HISTORICAL PAPER

Thomas Annandale: the first meniscus repair

Berardo Di Matteo • Vittorio Tarabella •

Giuseppe Filardo • Anna Vigano • Patrizia Tomba •

Maurilio Marcacci

Received: 26 January 2013 / Accepted: 25 March 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract A biographical insight about nineteenth century

Scottish surgeon Thomas Annandale (1838–1907),

describing his life and his milestone contribution to the

orthopaedics field, particularly analysing the first meniscus

repair in history, that Annandale performed in 1883 and

documented in his original paper titled ‘‘An Operation for

Displaced Semilunar Cartilage’’ (1885). The experience of

Annandale marks a shift in the treatment of meniscal

injuries, by introducing the practice of restoring and

repairing the original status of the tissue.

Keywords Meniscal repair � Meniscectomy � History of

medicine � Thomas Annandale

Introduction

Meniscal lesions are one of the most common orthopaedic

diseases, and their annual incidence can be estimated at

60–70 per 100,000 knees [11], in constant growth mainly

due to the increase in sport practice in all age groups.

Therefore, every day, orthopaedic practitioners face the

management of such lesions, whose treatment should never

be underestimated, because of the peculiar role played by

meniscal tissue in the maintenance of knee homoeostasis

and its fundamental contribution to congruency, stability,

load distribution, and shock absorption, as well as lubri-

cation and proprioception [9, 12, 16].

Approaching a meniscal lesion requires a careful eval-

uation: it is fundamental to understand that each treatment

should be tailored to the individual, specific patient and to

the overall status of the joint. At present, several options are

available: from ‘‘masterly’’ neglecting surgical approach

(i.e. conservative management) to meniscal resection,

meniscal suturing or even meniscal replacement by scaf-

folds or allografts. Each of these approaches has different

indications, and the right choice depends on the patient’s

intrinsic features, aetiology and comorbidities in the knee,

such as cartilage status and axial alignment [5]. Meniscal

treatment algorithms have changed markedly over time

[15], especially in recent years when new possibilities have

emerged after the introduction of meniscal allograft

replacement into clinical practice [7, 18] and, more

recently, bio-engineered meniscal scaffolds based on col-

lagen or polyurethane [6, 10, 14]. Furthermore, as for each

medical achievement, the way to reach such ambitious

goals has been quite long and it is the result of more than a

century-long evolution process. In medical history, there is

evidence of loose bodies removal from the knee joint since

1558, performed by Ambrose Pare [13]; after him, a number

of important surgeons have contributed to the development

of this orthopaedic field, especially from the twentieth

century onward. This paper focuses on the achievement of

Dr. Thomas Annandale, a Scottish surgeon who can be

considered the stage-setter of meniscal surgery [13, 15]: he

was the first to attempt and successfully perform a repair of

the meniscus in a way aimed at preserving its function and

structure, by carefully suturing back a displaced semilunar

cartilage (i.e. the meniscus) to its original position, thus

restoring the joint movements and opening the road to a new

surgical approach to manage meniscal injuries.

B. Di Matteo (&) � V. Tarabella � G. Filardo � M. Marcacci

Biomechanics Laboratory, Rizzoli Orthopaedic Institute,

Via di Barbiano n. 1/10, 40136 Bologna, Italy

e-mail: berardo.dimatteo@gmail.com

A. Vigano � P. Tomba

Donazione Putti, Biblioteche Scientifiche Istituto Ortopedico

Rizzoli, Rizzoli Orthopaedic Institute, Via Pupilli n. 1,

40136 Bologna, Italy

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-013-2490-3

Thomas Annandale

Thomas Annandale (Fig. 1) was born in Newcastle-on-

Tyne, UK, on 2nd November 1838, as the second son of

local surgeon Thomas Annandale sr. [8]: he was early

introduced to the medical practice by his father, and at the

age of 15, he had already started to assist him at the

Newcastle Infirmary where he learnt the basics of his

professional future. He then attended the University of

Edinburgh and graduated in 1860 with the highest honours,

winning the gold medal for his thesis on ‘‘The Injuries and

Diseases of the Hip-joint’’ [17].

The same year he became House Surgeon to the Edin-

burgh Royal Infirmary and a trainee under Professor James

Syme, chair of clinical surgery at Edinburgh University:

Annandale showed such talent and quality that Syme

appointed him as his personal assistant until his death in

1870.

