Global research output and highly-cited publications on prosthetic joint infections: A bibliometric analysis (2003-2022)

Abstract

Backgroundand aims

Prosthetic Joint Infection (PJI) is a serious clinical problem after Arthroplasty. The research field on PJI is emerging, but there is a paucity of information on the most impactful publications on it. This prompted us to conduct a bibliometric analysis of the global research output, from 2003 to 2022, to identify the growth of publications, the key players in this research field and to evaluate the characteristics of highly-cited publications (HCPs) on the PJI.

Methods

Publications related to PJI research were identified globally from the Scopus database, using specific keywords, covering the literature from 2003 to 2022. The HCPs were considered those with 100 or more citations. Information on publication year, citation count, funding sources, title, author, journal, country, institution, research area, and strategic keywords were collected from these HCPs. Publication data was imported into Microsoft Excel and analyzed further using VOSviewer and R software.

Results

There were 182 HCPs (3.12%), which received a total citation of 124701 (average CPP of 21.41), with the citation range from 100 to 1921. Research articles were the most predominant publications (69.2%), but their average citations per paper (CPP) of 189.78 was lower than that of Review articles (average CPP: 253.17). The USA has been the leading country in terms of total publications (31.58%), and HCPs (36.99%), followed by Switzerland, Spain, UK and China. There were no HCPs from developing countries. J. Parvizi of Thomas Jefferson University, USA (with a total publications of 31 and an average CPP of 315.7), and W. Zimmerli of Basel University, Switzerland (with a TP of 11 and an average CPP of 341.9), were the most productive and impactful authors in PJI global research output.

Conclusion

This bibliometric analysis identified the most productive and impactful authors, organizations, countries, and journals in the research of PJI, of the last two decades.

Graphical abstract

1. Introduction

Prosthetic Joint Infection (PJI) relates to infection occurring after implantation of a prosthesis in an Arthroplasty or Joint Replacement Surgery. It is one of the most serious and challenging complications of Arthroplasty. The number of arthroplasties is increasing in large numbers globally. It is estimated that around 1 million hip and knee arthroplasties are being done every year in the United States of America (USA) alone.^1,2 Proportionately, there has been a parallel escalation in the incidence of PJI and it is expected to quadruple over the next decade or so.³ The incidence of PJI is 1%–2%, and it usually occurs from 1 month to 2 years following primary arthroplasty.⁴ However, there remains a persistent risk of developing infection throughout the lifespan of the prosthesis.⁵

PJI is challenging to diagnose, in some cases, on routine microbiology tests, hence the newer biomarkers are being increasingly used to aid in diagnosis.⁶ There is no uniformly accepted definition for PJI. Accurately diagnosing a PJI requires combining clinical and laboratory results evaluation.^7,8 The risk factors for developing a PJI include preoperative, modifiable, nonmodifiable host, surgery-related, and postoperative factors.⁹ PJI poses significant clinical problems and often requires revision surgeries. It also has a profound impact on affected patients, puts a substantial financial burden, and is associated with increased morbidity, and overall mortality.^10,11

One of the important measures of a scientific publication is its citation frequency. The highly-cited publications (HCPs) are considered valuable in transmitting new knowledge, denote substantial influence, and engage meaningful readership.^12,13

The PJI is an important clinical problem in the present context and has reported an increase globally.^{1, 2, 3, 4} The research field on PJI is emerging, but there is a paucity of information on the most impactful publications on it.^9,10 This prompted us to conduct a bibliometric analysis of the global research output, from 2003 to 2022, to identify the growth of publications, the key players in this research field and to evaluate the characteristics of highly-cited publications (HCPs) on the PJI.

2. Methods

Publications related to “Prosthetic Joint Infections” research were identified globally from the Scopus database on November 27, 2023, using a search strategy based on keywords like “implant-associated infections," “prosthetic joint sepsis," and “joint arthroplasty infections." Covering literature from 2003 to 2022, the search yielded 5825 records, ranked by citation count. We set a cutoff of 100 citations, resulting in 182 HCPs for detailed analysis. Information on publication year, citation count, funding sources, title, author, journal, country, institution, research area, and strategic keywords were collected from these HCPs. Compound Annual Growth Rate (CAG), measures the average annual increase of publications over a specific period, considering the effect of compounding. Unlike a simple average, CAGR is more suitable for analysing long-term trends, especially when there are fluctuations in growth rates. It was calculated by the following formula: CAGR = ((Ending Value)/(Beginning Value))^(1/n) – 1. Average citation per paper (CPP) is a research metric used to assess the impact of published works. It refers to the average number of times a single publication has been cited by other publications.

