In 1973, I was appointed as a fellow to Dr Jack Hughston in Columbus Georgia. Arriving on the same day were Lyle Norwood [resident] and Jim Andrews[new partner returning from a fellowship with Albert Trillat].
Dr Hughston asked me what we needed for research and I told him we needed a bio-engineer. Within a week, Bill McLeod arrived from Georgia Tech. My first project was to establish the 3-D centre of rotation of the knee. I was to focus most of the research on the knee, especially the ligaments and their function.
We acquired fresh frozen specimens from Grady Hospital in Atlanta and did dissection and ligament studies. Many papers were the result of this work including the defining of the ACL bundles and the mechanism and function of the ACL.
Dr Hughston was invited that year to speak in Holland and he made many European contacts. The American Academy was held in Las Vegas that year and Dr Trillait could not come, so Dr Hughston asked me to come and I was able to use Dr Trillait’s suite as it had been paid for. The first night I was invited to Dr Hughston’s suite for pre-dinner drinks. In the room were the doyens of knee surgery, Dr O’Donoghue, Dr Slocum, Dr Ian Smillee, Dr Jim Nicholas as well as Dr Joe Godfrey the doctor for the Buffalo Bills, O J Simpsons team.
There was not a great deal of communication internationally, orthopedically, in those days for many reasons. Some countries had trauma surgeons separate from Orthopaedics. The language was also a great deterrent as well as fixed and conservative ideas. Large professorial departments controlled the thinking and research was not as common as today. Orthopaedics was on the brink of a technological revolution in 1973. It was necessary to blend great minds from all countries to benefit from these advances. Ideas needed to be tested in the clinic, in the operating room and in the laboratory, and communication was to be the key.
The idea of an International Knee Society was brewing and after diplomatic discussions in many quarters, it appeared that it could work. It was necessary to gain support initially from the American Knee surgeons led by Dr Hughston. Super-specialisation was just beginning and the American Orthopaedic Society for Sports Medicine was in its infancy. The knee surgeons taught and practised thorough clinical examination and surgery based on these findings. As the knee is injured both dramatically and commonly it became a large topic for research and discussion. I strongly supported the movement to widen the horizons of experience. For example, a Spanish surgeon presented “interposition skin arthroplasty for Arthritis”.
In 1973, a Sports Medicine meeting was held in Eugene chaired by Don Slocum. At this meeting, Bob Jackson presented his work and experience with the arthroscope. Arthroscopy was reported in the JBJS in 1936 by Watanabe.It was thought purely to be a diagnostic device in the early days. Like all advances, the American Arthroscopy Association was formed in 1981. This brought many minds together and soon we were performing arthroscopic surgery. The early instruments were based on cystoscopies with instruments sliding down the side of the telescope and were thus useless. Further instruments were developed and operative arthroscopy rapidly became common place. There was initial hesitance among “the establishment” regarding arthroscopy as they thought the clinical diagnosis would become a lost art.
Initially, it was important to have a society devoted to arthroscopy as this was a new and controversial technique and needed many minds to advance its role. By the time it came to join with the knee society, in 1995, it had outlived its usefulness, and ironically joining with the knee society has been shown to be a useless exercise. This is emphasised by the successive Presidents of ISAKOS; all being Knee surgeons.!!!!!!!!!!!!!!!!
As super specialisation leapt ahead particularly with the approval of knee replacement by the Americans[FDA] there became three groups, the Arthroscopists, the Knee replacers and the Sports Medicine Knee surgeons. There were three distinct groups, the arthroplasty, arthroscopic and sports medicine knee surgeons.
The initial idea for the IKS was to encompass all aspects of knee surgery, including arthroscopy, arthroplasty, and ligament surgery as well all other aspects.
The first International Knee meeting was held in Rome in 1977, the first President was Dr Don O’Donoghue and there were many Europeans, Americans, Australians, Asians and many others. This meeting really determined the feasibility of this new society. It was a success and subsequent meetings were held in Lyon, Scotland, USA, Australia, Italy, Canada, Denmark and eventually the last meeting in Hong Kong.
At the meeting in Copenhagen in 1993, we were approached by the International Arthroscopy association to form a combined society, ISAKOS. Being on the board of ISK, I strongly rejected the idea as I felt that the arthroscope was just a tool that surgeons used and needed. This would complicate future meetings with respect to the scientific program and there would be meetings of other joints. Why not form an International society of the scalpel.
An argument was put forward that our funds were depleted and the International Arthroscopy were flushed with funds. I discussed this situation with Hugh Tullos who could not convince me that we were in financial difficulties and, therefore, there was no reason to amalgamate. I could not accept this and Dr Neil Thomson and I spoke against amalgamation at the annual meeting in Copenhagen. It was decided to postpone the decision to the next meeting which was held in Hong Kong.
