The discovery of anaesthesia and the introduction of antiseptic principles in the 19th century together with the discovery of antibiotics in the early part of the 1940's have revolutionised knee surgery and provided a platform from which new surgical procedures are developed almost every day. Whilst open knee surgery has a long history spanning almost 2000 years, arthroscopy, or keyhole surgery is a rather new invention first discovered in the early part of the 20th century. Eugen Bircher, an ambitious Swiss surgeon pioneered arthroscopy. He used an altered cystoscopy for his initial attempt to look into cadaver knees before trying this new technique on humans. In 1922 he published his first experience with this new technique and concluded 'Arthroscopy is superior to all other methods of investigation and, like endoscopy of the bladder, can be used to define certain indications for surgery. It will be met with resistance but will gain in popularity and develop to the point at which it becomes indispensable'.

Dr Eugen Bircher, a Swiss surgeon is not only remembered through his pioneering role in the development of knee arthroscopy, but also because of his interest in knee injuries on which he published one of the first monographs in 1929

When Bircher performed arthroscopies, they were conducted without the luxury of a camera or monitor, making visualisation extremely difficult. Thereupon the technique was purely diagnostic and when a problem was discovered inside the knee, it was necessary to open the joint. Due to the technical requirements and limitations, arthroscopy did not receive worldwide appreciation and was more or less forgotten for over 50 years. Whilst Bircher discarded arthroscopy in favour of arthrography and later gave up surgery altogether Kenji Takagi in Japan continued to experiment. Together with Masaki Watanabe he was able to significantly improve arthroscopic instrumentation. However, it was not until Bob Jackson an American surgeon, visited Japan in 1968, that the idea of knee arthroscopy received a world wide resurgence. Many surgeons have since learned from Bob Jackson by visiting his institution and have subsequently popularised arthroscopy globally.

 A diagnostic arthroscopy performed by Bircher in Switzerland in the 1920s. Camera attachments, as seen on the right, did not become available until the mid 1980s requiring the surgeon to look directly through the scope, which was awkward and did not allow operative procedures to be performed. Modern arthroscopy equipment provides a blood free knee through pressure pumps and significant magnification of the internal knee structures through a linked video system.

Modern arthroscopy utilising autoclavable cameras and high-resolution monitor systems have further enhanced the technical abilities of this technique allowing us to perform a large number of procedures including ligament reconstructions and meniscal surgery through a 'key-hole'.