Abstract
Background:
Clinical research is an integral component of orthopaedic practice with the purpose of advancing the field and improving patient care. The Journal of Bone and Joint Surgery (JBJS) is a well-respected journal with a high impact factor and considerable influence on clinical practice. To our knowledge, there has been no systematic evaluation highlighting the variety of research published in this journal. Therefore, the purpose of this study was to evaluate trends in characteristics of articles published in JBJS from 2012 to 2022, including type of study, level of evidence, author information, and country of publication.
Methods:
Articles published in JBJS between 2012 and 2022 were retrieved from the JBJS Archives. Title, level of evidence, description of the study as delineated in the abstract, first author degree, number of authors, and country of publication were recorded for each published article.
Results:
A total of 2668 articles were published in JBJS from 2012 to 2022. The proportion of preclinical studies published per year significantly decreased (P = 0.0025), whereas no statistically significant change was observed in the proportion of clinical studies (P = 0.34). A significant increase was noted in the proportion of database studies published (P = 0.00012). Studies classified as level II decreased over the study period (P = 0.029), whereas level III increased over the study period (P = 0.034). The average number of authors per article was 6 ± 3 authors with a significantly increasing trend over the study period (P = 0.0043). The proportion of first authors who were MD or equivalent decreased (P = 0.025), whereas first authors who were non-MD or non-PhD equivalent increased (P = 0.0068).
Conclusion:
The publication trends in JBJS over the past decade demonstrate the changing landscape of orthopaedic research as it aims to address the burden of musculoskeletal injury and disease.
Evidence-based medicine is intended to optimize decision making, treatment, and diagnosis based on well-designed research to provide the best care for patients. The Center for Evidence Based Medicine assigns the highest level to systematic reviews (SRs) of randomized controlled trials (RCTs) and individual RCTs.1,2 SRs and meta-analyses have become a staple in research; a three-fold increase in the publication of SRs over the past few decades has out-paced the overall growth of research.3-5
It is not clear whether the previously mentioned publication trends hold true for orthopaedic literature. In 2021, submissions to the Journal of Bone and Joint Surgery (JBJS) were approximately 76.7% scientific articles and 23.3% reviews, editorials, forums, or other.6 Of these submissions, approximately 18% of the scientific articles and 50% of the reviews were accepted for publication.6 Furthermore, previous reports have demonstrated a continued increase in the quantity of RCTs published in JBJS from 1988 to 2022.7-9 These trends suggest high productivity among orthopaedic researchers. As the field of orthopaedics continues to expand and change over time, the type of research that is published and the characteristics of its authors can also be expected to change.
Therefore, the purpose of this study was to classify the characteristics of JBJS publications, including the type of study, level of evidence (LOE), and author information and evaluate these trends over time. We hypothesize that the proportion of nonoriginal data published and proportion of first authors that are non-MD or equivalent increases over the study period.
Materials and Methods
Literature Selection
All articles published in JBJS from January 2012 to December 2022 were reviewed. Only papers categorized as “Scientific Articles” were included for data extraction. This excluded any papers categorized as “Guest Editorials,” “Current Concepts Review,” “The Orthopaedic Forum,” or “Commentary and Perspective.” Articles from the following journals were not included: JBJS Reviews, JBJS Open Access, JBJS Essential Surgical Techniques, JBJS Case Connector, and JBJS JOPA.
Data Extraction
Titles and digital object identifiers of articles from all issues of volumes 94 to 104 (2012 to 2022) of JBJS were collected. For each paper meeting inclusion criteria, the journal information, type of study, LOE, author information, and country of origin were recorded. The type of study was classified as clinical, preclinical, or other (Table 1). Clinical studies were further sub classified as original data, database, or nonoriginal. Preclinical studies were further subclassified as biomechanical, cellular, or anatomic. Level of evidence was reported on a scale from I to V. Author information included the degree of the first author (MD, DO, international doctorate, MD/PhD, PhD, or non-MD/DO) as well as the number of authors. The senior author information was used to determine the country in which the study was based.
Table 1.
