Advances in Shoulder Arthroscopy
Arthroscopic surgery has arguably been the biggest Orthopaedic advancement in the last century. It affects people of all ages. Total joint replacement may be more dramatic, but arthroscopy has a greater effect on more people. The reduction of peri-operative morbidity and pain with faster rehabilitation are undisputed. Medical endoscopy began in the early 1800s by Bozzini. In 1918, Prof Kenji Takagi of Tokyo University did the first arthroscopy on a cadaver knee with a cystoscope. In the 1950s Dr. Masaki Watanabe, a former student of Takagi, began to make several major contributions to the field of arthroscopy. He advanced the technology of arthroscopes to functional and useable scopes specifically for the examination of joints and, along with his colleagues, published the first edition of the "Atlas of Arthroscopy". At the same time Dr Eugene Bircher in the USA was the first to use the arthroscope on live patients in the USA and publish on arthroscopic technique and results. During the 1980s technology had improved enough for the technique to be used for surgery. The use of the arthroscope in joint surgery was a major revelation that spurred many new instruments and techniques to be developed. The shoulder and knee joints have benefited the most from arthroscopy so far. Anatomical variants (e.g. Biceps anomalies, Buford complex) were described and pathological findings, previously undiagnosed were described (e.g. SLAP lesions, PASTA lesions). In fact the understanding of shoulder disorders and treatment has advanced significantly in the last ten years as a result of arthroscopy. The ingenuity in instrument technology and design has assisted the progress of techniques and procedures such as subacromial decompression and Bankart repairs are being done routinely arthroscopically now. Advanced arthroscopists have developed techniques for arthroscopic Weaver-Dunn procedures, Bone graft procedures and fracture fixation. The training curve for arthroscopic surgery is also shortened by the increase in experienced arthroscopists, training simulators and models and a new generation of keen trainees brought up on computer games. Considering all these advances, one must ask what we will be doing in ten years from now. Bearing in mind the innovative minds of surgeons and the ingenuity of industry anything is possible. Arthroscopic polymer resurfacing joint replacement and office needle arthroscopy developed are currently being trialled. Genetically engineered rotator cuff inserted via the arthroscope, Virtual arthroscopy, microbots and computer assisted surgery are already in development. Nanobots with 3-D sensors and instruments inserted and controlled through the arthroscope may not be just science fiction. This lecture will cover the past, present and future advances of shoulder arthroscopy.
Advances in Arthroscopic Shoulder Surgery
Lennard Funk, Asia Pacific Orthopaedic Association, Kuala Lumpur, 2004
The arthroscope, derived from Greek roots meaning "to look at joints". The arthritis society has called it "an everyday miracle that keeps getting better".
Arthroscopic surgery has arguably been the biggest Orthopaedic advancement in the last century. It affects people of all ages. The reduction of peri-operative morbidity and pain with faster rehabilitation are undisputed.
In 1806 Philip Bozzini built an instrument that could be introduced in the human body to visualize the internal organs. He called this instrument "LICHTLEITER". Bozzini has been credited to be the inventor of the first endoscope, however it was never tested in humans . It used a candle as the source of light. At that time people did not understand this procedure and he was reviewed by the medical faculty of Vienna and punished for his "curiosity".
Bozzini & his Leichleiter
The next major advancement in endoscopic surgery should be attributed to Thomas Edison, who invented the incandescent light bulb in 1879. Along with developments in the field of optics it now could be possible to develop useful endoscopic surgery.
This laid the foundation for the real pioneers in arthroscopy, Professor Kenji Takagi and Eugene Bircher, who at the same time proved that arthroscopy could be of clinical use. Professor Takagi performed the first successful arthroscopy of the human cadaver knee with a cystoscope at the Tokyo University, Japan, in 1918. Takagi saw arthroscopy as a tool to diagnose tuberculosis in its early stages and treat it before it caused major problems. In 1919, one year after Takagi's first procedure was performed, Dr. Eugene Bircher, in Switzerland, became the first to use arthroscopy on live patients. He examined the knees of 21 patients with osteoarthritis using a Jacobeous laparoscope. In 1922, Bircher was the first to publish results on arthroscopy which he called "arthroendoscopy."
