The Japanese Origins of Arthroscopy

Persistence was an important factors behind this instrument’s emergence in Japan. Its underlying research program began in 1918 when Dr. Kenji Takagi (1888-1963), professor at the University of Tokyo, used a Charrière number 22 cytoscope to examine a cadaver knee joint (Jackson and Dandy 1978, 2). He continued these investigations while incrementally improving his own prototype arthroscope design. By 1931, Takagi had developed the No. 1 Arthroscope, an instrument of 3.5 mm in diameter that he and other Japanese researchers applied to various clinical procedures.

Takagi’s No. 1 arthroscope, its accompanying sheath, and other arthroscopic tools. (Watanabe 1978, 2)

Takagi and his collaborators continued to develop the technology, eventually producing 11 different telescopes along with other accessories. Takagi arthroscopes were featured at the Japanese Government Display at the 1937 International Exhibition in Paris. Arthroscopy was featured at several meetings of the Japanese Orthopaedic Association. However, the international community of orthopaedic surgeons largely ignored these developments.

Takagi retired in 1949. Development of the arthroscope was continued by his younger colleague Dr. Masaki Watanabe (1911-1995), who took a position at Tokyo Teishin Hospital, a hospital for postal workers. The group produced the No. 19 arthroscope, which was likely the model used to develop the first edition of the Atlas of Arthroscopy discussed below. In 1959, Watanabe and his colleagues developed the No. 21 arthroscope that would revolutionize the field.

In 1957, Watanabe had presented the group’s ongoing work on the arthroscope at the annual meeting of SICOT (Société Internationale de Chirurgie Orthopédique et de Traumatologie) in Barcelona. The session was attended by Dr. Ian Macnab (1921-1992), then Professor of Orthopaedic Surgery at the University of Toronto and Chief of the Orthopaedic service at the Wellesley Hospital. Several years later, when Dr. Robert W. Jackson, a younger colleague, was planning to depart for a scholarship-funded research trip to the University of Tokyo, Macnab recalled for him a vague memory of the Japanese work on Arthroscopy. He advised him to identify the Japanese surgeon and to seek him out (Jackson 2002, 41).

In 1964, Dr. Robert W. Jackson located Dr. Watanabe at Tokyo Teishin and learned about the group’s advances. He returned to his position at Toronto General Hospital with a No. 21 arthroscope and became one of the instrument’s earliest promoters outside of Japan.

In 1966, he was joined by Watanabe’s colleague Dr. Isao Abe, who came to Toronto as a research fellow. Abe assisted him in conducting the first extensive clinical study demonstrating the instrument’s efficacy. (See Jackson and Abe, 1972.) Abe was a major factor in the success of this work. Robert Jackson noted the following in a 2002 interview:

“Fortunately, Abe had spent some time with Watanabe. When I got into trouble with a case, he would say, “Ah so, Just a moment.” I’d be getting frustrated, and he would calm me down and clear the field so that we could see through the scope again. Abe had a lot to do with my success. I might have quit if he hadn’t joined me at that point.” (Jackson and Roberts 2002, 177)

However, the system also had important limitations. The illuminator gave off heat and was fragile. With the offset illuminator, the instrument’s “double barrelled”  tip was quite broad. The arthroscopes could not be autoclaved. Sterilization required a formalin gas chamber. A broken instrument had to be sent to Japan for repair. 

A photograph from the early textbook on arthroscopy published by Robert W. Jackson and David J. Dandy in 1976. It shows the broad tip of the forward-looking Watanabe 21 scope with its halogen bulb adjacent to the lens. They note that the stepped/ offset light could be used to manipulate in some cases (Jackson and Dandy 1976, 15).

Such limitations were addressed by Watanabe’s team, which developed the Watanabe 22 scope with fibreoptic illumination, as well as a series of narrow “Selfloc” arthroscopes. However, with the success of the Watanabe 21, incumbent endoscope manufacturers soon entered the field. These manufacturers had many advantages including access to important patents (notably the Hopkins rod lens system) as well as experience making autoclavable instruments.

Dr. Watanabe’s dedication on the inside cover of the first edition Atlas.

Although photographs and film had been recorded through the arthroscopes in Japan as early as 1932, these were presumably of insufficient quality for publication. For this reason, this first edition of the atlas features 68 paintings created by Mr. Shinichiro Fujihashi, an artist specializing in endoscopy. Below are a series of Fujihashi’s paintings depicting osteoarthritis.

Published photographes taken using the Watanabe 21 arthroscope became a standard means of representing arthroscopy in its early years. A second edition of Watanabe’s atlas, which featured such photographs, was published in 1969. The third edition was published in 1978.

Photographs and accompanying illustrations from the third edition of Watanabe’s atlas. (Watanabe 1978, 111)

A listing of equipment from an early sales pamphlet. This list does not include a few additional components that were then available, such as the 90° teaching attachment and a formalin gas chamber for sterilizing the arthroscope.

These sets were distributed by Professional Orthopaedic Supplies Ltd. based in the Toronto suburb of Rexdale. It was likely the first North American distributor of Watanabe equipment. Dr. Jackson was probably involved in brokering this arrangement. The details of that process may be available among Dr. Jackson’s papers at Library and Archives Canada.