Arthroscopy emerged as a largely diagnostic process. The instruments of the Watanabe Type 21 set included a few rudimentary surgical tools, notably biopsy punch forceps meant for use in the diagnosis of arthritic knees. Nevertheless, new tools and techniques quickly emerged that would open the way to arthroscopic surgery and joints beyond the knee.
Dr. Jackson experienced, and contributed to, this developmental process. His collection provides a valuable record of this technological evolution. A few such instruments from Dr. Robert W. Jackson’s collection are shown here.
This theme is part of Documenting the History of Orthopedics: Dr. Robert W. Jackson’s Collection.
The O’Connor Operating Arthroscope, manufactured by Wolf, in use. (O’Connor and Shahriaree 1984, 115)
More Information
In 1962, Dr. Masaki Watanabe (1911-1995) performed the first arthroscopic meniscus resection, an episode cited as a landmark in the emergence of arthroscopic surgery (Jackson and Roberts 2002, 177). As arthroscopic techniques evolved, existing surgical tools were imported from other disciplines. For instance, the nerve hook was adopted as an all purpose probe, often described as the arthroscopist’s finger. In a 2002 interview, Dr. Jackson recounted a further example example:
One early surgical tool called a ‘basket’ forceps was adapted from cytoscopic surgery where every bit of tissue removed from the prostate had to be preserved for histological examination. Therefore, these instruments had wire baskets in the lower jaw of the cutting mechanism to collect the tissue fragments. The basket concept, however, proved disadvantageous in arthroscopy as the wires would break and, when debriding large amounts of articular cartilage, it was a nuisance to take the arthroscope [sic.] out of the joint to empty the basket after each bite. It became common technique to let the fragments float free, then flush them out of the joint or extract them using suction from the joint at the end of the procedure. (Jackson 2002, 42).
Basket forceps with lateral wires in the Jackson collection. (This item is not yet catalogued.)
Arthroscopic surgeons also developed new tools of their own. These included so-called “operative” arthroscopes that added a channel for a tool such that the tool tip would remain easily in view. Specialized arthroscopes for small joints, rotary tools to facilitate cutting and debriding, and sterile packaged consumables were added to the growing market. Some of these technologies remain in use. Others do not.
The late 1970s and 1980s saw the spread of arthroscopic techniques and technologies that established current norms. These include the triangulation process to orient the scope and tools using multiple portals, the use of probes, the use of CCD cameras and video monitors, the emergence of motorized tools, and the use of models for training. Many, no doubt, contributed to this process, though the teaching and demonstration work of Utah-based Professor of Orthopaedic Surgeon Robert W. Metcalf is given special mention (Johnson 1986, 9).
The O’Connor Operative Arthroscope (c. 1970s)
The O’Connor operative arthroscope was the first of several similar instruments that emerged during the early 1970s. These were attempts to modify the arthroscope with a port to allow surgical tools to be used within direct view of the operator. The O’Connor scope was designed to facilitate meniscectomies (O’Connor and Shahriaree 1984, 4).
The trend toward such operative instruments lasted about a decade. By that point, the skill of triangulating the position of lens and tool, applied through the double puncture technique, was becoming standard practice. This was also made possible by the increasing use of video in the operating room.
More Information
The O’Connor Operative (also called “Operating”) Arthroscope was invented by Dr. Richard L. O’Connor in 1974. His design, developed in collaboration with the Wolf Manufacturing Company of Germany, featured an offset eyepiece and a 3 mm port (later enlarged to 3.4 mm) channel into which specially designed tools could be inserted. The design was in the prototype phase in 1976 and was likely first produced shortly after that. The original instruments had a 3 mm channel.
The O’Connor scope with two specially adapted narrow forceps. Forceps are not yet catalogued.
This arrangement had obvious advantages. A single incision would accommodate both the surgical tools and the arthroscope while the surgeon could easily manage both. The tool tip was always in view. On the other hand, the port reduced the amount of fibre optic illumination on the arthroscope’s tip. The hollow channel resulted in a relatively wide instrument that could use only very narrow tools.
A close view of the tip of the O’Connor scope with a cutting tool in place. Below the channel for the tool is the lens with fibre optic ports on either side.
The Storz Operative Arthroscope (c. 1970s)
This Storz arthroscope is an example of an operative instrument that followed the O’Connor arthroscope. It was likely adapted, in part, from existing cytoscope designs. The centimetre markings on the barrel are a clue to this origin. This instrument is a good representation of incumbent endoscope manufacturers entering the growing market for arthroscopic equipment.
More Information
The 45° angle of the eyepiece relative to the operating angle proved disorienting to some. This model was later updated to reposition the eyepiece at the operating angle. This updated version had a horizontal offset like the O’Connor and Eder operating arthroscopes.
Instruments like the Storz and O’Connor/ Wolf arthroscope represent an early point in the entry of the incumbent endoscope manufacturers into the arthroscope market. Such instruments had advantages over the earlier Watanabe Type 21 arthroscopes, including the fact that they were autoclavable and featured fibre optic illumination
A close view of the tip of the Storz operative scope with a grasping tool in place. Below the channel for the tool is the lens with fibre optic ports on either side.
The Dyonics Needlescope (c. 1970s)
Introduced in 1973, the Needlescope from Dyonics, Inc. of Woburn, Mass. had a very narrow lens of either 1.7 mm or 2.2 mm outside diameter. It gained a wide following among North American arthroscopists.