Classification of Included Articles
| Type of Study | Definition |
| Original data | Any clinical study using patient data (cohort studies, case-control studies, randomized controlled trials) |
| Database | Any study using a national, insurance, or publicly available large database |
| Nonoriginal | Any study based on previously published research (systematic reviews, meta-analyses) |
| Biomechanical study | Any study using cadavers, bone models, and testing apparatuses |
| Cellular study | Any preclinical study involving in vitro experimental designs and/or animal models |
| Anatomic study | Any study defining anatomic distances, landmarks, and/or structural relationships without any biomechanical testing |
| Review | Any concept review article |
| Other | Any study not fitting into one of the above categories (cost/economic analysis studies, surveys of surgeons, education studies, validation of outcome instruments or classification systems, mathematical studies, computer modeling studies, technique articles) |
Statistical Analysis
Statistical analysis was performed using the R statistical package (Version 4.3.1, The R Foundation for Statistical Computing). Continuous variables were described with mean and standard deviation while categorical variables were described with frequencies and percentages. Pearson chi squared analysis or the Fischer exact test was used to determine whether there is an association between publication year and frequencies of key outcomes over the course of the study period, including type of study, LOE, degree of first author, and country of publication. Univariate linear regression analysis was used to determine whether key outcomes, including type of study, LOE, degree of first author, number of authors, and country of publication, can be predicted based on publication year. Trends over the course of the study period were analyzed for each outcome including, type of study, LOE, degree of first author, number of authors, and country of publication. For type of study, each specific category was analyzed separately. Statistical significance was set to P value of 0.05.
Results
There were 2668 articles published in JBJS between January 2012 and December 2022 that were included in the study. Overall, the most common type of study was clinical original data (62%), which was also the most common type of study for each year included (Table 2). Most articles were level IV evidence (26.2%; Table 3). The overall average number of authors per paper was 6.2 ± 2.6. Most first authors had a MD degree or equivalent (73.8%) and were from the United States (62.0%; Table 4).
Table 2.
Categories of Published Articles
| Publication Year | Type of Studya | |||||||
| Clinical | Preclinical | Other | ||||||
| Original Data | Database | Nonoriginal | Biomechanic | Cellular | Anatomic | Review | Nonreview | |
| Overall | 1655 (62) | 253 (9.5) | 49 (1.8) | 105 (3.9) | 184 (6.9) | 59 (2.2) | 32 (1.2) | 290 (10.9) |
| 2013 | 209 (66) | 13 (4.1) | 8 (2.5) | 9 (2.9) | 34 (10.8) | 8 (2.5) | 0 (0) | 33 (10.5) |
| 2014 | 208 (62.8) | 32 (9.7) | 8 (2.4) | 13 (3.9) | 26 (7.9) | 9 (2.7) | 5 (1.5) | 27 (8.2) |
| 2015 | 134 (65) | 16 (7.8) | 1 (0.5) | 8 (3.9) | 12 (5.8) | 6 (2.9) | 0 (0) | 28 (13.6) |
| 2016 | 135 (64) | 18 (9) | 7 (3) | 9 (4) | 15 (7) | 10 (5) | 0 (0) | 17 (8) |
| 2017 | 144 (65.2) | 23 (10.4) | 4 (1.8) | 6 (2.7) | 16 (7.2) | 4 (1.8) | 0 (0) | 22 (10) |
| 2018 | 135 (59) | 27 (12) | 1 (0) | 12 (5) | 10 (4) | 6 (3) | 0 (0) | 31 (13) |
| 2019 | 135 (61.9) | 23 (10.6) | 1 (0.5) | 12 (5.5) | 10 (4.6) | 3 (1.4) | 0 (0) | 28 (12.8) |
| 2020 | 114 (57) | 31 (15.5) | 2 (1) | 11 (5.5) | 4 (2) | 3 (1.5) | 0 (0) | 26 (13) |
| 2021 | 116 (56) | 27 (13) | 3 (1) | 6 (3) | 17 (8) | 1 (0) | 0 (0) | 27 (13) |
| 2022 | 134 (65.7) | 28 (13.7) | 0 (0) | 7 (3.4) | 11 (5.4) | 3 (1.5) | 0 (0) | 22 (10.8) |
Values presented as n (%).
