Minimal Invasive Orthopaedic Surgery: Where We Stand Now in the year 2025

Introduction Orthopaedic surgery, the branch of medicine that deals with the diagnosis and treatment of disorders of the musculoskeletal system, has been transformed since officially becoming a branch of medicine in the mid-19th century, especially after breakthrough developments such as the invention of X-ray technology and antibiotics.[1] The field nowadays is mainly focused on addressing osteoarthritis, musculoskeletal injuries (such as sports injuries), and osteoporosis.[1] Technological advances have been instrumental in defining contemporary orthopaedic practice, with developments like joint replacement surgery, arthroscopy, and minimally invasive surgery having greatly enhanced patient outcomes.[1] Orthopaedic surgeon training is rigorous, typically including intensive preparatory courses or “boot camps” to guarantee skill acquisition from the outset of medical school.[2] Also, the practice places high expectations on standards by using evidence-based procedures, clinical guidelines, and correct use criteria to provide maximum care delivery. As patient expectations continue to shift, orthopaedic surgery continues to be in the forefront of advancements, striving to improve recovery periods and functional outcomes.[1] Minimally invasive procedures in orthopaedic surgery have evolved substantially since the 1990s, largely fueled by heightened patient expectations and clinical benefits of lowered operative trauma.[3] Minimally invasive procedures aim to minimize soft tissue disruption without reducing the precision and effectiveness of the results from standard surgical intervention.[4] Huge progress has been made in reconstructing traditional forms of surgical interventions to restrict the size of the incision as well as injury to the tissue.[4] Advances in technology like the incorporation of operating microscopes, endoscopic instruments, and advanced imaging have improved intraoperative visual control and exposure.[4] In parallel, implant makers have created devices specifically designed for less invasive insertion methods that complement the trend toward minimal exposure.[4] Computer-assisted navigation and robotic systems also improved surgical accuracy. Early results suggest patients who undergo minimally invasive surgery have quicker recovery, averaging 116° of postoperative knee flexion during the initial 3 months versus 97° with conventional open methods.[3] The growing trend towards minimally invasive surgical techniques in orthopaedics is a compromise between clinical outcome, technological development, and patient expectations. Patients are predisposed towards these techniques due to the perceived benefits of less tissue injury and quicker rehabilitation.[5] Technological advances, like computer-aided navigation and robotic equipment, have immensely augmented intraoperative precision, and dedicated instruments, such as minimally invasive screws and cutting protection tools, have complemented the procedures.[6] Minimally invasive orthopaedic surgery (MIOS) has also shown clinical benefits such as less blood loss, fewer transfusions, lower rates of complications, and lower postoperative pain. Nonetheless, such limitations as decreased tactile feedback and difficulties in interpreting 3D anatomy from 2D imaging contribute to a steep learning curve. Even with these advances, wider adoption continues to be thwarted by expensive initial costs, an as-yet incomplete evidence base, and inadequate training programs for surgeons.[5] Historical Perspective and Evolution Conventional open orthopaedic surgery has been the cornerstone of the profession for many years, with the work of leaders such as Hugh Owen Thomas and Sir Robert Jones combining formal medical training with traditional bone setting art to inform contemporary surgical practices.[7] Whereas open surgery continues to be very effective for particular conditions, like osteoid osteomas in rare sites where it has proved to have great results with low complications,[8] the development of MIOS has made it important to highlight its possible benefits. MIOS is characterized by quicker recovery, shorter hospital stays, better functional outcomes, lower perioperative morbidity, and lower healthcare costs.[9] These methods have been implemented with success in treating a variety of conditions such as Achilles tendon pathologies and total hip replacement. Referred to as the use of anatomically ideal incisions based on optimally positioned incisions, MIOS is designed to provide surgical security and visibility and limit tissue disturbance.[9,10] Technological Advancements Driving MIOS The incorporation of newer technologies is rapidly transforming surgical techniques and patient management in orthopaedics. Robotic systems and artificial intelligence (AI)-based planning software have enhanced surgical accuracy and improved preoperative decision-making by analyzing complex anatomical and procedural variables.[11] Computer-assisted navigation systems and augmented reality also assist surgeons by providing improved intraoperative visualization and guidance, especially useful in technically challenging procedures.