In our bibliometric study, we employed three distinct tools: Microsoft Excel 2019, VOSviewer version 1.6.20 (van Eck & Waltman, 2010), and Bibliometrix 4.0.0 (Aria & Cuccurullo, 2017). Microsoft Excel 2019 served as a versatile platform for various data manipulations. VOSviewer, in its 1.6.20 version, was utilized for constructing and visualizing bibliometric networks, encompassing entities like journals, researchers, or individual publications. These networks were established based on citation, co-citation, or co-authorship relations. Additionally, we utilized Bibliometrix 4.0.0, an open-source tool specifically designed for quantitative research in scientometrics and bibliometrics. This tool encompasses a comprehensive set of bibliometric methods for analysis, making it a valuable resource for our study.

In co-citation networks, two items appear together in the bibliography of a third citing item. Co-occurrence networks represent relationships between items based on their frequency of appearance together in publications. Visualizations use nodes and links of various colours, with node size reflecting citation or occurrence count and link strength quantified by the total link strength (TLS) parameter. Our present study utilized the detailed flow diagram provided in Fig. 1 of the PRISMA flow chart.

Fig. 1.

PRISMA 2020 flow chart used for this Scientometrics study.

3. Results

3.1. Overall research output

During 2003-2022, we found total publications (TP) of 5825 on the PJI, with TP soaring from a modest 1 in 2003 to a remarkable 894 in 2022, and a compounded annual growth rate (CAGR) of 25.3%. The total citations (TC) parallelly witnessed an exponential surge from 4 in 2003 to a staggering 14,096 in 2022, reflecting a 3474% increase over two decades, and a CAGR of 40.1%. Funded papers (FP) constituted a negligible portion of the overall output throughout the period, with an average of around 0.4% (Table 1).

Table 1.

Publication and citation growth in prosthetic joint infection from 2003 to 2022.

S. No.	Year	TP	TC	CPP	FP	HCP	TC (HCP)	CPP
1	2003	1	4	4.00	0	0	0	0.00
2	2004	5	538	107.60	0	2	430	215.00
3	2005	10	698	69.80	0	1	336	336.00
4	2006	16	1039	64.94	0	3	739	246.33
5	2007	10	664	66.40	0	2	367	183.50
6	2008	9	361	40.11	0	2	238	119.00
7	2009	29	1209	41.69	0	5	754	150.80
8	2010	36	3119	86.64	1	12	2380	198.33
9	2011	71	5740	80.85	3	14	3982	284.43
10	2012	136	8226	60.49	8	24	5221	217.54
11	2013	173	10535	60.90	5	15	5446	363.07
12	2014	284	12395	43.64	5	23	5413	235.35
13	2015	285	9474	33.24	4	20	3219	160.95
14	2016	380	11389	29.97	4	16	2769	173.06
15	2017	504	12703	25.20	3	14	2001	142.93
16	2018	526	13354	25.39	5	13	2699	207.62
17	2019	740	14096	19.05	8	13	2393	184.08
18	2020	784	9196	11.73	0	1	106	106.00
19	2021	932	6909	7.41	1	2	402	201.00
20	2022	894	3052	3.41	0	0	0	0.00
	2003–2012	323	21598	66.87	12	65	14447	222.26
	2013–2022	5502	103103	18.74	35	117	24448	208.96
	2003–2022	5825	124701	21.41	47	182	38895	213.71

(TP = Total Publications; TC = Total Citations; CPP= Citations Per Publication; FP=Funded Papers; HCPs = Highly Cited Publications).