As there were not many surgeons doing all three, the groups remained distinct. The Arthroplasty Society developed from the Hip society and, unfortunately, there was not enough input from the knee surgeons into the designs of Total Knees.
Contemplating the IKS’s programme in Sydney 1987. A five-day meeting was evenly divided, with arthroplasty on Monday, Tuesday was devoted to basic science, ligament injuries and tumours. Wednesday was devoted to the ACL with reference to artificial ligaments. Thursday was devoted to meniscal injuries, repair, cartilage lesions and clinical signs. Friday was devoted to the patella-femoral joint. By this time, the majority of knee surgeons were competent with arthroscopic procedures.
Arthroscopy was being applied to many other joints at this time. The arthroscopic society decided to hold their meetings at the same time as the ISK, thus piggy-backing the IKS’s meeting, because many surgeons belonged to both societies. I could not understand how combining with shoulder, elbow, wrist and hip surgeons could possibly be of benefit to our society.
Arthroscopy has now simply become an instrument, much like a scalpel, and is used in all aspects of Orthopaedics and is not relevant to the knee as something needing further discussion or research. Each sub-specialty uses it, and I see no relevance to have such a society today.
Looking through the past Presidents of ISAKOS, there are few if any from a specialty other than the Knee. National meetings are the place for the different specialties to come together, not being tagged onto an International Knee meeting.
It would be interesting to check the registration of the 20th Anniversary to see the ratio of Knee surgeons to all other “arthroscopists”.
ISAKOS has taken over the role of ISK and I predict that it will infold and the number of other “arthroscopic surgeons” will separate to their own disciplines.
Mervyn J Cross OAM MD MBBS FRACS
Combined Congress of the International Arthroscopy Association and the International Society of the Knee
June 25-30, 1993
During the IAA congress, we had a meeting.
Before the meeting, I had the opportunity to greet Dr. Aleandro Ranalletta and Rodolfo Carpignano of Buenos Aires.
During the final part of the 1st meeting, our president, Dr. David Marshall, said 6 times that “in 1995 we will go to Hong Kong” and that it would be organized by K.M. Chan. He asked, “for 1997, what ideas do you have?” I proposed Buenos Aires, the capital of Argentina. To this, the directive members and Dr. David Marshall himself, froze and started asking questions like:
- Can Arthroscopy surgeries be performed?
- Do they have Sports Medicine clinics?
I replied to all of their queries and after that, the President declared the 1st meeting finished.
Outside of the meeting, I met Dr. A. Ranalletta and R. Carpignano—I invited them to join me at a nearby bar, and I told them:
“In 1997, you both need to organize the meeting because in 1995 they will go to Hong Kong.”
They replied with a scared tone: “Ramon, you’re crazy, we can’t do this,” and I replied, “This is the opportunity for all Latin America—don’t worry, I’ll help you out with this”.
They stayed for a long time thinking and trying to digest the news.
After that, that same afternoon, I told them to go to the Argentinian Embassy in Copenhagen and ask for three dossiers with completed information on:
- Congress Centers
- Airports and Connections
- Cost of Living
- Excursions- Waterfalls- Patagonia, etc.
The three dossiers were for:
- Dr. David Marshall - IAA
- Dr. Ian Gillquist - ISK
- Dr. Bertram Zarins - the person that related us to the directives of both ISK and IAA
From the 1st meeting to the 2nd of the IAA directive, B. Zarins, R. Carpignano, A. Ranalletta and R. Cugat started to work to publicize Buenos Aires, Argentina and the rest of the continent.
In the second IAA directive meeting, I handed the Argentina dossier to Dr. David Marshall, where everyone participated—Argentina was not a well known continent and no one knew how the adventure proposed by R. Cugat would end.
The directive decided to give a vote of confidence to such a proposal and the Argentinian commission presented the candidature in 1995 during the Hong Kong Congress.
After the Combined Congress in Hong Kong, Buenos Aires, Argentina was voted as the 1997 Congress venue. The Organizing committee started their hard work organizing not only the Congress, but the venue to show Buenos Aires as a great city. The Congress chairman, Terry Whipple, along with R. Cugat and the Argentinian members, all worked together to make it happen.
Additions to the history of the IAA
David Dandy, October 2015
In Europe, the first International Course was organised by Professor Theo van Rens at the University of Nijmegen in 1977.
The Faculty included RW Jackson, Jack McGinty, Bob Eilert from Denver, Harold Eikelaar and David Dandy.
In 1978, Ejnar Eriksson of the Karolinska Institute arranged a course in Skovde, Sweden, with a faculty that included RW Jackson, Dick O’Connor and David Dandy.