[11] Technological developments in miniaturization and imaging have enabled less invasive procedures with real-time high-resolution 3D images under surgery. Postoperative care is also being supported by wearable technology through the option of monitoring the patient continuously, with 99.2% concordance between physician and sensor estimates of tissue perfusion, as measured in one study.[11] Furthermore, monitoring of heart rate using wearable sensors has also been found to have moderate accuracy with a bias of 0.3 bpm and 95% limit of agreement of −15.5 to 17.1 bpm.[12] Application in Key Orthopaedic Domains MIOS is becoming a useful orthopedic technique in trauma treatment, providing minimally invasive means of fracture fixation at different sites of the body. Recent research by Wichlas et al.[13] on 57 fractures in 53 patients further emphasized MIOS’s versatility and clinical applicability with techniques like the “one way up” plate insertion in articular fractures and the “inside-up-and-down” approach in non-articular fractures showing good results. This was accompanied by lesser soft tissue disruption, consistent osteosynthetic stability, and minimal complications. In addition to MIO, a number of technological innovations are characterizing contemporary orthopedic practice, which include the use of AI and machine learning in joint reconstruction, spinal instrumentation, oncology, trauma, and sports medicine.[14] Moreover, technologies such as load-sensing implants for postoperative evaluation and computer-aided diagnostic systems for improved visualization and quantitative analysis are increasingly enhancing surgical accuracy and patient recovery in orthopedics.[13,14] Benefits and Outcomes MIOS has proven numerous benefits compared to traditional open techniques, leading to enhanced clinical and patient-satisfying outcomes. Studies confirm that MIOS is accompanied by reduced hospital stays, with patients receiving faster discharges than in the case of traditional procedures.[9,10] These methods also reduce perioperative blood loss to a large extent, overall enhancing the safety of surgery and healing.[10] Patients who have MIOS also tend to have quicker functional recovery and the ability to return to normal activities earlier, enhancing postoperative quality of life.[10] Smaller incisions not only reduce visible scarring but also maximize cosmetic outcomes, which, along with decreased postoperative pain and faster rehabilitation, lead to increased patient satisfaction. While not necessarily reported directly, the reduced tissue trauma and abbreviated hospital stay that are characteristic of MIOS are also expected to reduce the incidence of postoperative infections.[9,10] Future Directions Minimally invasive orthopedic surgery is evolving fast, with a number of emerging trends defining its future trajectory. Increased application of 3D printing and patient-specific instrumentation is making it possible to have more personalized surgical methods, where procedures can be customized exactly to the anatomy of an individual.[15] AI and machine learning are also becoming part of the equation, providing intraoperative decision-making support and helping in creating accurate diagnoses and personalized treatment plans.[16] Further, the incorporation of regenerative medicine, such as biologic and tissue engineering therapies, is also promising to further improve surgical outcomes and encourage quicker recovery. Enhancements in sophisticated imaging and computer-aided navigation are also streamlining surgical accuracy through intraoperative real-time feedback and safer, more efficient procedures.[16] Taken together, these technologies are promising to make orthopedic intervention less invasive, more precise, and able to provide quicker, more efficacious patient recovery.[15] Conclusion MIOS has become a valuable method in orthopedic surgery, offering less invasive means of fracture management and minimizing soft tissue injury. In spite of its benefits, routine use is still limited, with only a minority of surgeons approximately 16% utilizing MIO on a regular or sole basis in their practice. Technological advancements, including the minimally invasive spherical osteotomy assistant system, have maximized procedural control and accuracy while maintaining the requirement for balance between technological dependence and clinical acumen. To provide greater access for MIO, there is clearly a need for greater access since 62% of orthopedic surgeons report interest in having more of these procedures done. In addition, further advances in disciplines such as nanotechnology for design of implants and long-term outcome studies in clinics are required to inform evidence-based practice and mitigate barriers to wide-scale implementation. The development of standardized protocols and increasing specialized training opportunities will be crucial steps towards the integration of MIOS into orthopedic surgical practice on a broader basis. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.