3.2. Highly-cited publications (HCPs)

3.2.1. Citation frequency

There were a total of 182 HCPs accounting for 3.12% of the TP on PJI, with the TC ranging from 100 to 1921. A steady increase in HCPs over time was noted, with 2011 witnessing the highest number (14). Notably, the 100-199 citation bracket emerges as the dominant category, housing 133 HCPs, accounting for nearly 73% of all HCPs. Ascending the citation spectrum, a consistent decrease in the number of HCPs is observed as citation counts rise. The subsequent ranges, such as 200-299 and 300-399, demonstrate declining frequencies of 27 and 8 papers, respectively, representing approximately 15% and 4% of the total (Table 2).

Table 2.

Distribution of highly cited papers in prosthetic joint infection by citation frequency range (2003-2022).

Citation Slab	TP	TP Cumulative	TC	TC Cumulative
100–199	133	133	17709	17709
200–299	27	160	6481	24190
300–399	8	168	2535	26725
400–499	3	171	1342	28067
500–999	6	177	3989	32056
1000–1921	5	182	6839	38895

(TP = Total Publications; TC = Total Citations).

3.2.2. Publication types and impact

Research articles stand out as the predominant format, constituting 69.2% (n = 126) of all HCPs, with an average citation per publication (CPP) of 189.78. However, the review articles (n = 41) lead in terms of average impact, with a CPP of 253.17 (Table 3). Of particular interest, the sole editorial displays the potential for significant influence, with a CPP of 637.00.

Table 3.

Spread of highly cited papers on PJI by publication types from 2003 to 2022.

Type of Publication	TP	FP	TC	CPP
Research Article	126	36	23912	189.78
Review	41	10	10380	253.17
Conference paper	10	1	3354	335.40
Note	2	0	251	125.50
Short survey	2	0	362	181.00
Editorial	1	0	637	637.00
Total	182	47	38896	213.71

(TP = Total Publications; TC = Total Citations; CPP= Citations Per Publication; FP=Funded Papers).

3.2.3. Publication landscape by countries

The USA contributed the maximum of 31.58% of all the PJI publications worldwide., Germany follows as a distant second, contributing 9.28% of publications, while China and the United Kingdom (UK) secured the third and fourth positions with shares of 8.12% and 5.47%, respectively (Table 4). The USA maintains its dominance, claiming 36.99% of all HCPs authored by the top 10 countries.

Table 4.

Distribution of publication output among the top 10 most productive countries in PJI research: 2003–2022.

Country	TP	World Publication Share %	Rank	HCP	HCP Share (%)	Rank
USA	2198	31.58	1	91	36.99	1
Germany	646	9.28	2	15	6.10	6
China	565	8.12	3	15	6.10	5
United Kingdom	381	5.47	4	16	6.50	4
Italy	309	4.44	5	7	2.85	10
France	289	4.15	6	7	2.85	9
Spain	277	3.98	7	16	6.50	3
Switzerland	244	3.51	8	21	8.54	2
Netherlands	215	3.09	9	10	4.07	7
Australia	132	1.90	10	5	2.03	12
World	6961*	100.00		246**	100.00

(TP = Total Publications; HCP= Highly Cited Publication).

N.B.: The number of TP* and HCP** is higher here as some of the authors might have collaborated with the authors of other countries.

There is a dominance of the USA, with 91 HCPs and a TC count of 23680, resulting in a CPP of 260.2. This translates to a significantly higher relative citation impact (RCI) of 1.9 compared to the average RCI of 1.0. Following the USA, Switzerland emerges as the second-leading contributor with 21 HCPs and a CPP of 285.9, indicating robust research contributions despite a smaller volume. Notably, the UK, Spain, and Germany also feature prominently, each contributing between 15 and 16 HCPs with comparable CPP values (Table 5). The USA, Switzerland and the UK lead in international collaborative publications (ICP) showcasing active engagement in global research partnerships. Notably, Israel stands out with an impressive ICP of 4.8, indicative of a highly collaborative research culture despite a relatively smaller number of HCPs (Table 5).

Table 5.

Distribution of HCPs among the top most productive countries in prosthetic joint infection research: 2003–2022.