The first British course on arthroscopy was organised by Professor Brian O’Connor at the Robert Jones and Agnes Hunt Memorial Hospital in Oswestry in 1979.
IAA and the International Society of the Knee (ISK)
The ISK was founded in 1977 to embrace the interest of surgeons who did not then practise arthroscopy. The first informal discussions on the combination of the ISK and IAA took place at an IAA course held at the Southampton Princess Hotel in Bermuda in April 1981.
In 1984 Ken de Haven and David Dandy were elected as second Vice Presidents of the ISK and IAA respectively and considered how this might be achieved. Both recognised the practical difficulties involved and the need for a gradual approach. In 1987, the two organisations held their congresses on successive days in Sydney and again in Rome in 1989. In 1991, in Toronto, there was a shared day.
The two Congresses were held simultaneously as a combined meeting in Copenhagen in 1993, with Ken deHaven and David Dandy as Presidents. Both associations separately took the decision to amalgamate and formed an Integration Committee to achieve this.
Three difficulties we encountered in the final stages of integration. First, the IAA was constituted in the Commonwealth of Pennsylvania and the ISK in the state of Illinois. Both were not-for-profit organisations and would have been required to relinquish all their assets to the state on their dissolution. The laws of Illinois allowed a not-for-profit organisation to transfer its assets to another but in Pennsylvania, this was not permitted. The assets of the ISK were therefore transferred to the IAA which then changed its name to ISAKOS. ISAKOS is still constituted in Pennsylvania, retaining a link with the formation of the IAA in Philadelphia in 1974 and the original 1973 arthroscopy course.
The second difficulty was the emergence of a European group anxious to form a completely separate international body dedicated to sports medicine. It was felt this would lead to disunity and the draft rules of ISAKOS were amended to include orthopaedic sports medicine and make a third body unnecessary.
The third concern was to find a name with an acronym that had no unfortunate meaning in any language. ISAKOS was the result but was felt to be so clumsy that it would quickly be changed, a prediction that proved to be incorrect.
History of arthroscopy, from Japan to the world
Midori Oshida, MD, PhD, Yuki Kato, MD, PhD
Maximilian Carl-Friedrich Nitze (1848-1906) designed the modern cystoscope,
providing a foundation for urology. In 1877, he developed the first practical cystoscope,
which progressed with the use of a midget lamp in 1887, based on the invention of
incandescent bulb by Thomas Edison in 1879.
In 1918, Kenji Takagi (1889-1963), who was a professor at Tokyo University,
developed arthroscopy, because he realized with surprise that the cystoscope even
made it possible to clearly observe the inside of cadaveric knee joints. In 1931, he
developed Takagi No. 1 Arthroscopy, with a diameter of 3.5 mm. The arthroscopic
synovium biopsy became useful as a non-invasive method for early diagnosis of
tuberculous arthritis or rheumatoid arthritis.
Dr. Takagi's work was continued by Dr. Masaki Watanabe (1911-1994), who is
considered the father of modern arthroscopic surgery. Dr. Watanabe's major studies
began to be carried out when he started to work at the Tokyo Teishin Hospital in 1949.
His associates, Dr. Sakae Takeda (1921-1998) and Dr. Hiroshi Ikeuchi (1924-2010),
collaborated with him on many investigations and papers, and their work is noteworthy
insofar as they published three “atlases of arthroscopy” during the pioneering phase of
In 1957, Dr. Watanabe traveled to European countries and the United States for the
purpose of the introduction of the practical nature of Japanese arthroscopy. His main
purpose was participation in the SICOT (International Society of Orthopaedic Surgery
and Traumatology) meeting in Barcelona, Spain. He introduced Japanese arthroscopy for
the first time, using a prepared short movie and an atlas of arthroscopy. During his
three months of travel, he visited many hospitals in Germany, France, the UK, and the
In 1959, Dr. Watanabe developed Watanabe No. 21 Arthroscopy. Starting in the
1960s, Tokyo Teishin Hospital welcomed many doctors from all over the world, including
Robert Jackson (Canada), Richard L O’Conner (USA), and Henri Dorfman (France). After
that, those doctors introduced Watanabe No. 21 arthroscopy to their own countries.
In 1974, the first meeting of the International Arthroscopy Association (IAA) was
held in Philadelphia. ISAKOS was formed by the merger of the IAA and the
International Society of the Knee (ISK) in 1995 at the IAA and ISK Combined Congress
in Hong Kong. In 1975, Dr. Ikeuchi reported the first case of arthroscopic meniscectomy
for complete discoid lateral meniscus at the second meeting of the IAA. After that,
arthroscopic surgery spread extensively.
