Hispanic Authorship in Orthopaedics: A Bibliometric Analysis of Orthopaedic Literature in the United States

Abstract

Introduction:

Orthopaedic surgery has historically been among the least ethnically diverse fields in medicine. The latest American Academy of Orthopaedic Surgeons (AAOS) Census report in 2018 indicates that only 2.2% of all practicing orthopaedic surgeons in the United States identify as Hispanic/Latino. The effect of Hispanic representation on research and orthopaedic literature authorship is unknown. The purpose of this study was to establish Hispanic authorship trends in orthopaedic research by analyzing eight high-impact orthopaedic journals in a recent 10-year period.

Methods:

A bibliometric analysis was performed extracting original research articles with at least one US- based author from nine high-impact orthopaedic surgery journals from January 2012 to December 2021. Hispanic authorship was determined by matching author surnames to a modified Word and Perkins (1996) list of the most frequently occurring heavily Hispanic surnames. Data analysis was performed using Python and the statsmodels (v0.14.1) and SciPy (v.1.11.4) libraries. We determined the annual proportion of Hispanic authorship for first authors, senior authors, and any author, for all included articles and stratified by journal. Linear regression best-fit lines were employed to assess trends over time.

Results:

A total of 16,324 original research articles and 87,395 authors were included in the final analysis. Trend analysis of all included articles during the study period demonstrated increases in Hispanic first authorship (1.9% to 3.4%, P = 0.004), Hispanic senior authorship (2.0% to 3.0%, P = 0.087), and Hispanic total authorship (2.3% to 3.5%, P = 0.003). When stratified by journal, positive trends were seen in eight of nine journals for first and total authors. Six of nine journals demonstrated positive trends for senior authors.

Conclusion:

Although Hispanic orthopaedic authorship increased modestly over the study period, it appears to remain disproportionately low compared with the overall Hispanic population in the United States. These findings highlight the importance of future efforts needed to better understand possible causes of this underrepresentation in orthopaedic literature.

Orthopaedic surgery has historically demonstrated a lack of Hispanic representation relative to other surgical subspecialties^1,2, with Hispanic individuals comprising only 2.2% of the orthopaedic surgery workforce in 2018.³ Although this figure has increased from 1.8% in 2012,⁴ this proportion starkly contrasts the 65.1 million Hispanic individuals who make up 19.5% of the US population.⁵ Longitudinal data from 2001 to 2020 shows only modest gains, with Hispanic representation among incoming orthopaedic residents increasing from 0.3% to 4.4% over nearly two decades.⁶ In addition, the earliest data available from the Association of American Medical Colleges revealed that 6.5% of orthopaedic surgery residents were Hispanic. This is only slightly better than other surgical specialties such as neurosurgery (6.4%) and otolaryngology (6.1%). When compared with other specialties more broadly, Hispanics are much less likely to match into orthopaedics compared with specialties such as emergency medicine (8.8%), family medicine (10%), obstetrics and gynecology (9.6%), or plastic surgery (11.6%).⁷

The underrepresentation of Hispanic physicians in orthopaedic surgery has been attributed to limited early exposure and fewer mentorship opportunities.⁸ In response, several efforts have emerged to broaden access to the field through pipeline programs and early engagement opportunities such as American Association of Latino Orthopaedic Surgeons, J. Robert Gladden Orthopaedic Society, Nth Dimensions, and the Perry Initiative.^9,10 These organizations have continued efforts to examine and address potential structural and educational barriers that may limit entry into the field while fostering inclusive opportunities. Understanding how these efforts and overall Hispanic representation in orthopaedic surgery translates to research authorship is critical for evaluating progress.

Authorship and research productivity are considered key markers for success in academia. Current literature exploring trends in orthopaedic surgery research productivity and authorship has focused on gender disparities, with a notable paucity of studies examining racial or ethnic representation. For instance, a 25-year analysis revealed that although 42.7% of diversity, equity, and inclusion-focused publications addressed sex and gender disparities, only 11.9% concentrated solely on race and ethnicity, further highlighting a gap in the literature¹¹. The effect of Hispanic representation on research and orthopaedic literature authorship is, to our knowledge, unknown. Authorship and research productivity play a significant role in matching into orthopaedic surgery residency and overall academic promotion and ranking.¹² As a result, it would be of critical importance to determine baseline trends of Hispanic authorship in orthopaedic surgery. This may help elucidate broader challenges Hispanic medical students, residents, and attending orthopaedic surgeons face. Moreover, it may provide more insight into the barriers encountered when applying to residency and fellowship, navigating the academic promotion process, or securing leadership positions in academic medicine.