Table 3.
Level of Evidence for Published Articles
| Publication Year | Total Articlesa | Level of Evidencea | |||||
| 1 | 2 | 3 | 4 | 5 | N/A | ||
| Overall | 2668 | 300 (11.2) | 258 (9.7) | 531 (19.9) | 700 (26.2) | 1 (0) | 878 (32.9) |
| 2012 | 325 (12.2) | 39 (12.0) | 50 (15.4) | 44 (13.5) | 77 (23.7) | 0 (0) | 115 (35.4) |
| 2013 | 314 (11.8) | 42 (13.4) | 49 (15.6) | 37 (11.8) | 91 (29.0) | 1 (0.3) | 94 (29.9) |
| 2014 | 331 (12.4) | 39 (11.8) | 39 (11.8) | 61 (18.4) | 80 (24.2) | 0 (0) | 112 (33.8) |
| 2015 | 206 (7.7) | 20 (9.7) | 14 (6.8) | 43 (20.9) | 62 (30.1) | 0 (0) | 67 (32.5) |
| 2016 | 211 (7.9) | 17 (8.1) | 27 (12.8) | 52 (24.6) | 48 (22.7) | 0 (0) | 67 (31.8) |
| 2017 | 221 (8.3) | 25 (11.3) | 13 (5.9) | 55 (24.9) | 60 (27.1) | 0 (0) | 68 (30.8) |
| 2018 | 230 (8.6) | 25 (10.9) | 6 (2.6) | 56 (24.3) | 63 (27.4) | 0 (0) | 80 (34.8) |
| 2019 | 218 (8.2) | 29 (13.3) | 11 (5.0) | 43 (19.7) | 64 (29.4) | 0 (0) | 71 (32.6) |
| 2020 | 200 (7.5) | 28 (14.0) | 15 (7.5) | 33 (16.5) | 59 (29.5) | 0 (0) | 65 (32.5) |
| 2021 | 208 (7.8) | 21 (10.1) | 18 (8.7) | 45 (21.6) | 55 (26.4) | 0 (0) | 69 (33.2) |
| 2022 | 204 (7.6) | 15 (7.4) | 16 (7.8) | 62 (30.4) | 41 (20.1) | 0 (0) | 70 (34.3) |
Values presented as n (%)
Table 4.
Characteristics of Authorship
| Publication Year | No. of Authorsa | Degree of First Authorb | Countryb | ||||
| MD | MD/PhD | PhD | Non-MD | US | Non-US | ||
| Overall | 6.2 (2.6) | 1969 (73.8) | 255 (9.6) | 158 (5.9) | 286 (10.7) | 1655 (62.0) | 1013 (38.0) |
| 2012 | 5.29 (2.0) | 245 (75.4) | 30 (9.2) | 20 (6.2) | 30 (9.2) | 191 (58.8) | 134 (41.2) |
| 2013 | 6.16 (2.6) | 239 (76.1) | 27 (8.6) | 17 (5.4) | 31 (9.9) | 194 (61.8) | 120 (38.2) |
| 2014 | 6.17 (2.4) | 249 (75.2) | 29 (8.8) | 16 (4.8) | 37 (11.2) | 199 (60.1) | 132 (39.9) |
| 2015 | 6.16 (2.4) | 157 (76.2) | 17 (8.3) | 14 (6.8) | 18 (8.7) | 146 (70.9) | 60 (29.1) |
| 2016 | 6.09 (2.5) | 152 (72) | 25 (11.8) | 16 (7.6) | 18 (8.5) | 124 (58.8) | 87 (41.2) |
| 2017 | 6.14 (2.5) | 171 (77.4) | 14 (6.3) | 11 (5) | 25 (11.3) | 153 (69.2) | 68 (30.8) |
| 2018 | 6.13 (2.2) | 171 (74.3) | 25 (10.9) | 11 (4.8) | 23 (10) | 145 (63) | 85 (37) |
| 2019 | 6.77 (2.9) | 150 (68.8) | 28 (12.8) | 12 (5.5) | 28 (12.8) | 133 (61) | 85 (39) |
| 2020 | 6.65 (3.6) | 152 (76) | 14 (7) | 10 (5) | 24 (12) | 120 (60) | 80 (40) |
| 2021 | 6.27 (2.7) | 147 (70.7) | 18 (8.7) | 18 (8.7) | 25 (12) | 126 (60.6) | 82 (39.4) |
| 2022 | 6.92 (3.1) | 136 (66.7) | 28 (13.7) | 13 (6.4) | 27 (13.2) | 124 (60.8) | 80 (39.2) |
Values presented as mean (SD).