Prof Kenji Takagi
The arthroscope remained a curiosity until Dr. Masaki Watanabe, a former student of Takagi, began to make several major contributions to the field of arthroscopy. Dr. Watanabe made many improvements to the design of the arthroscope. He was the first to performarthroscopic partial meniscectomy, along with numerous other procedures. In 1957, Watanabe and colleagues published the first "Atlas of Arthroscopy", which is still available. Dr Watanabe advanced the technology of the arthroscopes, producing a range of scopes with different viewing angles and sizes. He was the first to apply fibre-optic technology as soon as it was available. The basic knee and shoulder scope we use today is based on the Watanbe No. 21 arthroscope.
During the 1980s technology had improved enough for the technique to be used for surgery. The use of the arthroscope in joint surgery was a major revelation that spurred many new instruments and techniques to be developed. Initially most of the work was on the knee, but many surgeons saw it's use in the shoulder and began to apply it in the 1980's. During the 1990's the technolgy and surgical experience advanced significantly. Fluid pressure pumps, shavers, radiofrequency devices, instruments and implants were improving to the stage where we now are able to perform almost all shoulder surgery arthroscopically.
TAG Shoulder Arthroscopy Instruments
Shoulder arthroscopy has not only provided us a new surgical tool, but also a greater understanding of shoulder injuries and diseases. New lesions, which were previously undiagnosed, have been detailed and classified. A good example is the SLAP lesion , described and classified by Steve Snyder in the USA in the early 1990's. We also understand normal anatomical variants better, such as the Buford complex, Biceps variants etc. The understanding of sports shoulder injuries has advanced, along with improved treatments for these patients.
In addition to the technological advances, surgeons have had to learn new skills. The ability to manually manipulate your instruments whilst looking at a two dimensional monitor is completely foreign to most surgeons trained and experienced in open surgery. The learning curve has been tough for surgeons. However, arthroscopy does lend itself to simulation training. Models, such as the 'Alex' shoulder model has given surgeons the ability to practice new techniques before applying them to live patients. Surgeons in training are now being taught the skills of arthroscopy, whist growing up on 3D computer games, which require similar basic skills. Their learning curve is much reduced. They will go on to advance techniques even further.
Training on the 'Alex' model
The future of arthroscopic surgery probably relies on advances in both technology and biology. Tissue engineering is already here and being used for cartiledge surgery. Tendon and muscle tissue engineering is possible and there are numerous research studies ongoing. It is highly likely that arthroscopy will be the approach to inserting these engineered tissues in the near future.
Advances in the arthroscope technology with micro-electronics, has resulted in the development of needle arthroscopes. These are scopes the size of an 18 guage needle. Therefore the procedure can be performed in the clinic (office) under local anaesthetic. Patients can see their pathology and treatment can be discussed and planned, without the inconvenience of further investigations.
Currently almost all shoulder surgery can be done arthroscopically, except for shoulder replacements. However, arthroscopic polymer resurfacing is already being trialled and is opening the way for advances in arthroscopic joint replacements.
In the future there may be no need for any surgical scar at all and surgery could be performed within a joint without penetrating the skin. Science fiction? Not really. Theoretically combining technologies already in development consider the joint replacement with a single needle:
Through a single needle injection into the shoulder joint nanobots are inserted into the shoulder joint. Nanobots are carbon-based robots less than 100 nanometers in size, invisible to the human eye. Some nanobots have cameras, allowing us to watch and manipulate the worker nanobots. These nanobots manipulate the molecules of injected ethylene monomer, placing them into the damaged regions of the joint. The freshly applied monomer is then irradiated by a tiny gamma emitter embedded within the nanobot. This begins free radical polymerization, joining the monomers together to form high-density polyethylene. The damaged articular surface is now "patched" with a nonreactive biocompatible compound that is strong and flexible. The nanobots, having completed their task, are then eliminated by the body's lymph system within several days. This may not be as far in the future as one might imagine. nanotechnologists are able to manipulate individual atoms and have already created working nanobots and nanotubes to transport the nanobots. It is only a matter of time.
Nanobots injected through needle
Driller Nanobots working on Red Blood Cells