S No	Country	TP	TC	CPP	RCI	ICP	%ICP	TLS	Cluster
1	USA	91	23680	260.2	1.9	16	17.58	33	3
2	Switzerland	21	6004	285.9	2.1	12	13.19	29	6
3	UK	16	4453	278.3	2.1	12	13.19	20	5
4	Spain	16	2445	152.8	1.1	9	9.89	15	2
5	Germany	15	3412	227.5	1.7	12	13.19	24	1
6	China	15	2701	180.1	1.3	7	7.69	12	4
7	Netherlands	10	1349	134.9	1	11	12.09	23	1
8	Canada	8	1527	190.9	1.4	5	5.49	6	5
9	Italy	7	1668	238.3	1.8	9	9.89	11	1
10	France	7	1134	162	1.2	5	5.49	8	2
11	Belgium	6	741	123.5	0.9	8	8.79	17	1
12	Hong Kong	4	1216	304	2.3	2	2.20	5	4
13	Portugal	3	520	173.3	1.3	7	7.69	9	2
14	Denmark	3	497	165.7	1.2	1	1.10	1	6
15	Japan	3	393	131	1	2	2.20	2	5
16	Israel	2	1276	638	4.8	1	1.10	2	3
17	Czech Republic	2	383	191.5	1.4	1	1.10	1	3
18	Austria	2	269	134.5	1	7	7.69	7	1
19	South Korea	2	260	130	1	2	2.20	2	4
20	Slovenia	1	203	203	1.5	6	6.59	6	2
21	Argentina	1	106	106	0.8	1	1.10	1	3

(TP = Total Publications; TC = Total Citations; CPP= Citations Per Publication; RCI= Relative Citation Impact; ICP= International Collaborative Publications; TLS = Total Link Strength).

A total of 26 countries participated in the 182 HCPs. Of these countries, 21 contributed 1 to 91 papers (Table 1), while 11 countries exceeded the group average productivity of 6 papers. Only nine countries exhibited a CPP and RCI higher than the group averages of 202.91 and 1.51, respectively. The total link strength (TLS) of the top 21 countries ranged from 1 to 117, with the USA (33) recording the highest number of links, followed by Switzerland (29), Germany (24), the Netherlands (23), and the United Kingdom (20). The number of collaborative links between individual countries varied from 1 to 16. The highest number of collaborative links was observed between the USA and Germany (5), followed by the USA Switzerland and the UK (4 each). Fig. 2 depicts the collaborative network linkage map of the top 21 countries with at least one paper each, generated using the VOSviewer tool.

Fig. 2.

Top 21 countries collaboration network map.

3.2.4. Most productive authors

J. Parvizi from Thomas Jefferson University (USA) emerges as the undisputed leader with 31 publications and garnering an impressive 9786 citations (CPP of 315.7). Following closely is W. Zimmerli from Universitat Basel, Switzerland, with 11 publications and a higher CPP of 341.9 and RCI of 2.55. The diverse institutional affiliations of the top authors, including C.J. Della Valle from Rush University Medical Center, USA, A. Trampuz from Charité – Universitätsmedizin Berlin, Germany, and B. Zmistowski from Washington University, USA, signify a global collaborative effort. Moreover, the top authors' profiles extend beyond sheer publication volume, reflected in quality and impact metrics. E.F. Berbari from Mayo Clinic, USA, and S.M. Kurtz from Drexel University, USA, exhibit remarkably high CPPs of 654.8 and 543.8, respectively, demonstrating the profound impact of their work in shaping PJI research (Table 6).

Table 6.

Most productive Authors in Prosthetic Joint Infection Research: 2003–2022.