Values presented as n (%).
Over the course of the study period, the proportion of preclinical studies published per year had a significant downward trend (P = 0.0025, R2 = 0.66), whereas there was no statistically significant change in the proportion of clinical studies (P = 0.34, R2 = 0.10; Figure 1 and Table 5). Although there was no overall change in the clinical studies category, the proportion of database studies published significantly increased (P = 0.00012, R2 = 0.82). A subanalysis of RCTs did not demonstrate a significant change over the course of the study period (P = 0.26, R2 = 0.14). There were not enough clinical nonoriginal articles to complete a regression analysis. Within the preclinical category, the proportion of cellular studies published significantly decreased (P = 0.039, R2 = 0.39). No significant change was observed within the biomechanic or anatomic studies.
Figure 1.
Graph showing trends in study types of publications from 2012 to 2022.
Table 5.
Trends in Evaluated Metrics From 2012 to 2022
| Dependent Variable | β coefficient from 2012 to 2022 | R 2 | P Value |
| Type of study (%) | |||
| Clinical | 0.32 | 0.10 | 0.34 |
| Original data | −0.34 | 0.09 | 0.37 |
| Randomized controlled trials | −0.32 | 0.14 | 0.26 |
| Database | 0.97 | 0.82 | 0.00012 |
| Preclinical | −0.57 | 0.66 | 0.0025 |
| Biomechanic | 0.00070 | 0.05 | 0.51 |
| Cellular | −0.46 | 0.39 | 0.039 |
| Anatomic | −0.17 | 0.26 | 0.11 |
| Other | |||
| Economics, policy, conference exhibits, occupational etc. | 0.34 | 0.28 | 0.096 |
| Level of evidence | |||
| 1 | −0.0018 | 0.077 | 0.41 |
| 2 | −0.0084 | 0.43 | 0.029 |
| 3 | 0.01 | 0.41 | 0.034 |
| 4 | −0.00082 | 0.0069 | 0.81 |
| 5 | — | — | — |
| First author degree | |||
| MD or DO | −0.74 | 0.44 | 0.025 |
| MD/PhD | 0.25 | 0.12 | 0.30 |
| PhD | 0.095 | 0.062 | 0.46 |
| Non-MD | 0.39 | 0.58 | 0.0068 |
| No. of authors | 0.10 | 0.61 | 0.0043 |
| US studies | −0.0096 | 0.0062 | 0.82 |
Values with P < 0.05 in bold.
There were statistically significant changes in the LOE of articles published during the study period; level II decreased (P = 0.029, R2 = 0.43), whereas level III increased (P = 0.034, R2 = 0.41; Table 5). The other LOE articles did not significantly change.
The average number of authors per article was 6.2 ± 2.6 authors with a significantly increasing trend over the study period (P = 0.0043, R2 = 0.61; Figure 2, Table 5). The proportion of first authors who were MD or equivalent decreased (P = 0.025, R2 = 0.44), whereas first authors who were non-MD or non-PhD equivalent increased (P = 0.0068, R2 = 0.58; Figure 2).
Figure 2.
Graph showing authorship trends in publications from 2012 to 2022.