He was lecturer on the principles of surgery in the

extramural school in Edinburgh from 1863, becoming

Acting Surgeon in 1871, and Regius Professor of Clinical

Surgery at the University in 1877. In this lapse of time, he

published 77 medical papers spanning from general surgery

to orthopaedics, from otolaryngology to urology.

On 5th July 1877, Annandale performed the first suc-

cessful orchiopexy in medical history: he treated a 3-year-

old boy with pain in the perineum caused by a displaced

testicle, by restoring it to its natural and correct position in

the scrotum and stitching it to the bottom of the scrotum to

obtain a permanent retention. He wrote about this landmark

operation in his 1879 article entitled ‘‘Case in which a

testicle congenitally displaced into the perineum was suc-

cessfully transferred to the scrotum’’ [3]. As revealed by

the article, Annandale was also very receptive and inter-

ested in the increasingly popular (for that time) concept of

performing surgery according to the principles of antiseptic

procedures stated by the epoch-making works of his con-

temporary Joseph Lister, the pioneer of antiseptic surgery.

In 1900, he was honoured by the Queen of England with

the role of Surgeon General to the Life-Archers of the Royal

Scottish Life-Guard, the royal bodyguards in Scotland, a

corps to which he had belonged as an archer since 1870.

He was found dead in his bed at home in Edinburgh on

20 December 1907, at the age of 69: he had operated up

until the day before his death.

In 1908, the Journal of the American Medical Associ-

ation celebrated his outstanding career and life describing

him as ‘‘one of the most notable surgeons associated with

the Edinburgh school; an enthusiastic leader in all move-

ments for the good of students’’; he was regarded to have

‘‘a ready wit, a keen sense of humor’’, and to be ‘‘a very

skilled surgeon and a lecturer to whom it was always a

pleasure to listen’’ [4].

Annandale’s meniscal procedures

This paper focuses on a specific procedure performed by

Thomas Annandale in 1883, which was an arthrotomy

aimed at repairing a displaced semilunar cartilage in the

knee joint: the first successful operation of meniscus repair.

Annandale himself described this operation in his paper

dated 1885: ‘‘An operation for displaced semilunar carti-

lage’’ [1].

Being a professor at heart, the author begins the article

as a university lecture, by explaining the theory and the

knowledge of the time about the pathology:

‘‘The pathology of the condition called by that wise old

surgeon Hey of Leeds, ‘‘internal derangement of the knee-

joint’’; by Sir Astley Cooper, ‘‘partial luxation of the thigh-

bone from the semilunar cartilage’’, and which is now by

some authors termed dislocation or displacement of the

semilunar cartilage, has not yet been thoroughly worked

out, as few opportunities occur for the dissection of a joint

so affected. It is, however, a clinical fact that one of the

semilunar cartilage, usually the internal one, does occa-

sionally become loosened from its attachments; and, in

consequence, this body is liable to be displaced either

forwards or backwards, and so to interfere with the proper

movements of the knee-joint’’.

According to the case reports known to Annandale, this

kind of pathology could occur in two different ways:Fig. 1 A picture of Dr. Thomas Annandale

Knee Surg Sports Traumatol Arthrosc

123

abruptly, following a ‘‘twist or wrench of the knee’’, or as a

‘‘gradual stretching of the attachments of the cartilage’’

owing to ‘‘some effusion in the joints’’ or to ‘‘some con-

tinued strain upon the joint’’. In the latter case, Annandale

assumed that causes were due to specific occupations.

It was known to Annandale that this condition tended to

become chronic and could occur at every slight movement

of the joint as a consequence of a rupture of the ligamen-

tous attachments. To this regard, Annandale writes: ‘‘The

movements of the joints may be merely stiffened in one

direction, or the joint itself may be firmly locked, and

remain so until manipulation returns the displaced

cartilage’’.

Here is the focus point: ‘‘manipulation’’ was the stan-

dard procedure to treat this pathology, by applying forced

flexion and extension to the joint in order to reduce the

displaced cartilage, then to keep it at rest with the aid of a

splint or bandage.

In 1883, a 30-year-old miner from the north of England

was sent to Annandale complaining of ‘‘acute pain in

certain movements of the joint, which frequently became

locked in the flexed position’’.

The miner remembered a sharp pain while working in a

kneeling position, followed by a debilitating swelling of the

joint: after being treated with manipulation, the swelling

was reduced, ‘‘but pain still continued, and the movements

of the joint were interfered with by something ‘slipping’ in

the knee’’.