S.No.	Author	Affiliation	TP	TC	CPP	RCI	TLS
1	Parvizi, J.	Thomas Jefferson University, USA	31	9786	315.7	2.35	39
2	Zimmerli, W.	Universitat Basel, Basel, Switzerland	11	3761	341.9	2.55	18
3	Della Valle, C.J.	Rush University Medical Center, USA	9	2573	285.9	2.13	17
4	Trampuz, A.	Charité – Universitätsmedizin Berlin, Germany	9	2098	233.1	1.74	5
5	Zmistowski, B.	Washington University, USA	7	2607	372.4	2.77	11
6	Bozic, K.J.	University of Texas, USA	7	1710	244.3	1.82	13
7	Berbari, E.F.	Mayo Clinic, USA	6	3929	654.8	4.87	11
8	Mont, M.A.	Cleveland Clinic Foundation, USA	6	2028	338	2.52	16
9	Soriano, Alex	Universitat de Barcelona, Spain	6	946	157.7	1.17	10
10	Osmon, D.R.	Mayo Clinic, USA	5	2529	505.8	3.77	7
11	Lau, E.	Exponent, Inc., USA	5	2023	404.6	3.01	10
12	Berry, D.J.	Mayo Clinic, USA	5	876	175.2	1.30	9
13	Soriano, A.	Universitat de Barcelona, Spain	5	750	150	1.12	0
14	Sendi, P.	University of Bern, Switzerland	5	693	138.6	1.03	5
15	Kurtz, S.M.	Drexel University, USA	4	2175	543.8	4.05	9
16	Tan, T.L.	University of California, USA	4	1618	404.5	3.01	13
17	Goswami, K.	Thomas Jefferson University, USA	4	1537	384.3	2.86	14
18	Shohat, N.	Tel Aviv University, USA	4	1527	381.8	2.84	15
19	Chu, P.K.	City University of Hong Kong, Hong Kong	4	1216	304	2.26	0
20	Deirmengian, C.	Jefferson Medical College, USA	4	874	218.5	1.63	3
21	Borens, O.	Centre Hospitalier Universitaire Vaudois, Switzerland	4	777	194.3	1.45	4
22	Berend, K.R.	Joint Implant Surgeons, Inc., USA	4	682	170.5	1.27	4
23	Higuera, C.A.	Cleveland Clinic Florida, USA	4	652	163	1.21	9

3.2.5. Authors Collaboration Network

Among the 958 authors, 21 individuals established 70 connections and a TLS of 121. In Fig. 3, Cluster Red comprises researchers, with 4–6 publications, in the Green Cluster, authors have 4 to 7 publications, in the Yellow Cluster authors have publication counts of 4–9, and in the Clusters Purple, Aqua, and the Orange display diverse publication counts, citation impacts, and local citation metrics, highlighting their unique collaborative and citation dynamics.

Fig. 3.

The top 21 authors collaboration network.

3.2.6. Analysis of keywords with occurrences

The “periprosthetic joint infection" reigns supreme, appearing a commanding 112 times, highlighting the central focus of research efforts on tackling this challenging infection. Terms like “prosthesis-related infections" (104 occurrences), “infection" (47 occurrences), and “anti-bacterial agents" (43 occurrences) further reinforce this emphasis, showcasing the multifaceted approach to prevention, diagnosis, and treatment. The prominence of specific joint replacements, namely “arthroplasty, replacement, knee" (41 occurrences) and “arthroplasty, replacement, hip" (39 occurrences), underscores the prevalence of PJI in these regions. Similarly, keywords like “hip arthroplasty" (36 occurrences) and “knee arthroplasty" (32 occurrences) solidify the dedicated research directed towards improving outcomes in these high-risk areas (Supplementary Table 1).

3.2.7. Most productive and impactful journals

The Journal of Arthroplasty published a maximum of 886 papers on PJI, followed by Clinical Orthopaedics and Related Research (n = 214), Bone and Joint Journal (n = 163), International Orthopaedics (n = 134), and Journal of Bone and Joint Surgery-American (n = 104). The top journals in terms of citation impact/CPP were Clinical Infectious Diseases, Clinical Microbiology and Infection, Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related Research, and Journal of Infection (Supplementary Table 2). A total of 108 journals have contributed to these papers, with 21 of them forming co-citations, creating 203 links and a TLS of 5001, which is represented in Fig. 4 as the journals’ co-citations network.

Fig. 4.

Journals' Co-citations network.

3.2.8. Most influential research articles

The details of the top 14 HCPs are presented in Table 7, where J. Parvizi dominates the table with three publications, particularly his 2018 article in the Journal of Arthroplasty titled “Periprosthetic Joint Infection: Current Concepts and Strategies." This publication's remarkable citation score of 42.38 underscores its significant influence on advancing PJI knowledge. Another noteworthy contribution is D.R. Osmon's 2013 paper in Clinical Infectious Diseases, which boasts a citation score of 31.55 and highlights the need for comprehensive diagnosis and treatment strategies. Moreover, S.M. Kurtz's contributions, focusing on PJI's epidemiology and burden, underline the importance of understanding the broader context for effective management strategies.

Table 7.

Details of the top 14 highly cited publications.