Discussion
This investigation reflects the publication trends of JBJS over the course of a decade. The overall proportion of clinical research publications did not change significantly, whereas the proportion of preclinical studies significantly decreased. A notable increase was seen in database studies, level III studies, average number of authors per article, and first authors who were non-MD or non-PhD equivalents during the study period.
Although there were not enough clinical nonoriginal studies to perform a regression analysis, the increase in database studies supports our hypothesis that there would be an increase in studies that use nonoriginal data. Registry research in orthopaedic surgery continues to grow as a high volume of data has emerged from the widespread adoption of electronic medical records. The results of our study demonstrate this trend as we found that the proportion of these database studies did increase significantly with a near perfect model fit (R2 = 0.97; Table 5). The increasing popularity of TriNetX, a clinical data repository including 220 healthcare organizations across 30 countries,10 has likely contributed to the significant increase in the amount of database studies published between 2012 and 2022. Publications using data from the TriNetX network have grown since 2015, more than doubling each year from 2018 to 2021.10 Although the use of TriNetX for research purposes is relatively new, the rapid adoption during the COVID-19 pandemic accelerated interest in and utilization of this analytic platform as the need for global data aggregation heightened. In a recent review of podium and poster presentations at the American Association of Hip and Knee Surgeons, the rates of registry abstracts and podiums have continued to trend upward since 2019, with the highest poster acceptances in 2020 and the highest podium acceptances in 2022.11 Looking at specific registries over this time frame, the National Surgical Quality Improvement Program followed by PearlDriver were the most frequent datasets used.11 Although these registries and databases can provide valuable information, these data sources have limitations. Lack of clinical detail limits insight into causations. In addition, as these data sets examine numerous variables with large numbers, they can often show statistically significant associations that might be of limited clinical relevance.12
An analysis reviewing clinical articles published in nine orthopaedic journals found that 11.3% were level I evidence.13 Although the analysis was published 20 years ago, the findings of our study exhibit a similar trend with 11.2% of the included articles being of level I evidence. Level I studies have a higher mean number of statistical tests when compared with lower-level studies.14 This discrepancy in statistical tests is important to recognize when reviewing articles, as it can indicate the generalizability of an article's results. More recent analyses have demonstrated a concerted effort to increase level I evidence, with podium presentations at both the American Shoulder and Elbow Surgeons and American Association of Hip and Knee Surgeons meetings with increasing rates up to 17% and 11.8%, respectively.15,16 The endeavor of expanding level I research is encouraging as a well-known weakness in the orthopaedic literature is its tendency to contain retrospective studies with a lower LOE. Although we found a statistically significant decrease in proportion of level II studies and increase in proportion of level III studies, there was not a strong model fit (R2) for either. Furthermore, the strength of evidence is important in clinical decision making, but all studies, regardless of LOE, should still be examined for inherent biases, methodological errors, and unclear reporting. Randomized controlled trials represent the study design with the highest LOE and are commonly used as the basis for recommendations in the American Academy of Orthopaedic Surgeons clinical practice guidelines. However, previous reports found that 40% of RCTs published in JBJS from 1988 to 2000 and 47% of those published from 2001 to 2013 were of high quality.8 This finding demonstrates that all research should be interpreted with a critical lens.
The average number of authors per article was 6.2 ± 2.6 authors with a significantly increasing trend over the study period (P = 0.0043, R2 = 0.61; Table 5). The proportion of first authors who were MD or equivalent decreased (P = 0.025, R2 = 0.44), whereas first authors who were non-MD or non-PhD equivalent increased (P = 0.0068, R2 = 0.58) as suspected. Our results demonstrate a similar trend to other literature. A 70-year analysis of the top 10 orthopaedic journals found that the number of authors increased significantly over time from 1.4 authors in 1946 to 5.7 authors in 2019, representing an average relative increase of 4.3% per year.17 Interestingly, JBJS had one of the lowest average numbers of included authors over this period, with a mean 3.7 authors.17 The increase in average number of authors per article may be explained by several phenomena, including (1) emergence of large-scale clinical multicentered trials and group authorship; (2) number of articles being used as a metric for scholarly impact regarding academic promotion and reputation; and (3) medical student involvement in research.
