow, and often I dispaired of ever learning this new orthopaedic operation. Although I thought of giving up entirely, I was motivated to continue largely by the fact that I had $700 invested in the scope, and the market for used arthroscopes in 1967 and 1968 was nonexistent. Initially, all my patients that were arthroscoped were also subjected to arthrotomy so that I could confirm what I had or had not seen through the arthroscope. By the time I had arthroscoped 50 knees, I was feeling a little more encouraged. Thirty of these cases were analyzed and presented at a meeting of the South Carolina Orthopaedic Association in the summer of 1968. At that time,
Arthroscopic surgery is being performed with such frequency and enthusiasm at the present time, that it is difficult to believe that when first reintroduced into the United States 20 years ago, it was greeted with skepticism, indifference, and neglect. Unfortunately, we have no way of knowing if there was a similar reaction to the efforts of Burman and Kreuscher who were the real pioneers in arthroscopy in the United States. Although the work of Burman, Mayer, and Finkelstein was successful enough that their paper was published in the Journal of Bone and Joint Surgery in 1931, they abandoned their efforts to establish arthroscopy on a firmer footing, and we do not know why. Both Burman and Mayer lived for more than 40 years after their paper was published. A part of our early history is lost. Fortunately, the modern pioneers are still with us and can provide an interesting historical background to the development of present-day arthroscopy. In previous issues we published Professor Masaki Watanabe's account of the problems he encountered in the early 1950s and 1960s. We also have Dr. Robert Jackson's history of his introduction to arthroscopy in Japan at Dr. Watanabe's clinic and his early efforts to establish arthroscopy in Canada. Somewhat later, arthroscopy spread to the United States. To these two earlier sketches, the editor of Arthroscopy adds his version of the early days of arthroscopy in the United States. My first interest and introduction to arthroscopy was serendipitous--it was the proximate result of dissecting cadaver knees in an attempt to learn something about chondromalacia of the patella. In the course of reading the literature in an effort to familiarize myself with the subject, I chanced on a paragraph in the Proceedings of the Journal of Bone and Joint Surgery which described the visit to Japan of a group of orthopaedic surgeons repreAddress correspondence and reprint requests to Dr. S. W. Casscells at 1205 Gilpin Avenue, Wilmington, Delaware 19806, U.S.A.
7/
S. W. C A S S C E L L S
scarcely anyone had even heard of an arthroscope. If I had given the paper in a foreign language, it could not have been less understood. A similar reaction followed a presentation of this subject at the sports medicine meeting in Oklahoma City in 1969. An exception to this indifference was an expression of interest on the part of Dr. Don O'Donohue who asked where he could obtain an arthroscope. He did purchase an arthroscope, but I learned subsequently from his residents and fellows that it lay on a shelf accumulating dust. From time to time, he did state that he wanted to come to Wilmington to learn more about this new operative technique, but he never did. My next effort to explain arthroscopy to an uninterested and skeptical group of orthopaedic surgeons was at the 1969 Quad-City Orthopaedic meeting in Washington, D.C. One person who saw some merit in arthroscopy was Goren Bauer who at that time was working at the Hospital for Special Surgery in New York. He asked me to repeat the talk a few weeks later at that hospital. I did this and, during the "question and answer period" that followed, someone in the audience asked me to compare the relative merits of arthroscopy and arthrography. Despite the fact that the New York Hospital for Special Surgery at Cornell Medical School had pioneered and developed arthrography, I ventured the opinion that in the future, when arthroscopy itself was well established, it would perhaps supplant arthrography. I was unaware of the fact that Dr. Robert Friberger, the father of arthrography, was in the audience. He promptly jumped to his feet and assured me and the audience that arthrography was a well-developed and highly accurate means of diagnosing intraarticular pathology and that it was very unlikely that it would be supplanted by this new technique of arthroscopy now or in the future. I had a c c u m u l a t e d 150 cases by the time of the Academy meeting in 1970, and the results were presented at that meeting. The discussant warned about the dangers of infection with this new technique but said little else. If my paper impressed anyone in that large audience, I was unaware of it, and this was also true of the reaction of the Sports Medicine Society to a presentation I gave in San Francisco a few months later. The discussor, who shall be nameless but who was a well-known figure in the Sports Medicine Society, was even less kind, and predicted a dismal future for arthroscopy and said it was just another way to make money. He Arthroscopy, Vol. 3, No. 2, 1987