This instrument shared a common origin with the groundbreaking Watanabe Type 21 arthroscope, which is described elsewhere in this exhibit. With the success of that earlier instrument in the 1960s, Watanabe experimented extensively with ways to create a narrower instrument that could be used on joints other than the knee. The Dyonics Needlescopes are the most successful instruments to have used that technology.
More Information
The technology behind the Needlescope, which allowed for its very narrow diameter, originated in Japan. In 1968, the Selfoc (“self focussing”) material was developed developed jointly by the Nippon Sheet Glass Company of Osaka and the Nippon Electric Company in Tokyo. This was a GRIN (gradient-index) lens made for laser applications that allowed for excellent light transmission along a very narrow glass rod.
The Selfoc material proved ideally suited to the work of the orthopaedic research group led by Masake Watanabe at Tokyo Teishin Hospital. Following the success of their Type 21 arthrosope, the group began developing instruments that could be used in more constricted spaces and in narrower joints. They experimented with fibre optics, producing a No. 23 and No. 25 “fibrescope” in 1967 and 1968 respectively, but found the image quality unsatisfactory (Watanabe 1985, 5).
When Selfoc became available, the group used it to develop the first Type 24 Selfoc arthroscope in 1970. After initial models proved insufficiently bright, the instrument’s optics were further refined in collaboration with Olympus Optical to produce the “Selfoscope” in 1974. The Selfoscope was available in two diameters, 1.7 mm and 2.4 mm. The difference lay in the thickness of the layer fibre optic light transmitting material that surrounded the 1 mm diameter Selfoc rod. Unfortunately, the Jackson collection does not include an example of the Type 24 or its accessories. The technology may not have been easily available outside of Japan. (Watanabe 1985, 7-8).
(Above) A photograph of the Type 24 Selfoscope and its accessories. (Below) A diagram of the optical system of the Type 24. (Watanabe 1985, 10, 11)
The precise relationship between the Type 24 and the Dyonics Needlescope is somewhat unclear beyond the fact that the Needlescope was based on the Selfoc technology. The third edition of Watanabe’s Atlas of Arthroscopy, published in 1978, notes curtly that “This Selfoc-Arthroscope is being distributed under the brand name Needlescope in the United States by the Dyonics Company” (Watababe, Takeda and Ikeuchi, 1978. 25). Watanabe’s 1985 texbook, Arthroscopy of Small Joints, which was the culmination of the group’s work on small joint arthroscopy, does not mention the Needlescope at all.
American texts, especially those by Dr. Lanny Johnson of Lansing Michigan, offer more detail on the Needlescope. Johnson promoted the instrument and appears to have played a significant role in its development. According to Johnson, the Type 24 was introduced to North America in 1972 by a Mr. Leonard Bonnell and first used clinically by Drs. Clement Sledge and J. Drennan at the Robert Brigham Hospital in Boston. Johnson notes that “After viewing the technique, Mr. Harold Neumann assessed the uses and the requirements for a small-diameter endoscope…”, but does not offer much further detail on process of its development.
Johnson notes that the Needlescope was progressively refined after initial versions became available after 1972. (The two examples in the Jackson collection are the third Needlescope model introduced in 1976.) As happened in Japan, the optical arrangement was refined after early models were found to be insufficiently bright. We might surmise that Dyonics imported the Selfoscope technology at a relatively early stage, after which Japanese and American instruments subsequently evolved independently.
As it happened, the Needlescope was the more successful of the two instruments, though this wasn’t due to the small joint applications that the Selfoc arthroscope was initially designed for. The Needlescope enjoyed a period of popularity as a less invasive means of inspecting the knee under local anaesthesia. However, by the late 1970s, the market for narrower instruments was moving towards small-diameter, rod lens-based arthroscopes. These produced a substantially brighter image that was better suited to the video displays that were increasingly used to guide arthroscopic operations. Selfoc-based instruments retained a limited niche in small joint operations (Johnson 1986, 181).
A significant drawback to the Selfoc arthroscopes was their fragility. The Jackson collection includes a broken example with a bent tip. Though its probably impossible to know how this damage took place, we might guess that Dr. Jackson kept this damaged instrument as a representation of the technology’s limitations.
Hall Arthrotomes (c. 1980s)
The Hall Arthrotome was likely introduced in the mid-1980s, part of an early generation of motorized instruments adapted to arthroscopy. These, along with a growing number of interchangeable blades, greatly facilitated the development of arthroscopic surgical technique.
There are several similar Hall motorized instruments in the Jackson Collection. One was a cutaway instrument, likely created for a commercial display. The other was a standard instrument that has been customized with Jackson’s signature. Such instruments probably indicate that Jackson was a consulting surgeon involved in the development of the system.
More Information
A close view of the cutaway Hall arthrotome.
The first motorized instrument for arthroscopy, the Intra-articular Shaver System, was developed by orthopaedic surgeon Lanny L. Johnson and and engineer Leonard Bonnell in 1976. It was introduced by Dyonics, Inc. in 1978 (Johnson 1986, 6).
The Dyonics Intra-Articular Shaver System pioneered a number of features that would become standard on arthroscopic motorized rotary tools including the various Hall arthrotomes. These included a quick release blade and a suction system for removing resected tissue from the joint (Johnson 1986, 226).
Documenting the History of Orthopaedics: Bibliography and Sources