It was the occasion Annandale was waiting for to try a

new procedure to definitively treat the pathology, a new

way to heal the patient and not only a way to temporarily

subdue the pain and restore some mobility.

Thomas Annandale was respected by his contemporaries

for his diligence, his perseverance and tireless devotion to

the practice: he was one of the first to understand the

necessity and importance to specialize his skills, constantly

studying and researching about human body and its

pathologies. Annandale was an innovator, a surgeon not

scared to go against the agreed tradition to find new ways

to improve the cure.

Here are Annandale’s words to describe his surgical

procedure of meniscal repair:

‘‘An incision was made along the upper and inner border

of the tibia, parallel with the anterior margin of the internal

semilunar cartilage; and the few superficial vessels having

been secured, the joint was opened. It was then seen that

this semilunar cartilage was completely separated from its

attachments and was displaced backwards about half an

inch. The anterior edge of this cartilage was now seized by

a pair of artery catch forceps, and it was drawn forwards

into its natural position, and held there until three stitches

of chromic catgut were passed through it and through the

fascia and periosteum covering the margin of the tibia. The

forceps were then withdrawn, the cartilage remaining

securely stitched in position. The wound in the synovial

membrane and soft textures having been closed with catgut

stitches, a splint and Plaster-of-Paris bandage were applied,

so as to keep the joint at rest […].

Seven weeks after the operation, the splint and bandages

were removed, and gentle movements of the joint

practised’’.

About 6 months later, Annandale met the patient again

to check his condition and to examine the results of the

procedure in the long term: ‘‘he had perfect movement in

the joint, and had never had the slightest stiffness of

locking of the joint since he commenced to go about after

the operation’’.

After this success, the meniscal procedures became

more frequent in medical practice due to the good clinical

outcome achieved. In 1889, reporting about a case with

similarities, Annandale could state: ‘‘I think it may be

fairly said that operative interference in connection with-

injured or diseased semilunar cartilages has now become

an established procedure’’ [2]. In the aforementioned

paper, Annandale described an exemplar case of a semi-

lunar cartilage so separated from its attachments (Fig. 2) to

be irreparable: the only solution was an excision of its

greater part that allowed the patient a ‘‘perfect recovery’’

and a complete return to his normal life.

It is worthy of attention that Annandale, the pioneer of

this kind of surgery, performed both meniscal repair and

meniscectomy according to the specific meniscal condition,

thus demonstrating that each treatment option is related to

the particular clinical condition. The discussion about

correct indications started in Annandale’s times and is still

Fig. 2 Original picture representing the medial meniscal lesion

treated by Annandale by excision in 1889

Knee Surg Sports Traumatol Arthrosc

123

actual nowadays: the therapeutic options to address meni-

scal pathology are several, thus defining the right indica-

tions is crucial to obtain a positive clinical outcome at long

follow-up.

Conclusion

Meniscal treatments are everyday clinical practice for

orthopaedic surgeons. What now seems absolutely com-

mon to us was very different in the past: we have inves-

tigated the life and work of Thomas Annandale and his role

as forerunner of meniscal surgical treatment. The most

important current clinical indication for meniscal treatment

is to try to preserve meniscal tissue as much as possible

and, in case of previous meniscectomy, even to replace it

with scaffolds and allografts. It is interesting to point out

that the first documented operation performed on a

meniscus was not a resection but a reattachment, which is a

form of repair: the history of meniscal surgery started

130 years ago with the same conceptual principles that we

try to apply nowadays. Surely a lot has changed: the first

arthrotomic treatment here described required 70 days of

hospitalization before discharge (including the post-op

management), whereas today arthroscopic meniscal sur-

gery is essentially day-surgery activity.

Much has changed, but without the intuitions and the

pioneering works of innovative personalities like Annan-

dale, what we have achieved would not have been possible:

a sharp mind, a strong will and an imperishable desire to

learn and to convey knowledge made Thomas Annandale a

key figure in the history of medicine, and that is the reason

why he deserves to be properly acknowledged and

remembered.

Acknowledgments Authors would like to thank Liliana Draghetti

(Donazione Putti, Biblioteche Scientifiche, Rizzoli Orthopaedic

Institute) and Keith Smith (Task Force, Rizzoli Orthopaedic Institute)

for their help.

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