In 1998, Dr. Ikeuchi, Tokyo Teishin Hospital Dept. Chief, held the first meeting of
the Ikeuchi International Society for Arthroscopy & Musculoskeletal Endoscopy (ISFA
& ME) in Okinawa, Japan. Even though it was a private meeting, twenty-two
arthroscopists (*) came from around the world. In 2005, the fifth Meeting of “ISFA &
ME” was held in Barcelona. It was organized by Dr. Ramon Cugat Bertomeu. This was an
unforgettable international meeting of arthroscopy, because the doctors enjoyed the
beautiful architecture from Gaudi and the delicious Spanish food and wine, not to
mention the heated discussion at the meeting.
Dr. Ikeuchi revealed the importance of international exchange. He was a mentor to
many young doctors. He died in 2010, but his image is still fresh in our minds.
(*) Robert W. Jackson (US), Grady L. Jeter (US), James H. Garner (US), Marco M.
Amatuzzi (Brazil), Ramon Bertomeu Cugat (Spain), Henri Dorfmann (France), Jacques P.
Laboureau (France), Vatanachai Rojvanit (Thailand), Jin Hwan Ahn (South Korea), Qi
Jianhong (China), Xue Qingyun (China), Leu Hansjorg F. (Switzerland), Christopher
Kieser (Switzerland), Gert Kristensen (Denmark), Mahumut N. Doral (Turkey), Wilfried
K Krudwig (Germany), Franz Landsiedl (Austria), Leonard Osti (Italy), Kiran P. Rijal
(Nepal), and Pravin H. Vora (India).
ISAKOS Played a Key Role in the Development of Wrist Arthroscopy
At the ISK meeting in Salzburg Austria on May 10th 1985
in the Winkler hotel at dinner we discovered that Dr. Terry Whipple from Richmond Virginia, Dr. James Roth from London Ontario Canada and Gary Poehling from Winston Salem had been in
various stages of applying arthroscopy to the wrist Joint. At that meeting we decided to work together and Jim Roth would lead on writing an article, Terry Whipple would develop a model
and Gary Poehling would organize a meeting which was held in January 1986. We reasoned that knee arthroscopy was so contentious when first introduced because the younger surgeons were
the primary advocates, and we wanted the acceptance to come from the more senior members so we had an invitation only meeting with primarily senior hand surgeons from the US.
This was a cadaver demonstration done by Terry Whipple which amazed the audience. After demonstrating the proximal and distal row anatomy he was challenged to see the distal
radial ulnar joint and without hesitation stated that he had never done that before but he couldn’t see why it could not be accomplished. We had a 1.8 mm scope available and
on the first try he had perfect visualization of the radioulnar joint and the undersurface of the TFC. We had all of this to be televised with both inside and outside views
which was a difficult feat at the time. The interest in Wrist Arthroscopy grew rapidly with better understanding of pathology and new treatment algorithms.
Historia de Sociedad Internacional de Artroscopia
Estimado Ramón, tal como conversamos en Lyon, te envío lo que he encontrado
con respecto a la IAAS y porque cuando fui a formarme en Japón en 1982 se
daba tanta importancia al Congreso de Hawái.
En 1978 Richard O`Connor realiza el primer Congreso de Cirugía Artroscopica,
en USA, luego se realizan tres cursos más en la UCLA, todos con gran éxito
por lo que se organiza el Primer Seminario Internacional de Artroscopia
Quirúrgica en Hawái en 1979. A este asistieron los japoneses. El segundo
se estaba organizando con la UCLA en 1980 pero Richard O`Connor fallece
el 29 de Octubre de 1980. Así la IAA organiza su primer curso de Cirugía
artroscopica a la semana siguiente de su muerte en Palm Beach y lo hace en
Honor a O`Connor. En ese tiempo O`Connor había popularizado el artroscopio
quirúrgico mientras Watanabe insistía en que con la triangulación no era
necesario este. Existen antecedentes sin embargo que Michael Harty y John
Joyce III organizan el primer curso de artroscopia en USA en 1973 en la U.
de Pensilvania, Filadelfia, el que se repitió en 1974 y al cierre de este
se formo la IAA con Watanabe como primer presidente, Jackson vicepresidente
y Cassells como secretario.. En Julio de 1975 se realiza el 2º Congreso de
la IAA en Copenhague. En 1975 la AAOS inicia cursos de Artroscopia y
Artrografia, liderados por John McGinty.
De todo lo anterior se entiende que la confusión radica en que el Congreso
de Hawái fue organizado como primer congreso de Artroscopia Quirúrgica ya
que la gran mayoría hacia artroscopias diagnosticas y O`Connor diseño
numerosas técnicas quirúrgicas artroscopicas.
Con mis saludos y recuerdos