Paper	DOI	TC	TCpY	Normalized TC
OSMON DR, 2013, CLIN INFECT DIS-a	10.1093/cid/cis803	1921	174.64	31.55
PARVIZI J, 2011, CLIN ORTHOP RELAT RES-a	10.1007/s11999-011-2102-9	1400	107.69	17.32
KURTZ SM, 2012, J ARTHROPLASTY	10.1016/j.arth.2012.02.022	1298	108.17	21.46
TANDE AJ, 2014, CLIN MICROBIOL REV	10.1128/CMR.00111-13	1144	114.40	26.21
PARVIZI J, 2018, J ARTHROPLASTY	10.1016/j.arth.2018.02.078	1076	179.33	42.38
TURNER NA, 2019, NAT REV MICROBIOL	10.1038/s41579-018-0147-4	841	168.20	44.15
PARVIZI J, 2013, BONE JT J	10.1302/0301-620 × .95B11.33135	729	66.27	11.97
ZHAO L, 2011, BIOMATERIALS	10.1016/j.biomaterials.2011.04.040	676	52.00	8.36
PARVIZI J, 2014, J ARTHROPLASTY-a-b	10.1016/j.arth.2014.03.009	637	63.70	14.60
KAPADIA BH, 2016, LANCET	10.1016/S0140-6736(14)61798-0	553	69.13	18.40
KURTZ SM, 2010, CLIN ORTHOP RELAT RES	10.1007/s11999-009-1013-5	553	39.50	6.38
ZMISTOWSKI B, 2013, J BONE JT SURG SER A	10.2106/JBJS.L.00789	465	42.27	7.64
RABIN N, 2015, FUTURE MED CHEM	10.4155/fmc.15.6	451	50.11	13.57
TRAMPUZ A, 2006, CURR OPIN INFECT DIS	10.1097/01.qco.0000235161.85925.e8	426	23.67	6.56

(TC = Total Citations; TCpY = Total Citations per Year).

These top-cited papers explore diverse themes critical to understanding PJI. A.J. Tande's review on “Staphylococcus aureus Biofilm: Structure, Pathogenesis, and Treatment" and N.A. Turner's exploration of “Molecular Imaging of Microbial Infections" in Nature Reviews Microbiology, respectively, spotlights fundamental microbiological insights and cutting-edge technologies shaping clinical strategies and diagnosis methods. Additionally, promising newcomers like L. Zhao and N. Rabin contribute to material science and antibiotic strategies, revealing ongoing pursuits of innovative solutions to combat PJI.

The analysis reflects a dynamic landscape shaped by renowned researchers like Parvizi, Osmon, and Kurtz, alongside promising newcomers like Tande, Turner, Zhao, and Rabin. These highly cited papers demonstrate the evolving nature of PJI research, underscoring the importance of fundamental knowledge, technological advancements, and innovative approaches for understanding, diagnosing, and managing prosthetic joint infections. The HCPs co-cited network is presented in Supplementary Fig. 1.

3.2.9. Institutions’ collaboration

The details of the institutions’ collaboration and network are presented in Supplementary Table 3 and Fig. 5 respectively. The central hub of collaboration was between renowned institutions like Thomas Jefferson University Hospital, Mayo Clinic, and Rush University Medical Center (All from the USA).

Fig. 5.

Institutions' collaboration network.

4. Discussion

Our bibliometric analysis of the global publications data of the Scopus on PJI, from 2003 to 2022, revealed a total of 5825 publications, which received total citations of 124701 (average CPP of 21.41). 182 (3.12%) of these publications were HCPs, with the citation range from 100 to 1921. The Research articles were the most predominant publications (69.2%), but their average CPP of 189.78 was lower than that of Review articles (average CPP: 253.17). The USA has been the leading country in terms of total publications (31.58%), and HCPs (36.99%), followed by Switzerland, Spain, the UK and China. J. Parvizi of Thomas Jefferson University, USA (with a TP of 31 and an average CPP of 315.7), and W. Zimmerli of University of Basel, Switzerland (with a TP of 11, and CPP of 341.9), were the most productive and impactful authors in PJI global research output.