was partially right in that arthroscopy did make a great deal of money for many people, but, at that time, it seemed to be a preposterous statement, as my early charge for diagnostic arthroscopy was $40. By the early 1970s, those of us who were involved in arthroscopy thought that there was a definite future for this new technique. However, there were very few in the country who agreed, and the prevailing mood was one of indifference, skepticism, and even ridicule. Strangely enough, arthroscopy had very little appeal to those in academic centers, at least in the United States. This may be the main reason why it took so many years for arthroscopy to become established. In looking through my files I discovered a 1968 worldwide list of all those who owned arthroscopes apart from those in Japan. There were 20 people on this list, 10 of whom resided in the United States and three of whom were in Canada. From a standpoint of contributions to arthroscopic surgery, the only name on this list that I now recognize is that of Dr. Robert Jackson. Presumably, the others lost interest, including one who went on to become president of the American A c a d e m y of Orthopaedic Surgeons. The combined meeting of the English-speaking nations was held in Sydney, Australia, in the spring of 1970. Dr. Robert Jackson of Toronto presented his paper outlining his experience with 200 cases. Although it was a fine paper, I do not recall that it g e n e r a t e d much e n t h u s i a s m for a r t h r o s c o p y perhaps, in part, due to the fact that Dr. Don O'Donohue, who had never arthroscoped a patient himself, was the discussant. There was nothing derogatory in his discussion, but it is difficult to be enthusiastic about a surgical procedure that you never have attempted. It is my recollection that Dr. William McAusland, former president of the Academy, was the first one to suggest to me that we should have courses to teach arthroscopy to others. After some delay and much discussion with Dr. John Joyce, who had become one of the early supporters of arthroscopy, the first course in the United States, and perhaps anywhere in the world, was given at the University of Pennsylvania in 1973. At this first course, attended by 75 people, there were five faculty members, one of whom was a professor of radiology at the University of Pennsylvania and the other, Dr. Michael Harty, a professor of anatomy, who spoke on the gross anatomy of the k n e e . The
E A R L Y D A Y S OF A R THR OSCOP Y I N THE U.S.A.
arthroscopic presentations were made by Dr. John J. Joyce, Dr. Robert W. Jackson, and by me. In addition to the presentations, there was a laboratory dissection of cadaver knees. The course lasted 1 day. The second course in arthroscopy was given in April 1974, again at the University of Pennsylvania. This was a 2-day course with a slightly enlarged faculty that included Dr. Lanny Johnson and Dr. Masaki Watanabe who, at that meeting, was elected the first president of the newly formed International Arthroscopy Association. At this meeting, an audiovisual presentation was tried for the first time, using closed-circuit television during an actual arthroscopic procedure. As might be imagined, there were some technical difficulties encountered, but it is interesting to think that even at this early stage of development, plans were being made to teach this new technique by audiovisual means. Dr. John McGinty attended this meeting to prepare himself for launching the first Academy course in arthroscopy the following year in Boston. Although he was not on the faculty, Dr. Richard
73
O'Connor also attended this 1974 meeting in Philadelphia. Largely through his efforts in the ensuing years, arthroscopic meniscectomy and many other surgical procedures performed through the arthroscope became possible. That arthroscopy had the potential for being something other than a diagnostic procedure stimulated the imagination of orthopaedists, and it soon became the most exciting and challenging operation of the decade. Here again, we have lost part of our valuable arthroscopic history with the untimely and tragic death of Dr. Richard O'Connor in November 1980. Arthroscopy is still evolving quite rapidly and, although there have been problems with overuse and serious complications that were not foreseen, it is certainly one of the major contributions to the field of orthopaedics. This is true not only because of the technique involved, which obviates the need for more major surgery, but also because it has increased our knowledge of intraarticular pathology and has a marvelous future as a research tool, although, unfortunately thus far, this has not been realized.
Arthroscopy, Vol. 3, No. 2, 1987