The rate of group authorship increased from virtually 0% in 1946 to over 15% by 2019, with group authorship being most prevalent in journals that placed restrictions on the total number of authors allowed per manuscript.17 Most articles with a high number of authors credited for contribution are collaborative, large multicenter trials, such as the MultiCenter anterior cruciate ligament Revision Study groups (average of 192 authors per publication) or the Science of Variation Group (average of 134 authors per publication).17 Despite the changing landscape of authorship, it still remains the primary metric by which academicians are evaluated, affecting promotion and reputation. The potential implications of this culture seem to be authorship inflation and dishonest authorship practices.18,19 Regarding who qualifies for authorship, the International Committee of Medical Journal Editors has developed guidelines covering authors' roles and requirements.20 However, persistent expansion of authorship raises concerns regarding whether International Committee of Medical Journal Editors recommendations are being adhered to, leading to unwarranted authorship. A similar phenomenon may exist among applicants to orthopaedic surgery residency or fellowship.
An increase in medical student involvement in research may also explain the increase of non-MD or non-PhD equivalents as first authors. Although not specific to orthopaedic research, Wickramasinghe et al found an exponential increase in medical student research from 1980 to 2010, with medical students listed as the first author in 48.6% of studies.21 In the setting of increasing competition for orthopaedic surgery residency and fellowship spots, research is one way for applicants to distinguish themselves and bolster their applications. Unfortunately, a recent SR found that approximately one-fifth of applicants have a publication misrepresentation reported on their Electronic Residency Application Service application.22 Claimed authorship of a nonexistent article was the most commonly reported type of misrepresentation, followed by nonauthorship on an existing article.22 Future research should focus on ensuring integrity related to information that is self-reported by applicants. Despite this relatively concerning finding, previous investigations in other surgical fields have found that having students involved in research should be encouraged as it does not have a detrimental impact on the corresponding authors' H-index or scholarly advancement.23
The strengths of this study were the comprehensive manual search of the JBJS Archives, defined classifications for included articles, and the 10-year duration of the study period.
Limitations
Although this study strove to accurately represent the publication trends of JBJS, it should be interpreted with consideration of the following limitations. This investigation only evaluates the trends of a single journal, which limits the generalizability of these findings. Future research should assess other high-impact, orthopaedic journals to determine any comparable trends. The quality of reporting of the included studies may have hindered the evaluation of the true LOE. Notably, most the included studies self-reported LOE. However, when the LOE was not reported it was up to the discretion of the study team to assign one as necessary. The impact of this was mitigated by using criteria set forth by the Center for Evidence Based Medicine. Furthermore, the senior author reviewed any articles in which the study team could not determine a LOE.
Conclusion
This investigation reflects the dynamic environment of orthopaedic research by presenting publication trends of JBJS over the course of a decade. There have been notable changes in the types of studies being published and who is publishing them. As the research community grows, future endeavors should focus on conducting high-quality investigations and maintaining authorship integrity.
Footnotes
Dr. Gillespie or an immediate family member has received royalties from Shoulder Innovations; is a member of a speakers' bureau or has made paid presentations on behalf of DJ Orthopaedics; serves as a paid consultant to DJ Orthopaedics and Shoulder Innovations; has stock or stock options held in Aevumed, Collamedix, and Genesis Innovation Group; serves as a board member, owner, officer, or committee member of, American Shoulder and Elbow Surgeons. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Smith, Lavu, Piper, Dr. Maheshwer, Dr. K. J. Chen, and Dr. R. E. Chen.
Contributor Information
Monish S. Lavu, Email: msl142@case.edu.
Molly M. Piper, Email: molly.piper@uhhospitals.org.
Bhargavi Maheshwer, Email: bhargavi.maheshwer@uhhospitals.org.
Kallie J. Chen, Email: kallie.chen@uhhospitals.org.
Robert J. Gillespie, Email: robert.gillespie@uhhospitals.org.
Raymond E. Chen, Email: raymond.chen@uhhospitals.org.
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