PJI is a major healthcare problem as it is associated with prolonged hospital stays, poorer outcomes, diminished quality of life, and higher mortality, compared to non-infected arthroplasties.^{14, 15, 16, 17, 18} PJI also has a significant physical, social, and emotional impact on patients.¹⁵ In addition, the hospital expenditure for the management of the PJI is very high. It is estimated to be is estimated at approximately $89,000 for hip infections and $116,000 for knee infections, per PJI episode.¹⁹ The last two decades have witnessed an increase in the PJI, but a significantly improved comprehensive management at specialized centers. The diversity in the management of PJI due to multiple surgical scenarios, a variety of etiologic microorganisms, and rising resistance to antibiotics has necessitated the need for such specialized care.²⁰

There are a few bibliometric studies available on the PJI in various aspects, using different databases. Dong et al. extracted 7288 articles from the Web of Science (WOS) database from 1980 to 2022 and found that the number of publications increased per year globally, with the USA making the highest contributions and receiving the most citations.²¹ Li et al. analyzed the PJI publications between 1998 and 2018 from the WOS database and found a rising trend of publications, with the largest contribution coming from the USA.²² These findings are similar to our observations. Li et al. studied the publications related to revision hip and knee arthroplasty (RHKA), from 2000 to 2020 in the WOS, and reported increasing publications in RHKA, with the dominance of USA. The authors commented that PJI was likely a potential development trend and the hotspot of RHKA.²³ Shen et al. used WOS data for searching the PJI after total knee arthroplasty (TKA) and found the USA, China, Germany, the UK, and Spain, as the top five contributing countries, similar to our findings. There was a lack of studies with a high level of evidence and hence suggested that more randomized controlled studies are required to provide evidence-based treatments.²⁴ Li et al. (2020) commented that there was no single database that could cover all the relevant subject articles.²⁵

The preponderance of HCPs within the lower citation ranges in our analysis suggests a broad landscape of impactful research, addressing diverse facets of the field. Simultaneously, the scarcity of HCPs underscores the competitive nature of achieving exceptional influence, often reserved for groundbreaking discoveries or paradigm-shifting investigations. This distributional analysis illuminates the varying degrees of influence and impact held by HCPs within distinct citation frequency ranges, providing a nuanced understanding of the depth and breadth of research contributions in PJI over the studied period. The HCPs significantly contribute to impactful research within the field. This dominance is attributable to their capacity to present comprehensive original findings, methodologies, and analyses, fostering robust engagement and discussion among researchers. HCPs have different characteristics than the ‘ordinary’ cited articles. These are typically having several contributing authors, involving international collaborations. The HCPs often obtain citations from a larger number of journals and papers from close and remote fields.¹² We concur that the HCPs can influence the research frontier and attract more readership and thus can create a substantial influence.^{13,26, 27, 28, 29, 30, 31, 32} Ennis et al. evaluated the 50 most cited articles on PJI. They observed that the most common Levels of Evidence of these papers were 2 and 3, and the clinical outcomes were the most common article types. They found analysis of these publications provided an enhanced understanding of the diagnosis, treatment, and future research of PJI.³³

Most of the research on PJI has been done until recently in high-income countries (HIC), and minuscule in Low and Low-Middle-Income countries (LMIC), where the number of arthroplasties is increasing, and hence the incidence of PJI is also likely to increase proportionately. In a Scientometric analysis of India's publications in Arthroplasty over two decades, there were 872 publications, constituting a 1.36% share of global output. There was a low contribution of India in Arthroplasty-related research on a global platform, however, there was an increasing trend seen in the last two decades. The authors suggested more international and multicentric collaboration and external funding to improve arthroplasty-related research and publications.³⁴ There are several challenges in the LMIC/developing countries in implementing Arthroplasty programs, like the high costs, sterility, patient demographics etc. Despite these challenges, several developing countries have started to offer arthroplasty of the knee and hip to meet the increasing demand of their patients with arthritis etc.³⁵ Gausden et al. noticed a lack of access to basic surgical care, including Arthroplasty in LMIC, and suggested multiple strategies, like short-term surgical trips, the establishment of dedicated Arthroplasty centers, international collaborations to bridge the gap in access to quality Arthroplasty.³⁶ Jennison et al. reported 36-fold variations in the practice of hip arthroplasties across the Organisation for Economic Co-operation and Development (OECD) and found an increase of more than 20% over the past decade.³⁷ In response to the growing burden of joint disease, developing countries have started to create their arthroplasty programs and registries.³⁸ However, there has been limited research on predictors of Arthroplasty in developing countries.³⁹ The training of surgical team members, operating facilities, and available resources in LMIC are substantially different than HIC setups. The long-term outcomes and survivorship of Arthroplasties performed in LMIC are not well-known.⁴⁰

