ISAKOS Storytellers

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 20^th 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.

Regards,

Mervyn J Cross OAM MD MBBS FRACS