The purpose of this study was to analyze and characterize the trends in Hispanic authorship in orthopaedic research by analyzing nine high-impact orthopaedic journals in a recent 10-year period (2012 to 2021). By examining first authorship, senior authorship, and total authorship trends, this study aims to provide a comprehensive overview of US- based Hispanic contributions to literature to identify potential areas for future growth and support. We hypothesize that there have been increasing trends in Hispanic authorship in orthopaedics over a 10-year period.

Methods

Articles and authorship information from nine high impact, orthopaedic surgery journals were extracted during a ten-year period (January 2012 to December 2021) using the Clarivate Web of Science database. The following journals were included for review: Journal of Pediatric Orthopaedics (JPO), Journal of Orthopaedic Trauma (JOT), Journal of Shoulder and Elbow Surgery (JSES), Foot and Ankle International (FAI), Journal of the American Academy of Orthopaedic Surgeons (JAAOS), Journal of Arthroplasty (JOA), Clinical Orthopaedics and Related Research (CORR), Journal of Bone and Joint Surgery: American Volume (JBJS), and American Journal of Sports Medicine (AJSM). The journals included were either the highest-impact journals for orthopaedic surgery or the highest-impact factor journals for their respective orthopaedic subspecialty. Notably, the Journal of Hand Surgery and The Spine Journal were excluded from this review. This decision was made because of their overlap with other specialties, including plastic surgery and neurosurgery. Journal impact factors were obtained from the Clarivate Journal Citation Reports database for the year 2021 (Table 1).

Table 1.

Publication and Author Data for Journals Included

Journal	Impact Factora	Articles	Authors
Journal of Pediatric Orthopaedics (JPO)	2.5	1557	7929
Journal of Orthopaedic Trauma (JOT)	2.9	1582	8213
Journal of Shoulder and Elbow Surgery (JSES)	3.5	1794	10,169
Foot and Ankle International (FAI)	3.6	1099	5709
Journal of the American Academy of Orthopaedic Surgeons (JAAOS)	4.0	1482	6461
Journal of Arthroplasty (JOA)	4.4	3303	17,679
Clinical Orthopaedics and Related Research (CORR)	4.8	1544	7693
Journal of Bone and Joint Surgery: American Volume (JBJS)	6.6	1906	10,869
American Journal of Sports Medicine (AJSM)	7.0	2057	12,673
Total		16,324	87,395

^aImpact factor from 2021.

Inclusion criteria for articles required at least one listed author for each article to be from a university or institution located within the United States. This was done to specifically highlight the trends for contributions from authors in the United States and to minimize the possibility of authors from Hispanic countries that would otherwise be included in the study from affecting the goals of the study. For authors with hyphenated names, they were included into the study if any of the surnames listed were a direct match to the list of 926 identified Hispanic surnames. Articles with research study groups as the listed authors were also excluded from this study because of difficulty in ascertaining their degree of contribution to the listed article. Other publications such as newsletters, editorials, and commentaries were also excluded.

Determination of Hispanic author surname origin was performed by cross-referencing the author's surnames to a unique list of Hispanic surnames from the Word and Perkins¹³ list of Spanish Surnames, which accounted for the most frequently occurring Hispanic surnames from the 1990 US Census. In addition, a list of surnames of Hispanic origin was obtained from Name Census, a website that aggregates US demographic information from a variety of sources including the Bureau of the Census, the Library of Congress, and the Social Security Administration (https://namecensus.com/last-names/common-hispanic-surnames). Overall, a total of 926 Hispanic surnames were collected, with 639 of them coming from the Word and Perkins list and 287 from the Name Census list. This final list of 926 Hispanic surnames served as the reference list to identify Hispanic authors from the articles that were extracted from the journal search.

For each included article, the lists of authors were recorded by using openpyxl Python library and collections module to process and filter unique first, senior, and total authorship data. Data analysis was conducted using Python and the statsmodels (v0.14.1) and SciPy (v1.11.4) libraries, including scipy.stats.lineregress for linear regression calculations. Linear regression best-fit lines were used to assess trends over time. A P-value of less than 0.05 was considered statistically significant.

Results

A total of 16,324 original research articles and 87,395 authors were included in the final analysis. Trend analysis of all included articles during the study period (2012 to 2021) demonstrated increases across all authorship positions with first (1.9% to 3.4%, P = 0.004) and total (2.3% to 3.5%, P = 0.003) Hispanic authors demonstrating the sharpest improvement. Hispanic senior authors improved from 2.0% to 3.0% (P = 0.087) (Figure 1).

Figure 1.

Graph showing trends of Hispanic authorship (first, senior, and any authors) during a 10-year period (2012 to 2021). First authorship had the greatest positive slope (0.17), compared with total and senior authorship (0.13, 0.11). The use of best-fit lines was used to provide a clear visual representation of each trend.

The annual values for each journal's Hispanic authorship are included in Table 2. In aggregate, all author positions demonstrated positive trends. Eight of nine journals had increases in Hispanic total and first authorship (avg. increase of 1.1% [range, −0.4% to 2.9%] and 2.1% [range, −1.6%% to 4.8%], respectively). The senior authorship was found to have the most variability with only six of nine journals demonstrating a positive trend (avg. increase 0.8%; range, −3.1% to 2.5%). FAI was the only journal with a negative trend across all author positions throughout the study period.

Table 2.

Percent of Authors Identified as Hispanic (%)

Journal	Author Position	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	P
JPO	First	1.05	1.67	1.83	4.31	0.82	4.82	4.79	2.16	3.23	3.59	0.147
	Senior	2.25	1.74	0	0.92	0	0.7	2.38	1.97	1.2	6.02	0.163
	Any	2.66	2.22	1.38	2.4	1.09	3.48	2.09	2.32	3.23	2.83	0.300
JOT	First	2.75	0.89	1.59	5.3	2.52	2.74	1.27	2.98	3.4	3.37	0.461
	Senior	1.04	1.87	1.9	4.76	1.54	3.54	2.11	2.17	2.38	0	0.686
	Any	1.75	1.91	3.07	4.56	2.97	3.59	4.35	3.4	3.94	2.02	0.347
JSES	First	0.75	3.97	3.57	2.47	4.46	2.67	3.01	1.3	2.59	3.85	0.773
	Senior	0.9	1.82	3.92	6.06	3.01	4.17	1.5	3.85	5.73	2.38	0.409
	Any	2.12	1.35	3.81	3.16	4.16	4.63	3.15	3.46	4.5	3.25	0.097
FAI	First	2.5	3.39	4.12	3.96	2.44	1.04	0	1.71	2.53	0.93	0.057
	Senior	4.0	4.3	2.27	4.76	2.67	1.12	0	1.02	1.47	2.35	0.036
	Any	2.16	3.96	3.31	3.62	2.92	1.7	1.99	2.1	4.16	2.47	0.647
JAAOS	First	1.16	1.39	1.39	0	5.88	1.6	1.42	2.68	2.16	3.72	0.267
	Senior	1.16	0	1.35	3.03	0.93	2.44	2.9	0.47	4.48	3.17	0.069
	Any	2.21	1.07	2.83	1.76	2.95	2.79	2.31	3.05	2.54	2.75	0.116
JOA	First	0.63	2.42	4.8	1.38	4.98	1.77	1.71	3.11	3.73	2.45	0.602
	Senior	0.74	2	5.29	4.55	5.73	5.83	3.59	4.11	4.07	4.27	0.215
	Any	3.61	3.18	4.18	3.23	5.51	5.69	2.8	4.42	4.47	4.04	0.491
CORR	First	1.55	3.06	2.3	3.05	1.76	5.62	4.12	7.59	2.33	4.55	0.112
	Senior	2.96	2.43	4.04	2.25	1.88	4.55	2.27	2.6	3.8	1.2	0.603
	Any	2.9	3.15	3.18	2.79	2.42	3.67	2.94	4.36	4.19	3.08	0.154
JBJS	First	1.73	0.54	1.36	2.82	1.12	1.44	2.6	3.91	3.68	4.03	0.005
	Senior	0.61	1.76	1.52	0.61	0	2.6	3.24	1.82	2.65	2.9	0.042
	Any	1.7	1.82	1.92	2.11	1.56	2.43	2.39	2.6	3.01	2.99	0.001
AJSM	First	1.53	1.26	0.57	2.2	2.48	3.23	2.06	2.3	4.17	6.28	0.004
	Senior	0	2.11	0.67	0.66	1.84	1.25	0.65	1.78	2.74	1.02	0.243
	Any	0.85	1.54	0.89	1.27	2.56	1.58	2.92	3.27	3.28	3.73	<0.001

AJSM = American Journal of Sports Medicine, CORR = Clinical Orthopaedics and Related Research, FAI = Foot and Ankle International, JAAOS = Journal of the American Academy of Orthopaedic Surgeons, JBJS = Journal of Bone and Joint Surgery: American Volume, JOT = Journal of Orthopaedic Trauma, JOA = Journal of Arthroplasty, JPO = Journal of Pediatric Orthopaedics, and JSES = Journal of Shoulder and Elbow Surgery

Bold text indicates P < 0.05.

AJSM demonstrated the largest increase in Hispanic first authorship (4.8%, P < 0.004) (Figure 2). On average, there was a 1.1% (range, −1.8% to 3.8%) increase in Hispanic senior authorship during the 10-year study period; however, three of the journals (JOT, FAI, and CORR) demonstrated decreases in Hispanic senior authorship (Figure 3) during the same period. JPO demonstrated the largest increase in Hispanic senior authorship (3.8%, P = 0.163). The overall Hispanic total authorship increased, on average, 0.8% (range, 0.2% to 2.9%), with the largest increase observed for AJSM (2.9%, P < 0.001) (Figure 4).

Figure 2.

Graph showing trends of Hispanic first authorship for each journal during a 10-year period (2012 to 2021).

Figure 3.

Graph showing trends of Hispanic senior authorship for each journal during a 10-year period (2012 to 2021).

Figure 4.

Graph showing trends of total Hispanic authorship for each journal during a 10-year period (2012 to 2021).

Several journals revealed occasional years with zero publications containing Hispanic authors. For instance, zero Hispanic senior authors were found in select journals and years including JPO (2014, 2016), JOT (2021), JBJS (2016), AJSM (2012), or FAI (2018). In addition, zero Hispanic first authors were found in JAAOS (2015) and FAI (2018) publications.

Discussion

Our results suggest that Hispanic authorship has slightly increased over the 10-year study period. Hispanic authorship increased across first, senior, and total authorship during the 10-year study period, with first and total authorship demonstrating the greatest increases. In addition, Hispanic first authorship displayed the steepest growth. Across journals, first and total authorship increased in eight of the nine journals analyzed and senior authorship increased in six of the nine journals. These findings provide evidence for progress in Hispanic authorship in the orthopaedic literature.

According to the Orthopaedic Surgeon Census conducted by the AAOS,^3,4 Hispanic orthopaedic surgeons represented 1.8% of practicing surgeons in 2012 and 2.2% in 2018. During this same 6-year timeframe, Hispanic authorship in our study for first, senior, and total authorship increased by 1.6%, 0.7%, and 0.8%, respectively. Over the 10-year period of the study, Hispanic authorship for first, senior, and total authorship increased by 2.2%, 1.3%, and 0.9%, respectively. Although differences in timeline and data sets make definitive conclusions difficult, the larger rise in Hispanic authorship compared with the number of practicing Hispanic orthopaedic may suggest that Hispanic research and academic productivity is growing at a faster rate than the overall Hispanic orthopaedic workforce. Although this phenomenon is likely multifactorial, the rise in authorship could stem from the increased research involvement of Hispanic medical students and residents. Almost 8% of all orthopaedic residents in the United States are of Hispanic origin 8, a population that is growing at a faster rate than the overall orthopaedic workforce. This growth is likely the result of recent efforts to diversify the field of orthopaedic surgery with pipeline programs and early engagement organizations, such as American Association of Latino Orthopaedic Surgeons, J. Robert Gladden Society, and Perry Initiative, have played a role in such changes^7,14.

Despite the notable improvements in Hispanic authorship, representation remains disproportionately low compared with the Hispanic population in the United States. The absence of Hispanic authors for entire years across multiple journals (JPO, JOT, FAI, JBJS, JAAOS, and JBJS) is noteworthy. Several journals had zero Hispanic authors identified in a year during the study period, including JPO, JBJS, AJSM, JOT, and JAAOS. There were nine instances in which zero Hispanic authors were identified when stratified by journal and author position, and seven of the nine occurred in senior authorship positions. These findings may reflect a small number of Hispanic orthopaedic surgeons in academic roles. It is particularly notable the absence of Hispanic senior authors on many of those years. Senior authors are typically the engine behind the design and execution of research projects, with direct responsibility and oversight. Their leadership is also closely tied to mentorship for younger generations of students and surgeons. Although the number of Hispanic orthopaedic surgeons has been increasing over the past few years, it is likely that only a fraction of them practice in an academic environment, as compared with a private or community-based practice, with a direct effect on the number of published articles on a given year.

The increasing trend in Hispanic authorship observed in this study was primarily due to increases in first author publications, which is similar to a phenomenon described by Okewunmi et al.,¹⁵ when analyzing female authorship trends in orthopaedic surgery. It may be reasonable to attribute some of the observed increases in Hispanic first authorship representation to a combination of successful diversity efforts and the effect of research for an individual's competitiveness in the field. Research items are frequently used as measures of academic success and often used to assess competitiveness for residency, fellowships, and faculty appointments. The slower growth seen in senior authorship may represent either that fewer Hispanic orthopaedic surgeons are choosing academic careers or a lag effect for those choosing academics in reaching a senior position.^16,17 It may be reasonable to expect slower growth in senior authorship given the additional time required for junior academic faculty to progress into more senior leadership and research roles. As representation increases in medical schools and residencies, we should expect senior-level positions to demonstrate similar growth in the future.

This study has several limitations. The authors were identified as Hispanic by cross-referencing the authors' surnames to a unique list of Hispanic surnames from either the Word and Perkins¹³ list of Spanish Surnames and/or a list of surnames of Hispanic origin from Name Census (https://namecensus.com/last-names/common-hispanic-surnames), a website that aggregates US demographic information from a variety of sources including the Bureau of the Census, the Library of Congress, and the Social Security Administration. Although every effort was made to use reliable, verified information, there are certainly several Hispanic surnames that may not have been included. This ultimately may have resulted in underestimating the true representation of Hispanic authors. This is particularly applicable to those individuals of mixed heritage whose surname may not have been identified as Hispanic in the analysis. Moreover, there are certainly individuals who may have changed their surname due to marriage, or who are from a country like the Philippines were Hispanic surnames are common but who do not identify as Hispanic/Latino, which could have resulted in either overrepresentation or underrepresentation of Hispanic authorship. We believe that the large number of authors and journals captured during the 10-year study period may have helped reduce this potential limitation. It is likely that the inclusion of demographic data on future publications will help provide a more accurate understanding of authorship trends across the specialty. Future research may consider incorporating self-reported demographic data to explore the intersectionality of race, ethnicity, and sex in authorship trends. In addition, certain subspecialty journals were excluded, such as the Journal of Hand Surgery and The Spine Journal. Although our intention was to minimize a potential overlap between orthopaedic surgeons and surgeons in other specialties (plastic surgery and neurosurgery), this decision might have resulted in an incomplete understanding of Hispanic authorship trends across the full spectrum of orthopaedic surgery.

To the authors' knowledge, this is the first study investigating trends of Hispanic authorship in the orthopaedic literature. Our results suggest that Hispanic authorship has slightly increased over the 10-year study period, with first authorship and total authorship demonstrating the largest increases. Although these trends could reflect the rise in Hispanic representation within the orthopaedic surgery specialty, the overall increase in Hispanic authorship is small. Although encouraging, these numbers represent a very small fraction of both the overall orthopaedic surgery authorship and its Hispanic representation.