PJI has been an emerging field of research in the recent past, as is evident from our analysis, with the number of publications increasing from only 1 in 2003 to 894 in 2022, and a CAGR) of 25.3%. Zeng et al. have also reported a rapidly increasing number of articles on PJI after Total Hip Arthroplasty (THA).⁴¹ The increasing publications and citations indicate an active research community, with intensifying engagement in the PJI research. Our analysis sheds light on the limited funding in the published PJI research, with only 0.4% funded paper. This implies that the field has largely been driven by independent research efforts, highlighting researchers' dedication to understanding and addressing this critical challenge. As PJI research continues to flourish, understanding these trends will be crucial for maximizing the impact of future investigations and ultimately improving patient outcomes.

This analysis portrays a multinational effort in combating this formidable infection on a global scale, with the USA spearheading efforts while a diverse range of nations significantly contributes to the knowledge base. The USA emerges as the unequivocal leader, contributing a remarkable 31.58% of all PJI publications worldwide. This substantial share represents nearly one-third of the global research output from a single country, highlighting the USA's substantial commitment and dedicated resources toward addressing PJI. Germany follows as a distant second, contributing 9.28% of publications, while China and the United Kingdom secure the third and fourth positions with shares of 8.12% and 5.47%, respectively.

About 1/3rd of the global contribution of the USA highlights a substantial commitment and dedicated resources toward addressing PJI. Parvizi's contribution surpassing the average citation rate, underscores the substantial influence of their research. This significant contribution reflects the vital role of American researchers, particularly from institutions like Thomas Jefferson University, in advancing PJI knowledge. Recognizing these leading authors, their diverse affiliations, and their substantial contributions is vital to appreciating the collaborative and dynamic nature of PJI research. Their collective efforts, from investigating PJI pathogenesis to developing innovative diagnostic and treatment strategies, stand as a testament to the ongoing dedication and advancements in combatting this challenging infection.

5. Conclusion

This bibliometric analysis identified the most productive and impactful authors, organizations, countries, and journals in the research of PJI. In addition, the study identified the research trends and hotspots of the last two decades. We believe that such analyses should help in better understanding of PJI and provide crucial insights for researchers, clinicians, and healthcare providers who are involved in the management of PJI.

Funding

No funding in any form was received for this research.

Data availability

The raw data is available with the corresponding author and can be produced, whenever required.

Ethical approval

Not applicable for such bibliometric studies.

Declarations

• All the following authors hereby declare that there is conflict of interest regarding this manuscript & no funding was received from any source:

• -Raju Vaishya (Email: raju.vaishya@gmail.com)
• -Brij Mohan Gupta (Email: bmgupta1@gmail.com)
• -Mallikarjun M Kappi (Email: mkmallikarjun@gmail.com)
• -Ghouse Modin Nabeesab Mamdapur (Email: 20915@yenepoya.edu.in)
• -Abhishek Vaish (Email: drabhishekvaish@gmail.com)

• We declare that this manuscript has been solely submitted to Journal of Clinical Orthopaedics and Trauma and is not under consideration by any other journal.

• All the research presented in this paper is original.

Use of AI tool

No AI tool was used for this study.

CRediT authorship contribution statement

Raju Vaishya: Conceptualization, Literature search, Manuscript writing, editing, and final approval. Brij Mohan Gupta: Data curation, analysis, Literature search, Manuscript writing, editing, and final approval. Mallikarjun M. Kappi: Data curation, and analysis, Literature search, Manuscript writing, editing, and final approval. Ghouse Modin Nabeesab Mamdapur: Data curation, and analysis, Literature search, Manuscript writing, editing, and final approval. Abhishek Vaish: Conceptualization, Literature search, Manuscript writing, editing, and final approval.

Declaration of competing interest

None of the authors of the present study have declared any competing interests.

Appendix A. Supplementary data

The following is the Supplementary data to this article: