Abstract
Scaphoid fractures are commonly seen following a fall on an outstretched hand and often missed on initial presentation. An untreated scaphoid fracture may result in avascular necrosis of the scaphoid due to its retrograde blood supply. Published articles guide our investigation and management of these injuries. A citation analysis was performed on the top 30 articles relating to scaphoid fractures ranked by citation number. The 30 articles have been cited a total of 4595 times originating from 9 different countries. The leading article was cited 443 times with an average of 12.66 citations/year. Although this may not directly correlate with study quality, it does provide an insight to the influence which a paper has had on the scientific community. This list may prove invaluable to clinicians involved in the treatment of patients with scaphoid fractures and those actively furthering the development of the field.
Keywords: Scaphoid fracture, Citation, Bibliometric analysis, Orthopedic surgery, Altmetrics
1. Introduction
Scaphoid fractures account for 50–80% of carpal bone fractures in young active individuals. Commonly this is secondary to a fall on an outstretched hand.1 Due to the scaphoid’s retrograde blood supply, a fracture of the waist of the scaphoid may result in nonunion. Early diagnosis and appropriate management of the fracture is essential to ensure satisfactory healing, and reduce the likelihood of avascular necrosis (AVN). A plethora of articles have been published investigating the diagnosis and management of scaphoid fractures. Unquestionably, we have learned a great deal from historical authors with their published literature serving as an important tool in the growth of the field. Detailed ranking and analysis of these published articles acts as a useful tool for identifying which papers are most influential in guiding our decision making.
A citation acts to acknowledge author(s) or sources for research undertaken and published in the literature, which proves to be of significance for inclusion in the current author’s work. The number of citations an article receives indicates the impact which that article has had on its particular specialty. Citations also influence the Impact Factor (IF) of the journal in which the cited work is published, which therefore influences which journals are read. It is a measure of the frequency which an average article published in a journal has been cited during the previous two years. The IF was devised by Eugene Garfield, the founder of the Institute for Scientific Information (ISI). It is calculated by dividing the number of citations received in a year, of articles published in that journal during the preceding two years, by the total number of articles published by that journal in the preceding two years.2
There have been numerous publications investigating the most influential papers in a wide variety of specialties including orthopedics,3 breast surgery,4 general surgery,5 urology6 and plastic surgery.7 These specialties have also been broken down to sub-specialties to examine, for example in orthopedics, spinal deformity surgery,8 hip and knee arthroplasty,9 foot and ankle10 and shoulder surgery.11 To our knowledge, no study has investigated the most influential articles relating to scaphoid fractures. The aim of this study was to identify the 30 most cited articles and perform a bibliometric analysis to establish the most influential articles relating to scaphoid fractures.
2. Materials and methods
To identify the most cited articles relating to scaphoid fractures, a search of the Clarivate Analytics Web of Science Collection search engine was performed in June 2020 using the search term: Scaphoid Fracture, from 1945 to 2020. No limitations were applied to the Web of Science databases, categories, document types, or journals. 3736 articles were retrieved. Results were sorted by number of citations from highest to lowest. Article abstracts were analyzed for relevance to scaphoid fractures. When an abstract did not provide enough information, a review of the full text was performed. Papers not relevant to scaphoid fractures were excluded. A total of 42 papers were examined in detail with 12 papers being excluded based on irrelevance to the subject (Appendix 1). We decided to halt our search at the top 30 as beyond this number, the number of citations did not fall significantly. The difference between the 30th and 50th paper was 9 citations. The resulting 30 most cited articles were tabulated and further analyzed based on; publication year, country of origin, institution, journal, and mean citation number. Publication year was sorted by decade. Country of origin was defined as the address provided by the first named author. Mean citation number was calculated as the total number of citations the article has received divided by the number of years since publication (total citations/years since publication).
3. Results
The Top 30 articles relating to scaphoid fractures have been cited a total of 4595 times. The average number of citations is 153. The Top 30 articles, numbers of citations and mean citation number are listed in Table 112, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41. The most frequently cited paper was by Herbert et al.29 in 1984 investigating the management of scaphoid fracture fixation with a new bone screw with a total of 443 citations (mean citations 12.66/year). The earliest publication was in 1970 by Fisk27 and the most recent publication was in 2009 by Mulford et al.37. The most frequent decades in this list were the 80’s and 2000’s with 11 papers each published (Table 2). A total of 10 journals published the Top 30 articles (Table 3). Impact factors of these journals ranged from 0.39 to 7.608. The Journal of Hand Surgery – American Volume was top of this list with 10 publications (33%) and a combined 1493 citations (32.5%), followed closely by the Journal of Bone and Joint Surgery – American Volume (n = 6) (20%) and Journal of Bone and Joint Surgery – British Volume (n = 5) (16.6%). All papers were published in the English language. The top 30 articles originated from 9 different countries (Table 4), with the USA supplying 14 articles (46.6%), followed by England with 5 articles (16.6%). A total of 22 different institutions were responsible for the top 30 articles with four institutions responsible for more than one publication (Table 5). Mayo Clinic, USA published 6 (20%) of these articles followed by the University of Leicester, University of Washington and Medical University of Vienna with 2 publications each (6.67%). Cooney19, 20, 21 appeared 3 times as first author on the top 30 list with 366 citations. A number of topics were represented in this list of top 30 articles. 4 articles (13.3%) studied the radiological imaging of scaphoid fractures. 7 articles (23.3%) examined the use of screw fixation of scaphoid fractures. 8 articles (26.6%) examined the use of bone grafting for scaphoid nonunions.
Table 1.
Top 30 cited articles relating to scaphoid fractures.
| No | Title | 1st Author | Citations | Mean Citation No. (citations/year) |
|---|---|---|---|---|
| 1 | Management of the fractured scaphoid using a new bone screw | Herbert | 443 | 12.66 |
| 2 | Scaphoid malunion | Amadio | 252 | 8.4 |
| 3 | A new vascularized bone-graft for scaphoid nonunion | Zaidemberg | 245 | 8.75 |
| 4 | The natural-history of scaphoid nonunion | Mack | 219 | 6.26 |
| 5 | The fractured carpal scaphoid - natural-history and factors influencing outcome | Leslie | 217 | 5.71 |
| 6 | Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures | Bond | 206 | 11.44 |
| 7 | Herbert screw fixation of scaphoid fractures | Filan | 190 | 8.26 |
| 8 | Treatment of scaphoid nonunions: Quantitative meta-analysis of the literature | Merrell | 172 | 10.12 |
| 9 | Carpal instability and the fractured scaphoid | Fisk | 167 | 3.41 |
| 10 | The natural-history of scaphoid nonunion - a review of 55 cases | Ruby | 154 | 4.53 |
| 11 | Fractures of the scaphoid - a rational approach to management | Cooney | 135 | 3.46 |
| 12 | Free vascularized bone graft for nonunion of the scaphoid | Doi | 130 | 6.84 |
| 13 | Radiographically occult scaphoid fractures: Value of MR imaging in detection | Breitenseher | 129 | 5.86 |
| 14 | Early MRI in the management of clinical scaphoid fracture | Brydie | 126 | 7.88 |
| 15 | Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid - A prospective randomized study | McQueen | 125 | 11.36 |
| 16 | Nonunion of the scaphoid - analysis of the results from bone-grafting | Cooney | 124 | 3.18 |
| 17 | The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions | Chang | 123 | 9.46 |
| 18 | Degenerative change in symptomatic scaphoid nonunion | Vender | 122 | 3.81 |
| 19 | Central placement of the screw in simulated fractures of the scaphoid waist - A biomechanical study | McCallister | 118 | 7.38 |
| 20 | 20 questions about scaphoid fractures | Barton | 114 | 4.22 |
| 21 | Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion | Steinmann | 113 | 6.65 |
| 22 | Should acute scaphoid fractures be fixed? A randomized controlled trial | Dias | 112 | 8.00 |
| 23 | Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid | Gellman | 112 | 3.73 |
| 24 | Proximal row carpectomy vs four corner fusion for scapholunate (SLAC) or scaphoid nonunion advanced collapse (SNAC) wrists: a systematic review of outcomes | Mulford | 109 | 10.90 |
| 25 | Occult scaphoid fractures: Comparison of multidetector CT and MR imaging - Initial experience | Memarsadehi | 108 | 8.31 |
| 26 | Need the thumb be immobilized in scaphoid fractures - a randomized prospective trial | Clay | 107 | 3.82 |
| 27 | Scaphoid nonunion - role of anterior interpositional bone-grafts | Cooney | 107 | 3.45 |
| 28 | MR imaging of clinically suspected scaphoid fractures | Hunter | 106 | 4.82 |
| 29 | Fractures of scaphoid | Eddeland | 105 | 2.39 |
| 30 | A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability | Fernandez | 105 | 3.00 |
Table 2.
Top 30 articles published by decade.
| Decade | Number |
|---|---|
| 1970’s | 2 |
| 1980’s | 11 |
| 1990’s | 6 |
| 2000’s | 11 |
Table 3.
Top 30 articles published per medical journal.
| Journal | Number | Impact Factor 2018 |
|---|---|---|
| Journal of Hand Surgery-American Volume | 10 | 2.09 |
| Journal of Bone and Joint Surgery- American Volume | 6 | 4.716 |
| Journal of Bone and Joint Surgery- British Volume | 5 | 4.301 |
| Journal of Hand Surgery- European Volume | 2 | 2.225 |
| Radiology | 2 | 7.608 |
| American Journal of Roentgenology | 1 | 1.32 |
| Clinical Orthopedics and Related Research | 1 | 1.28 |
| Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery | 1 | 0.52 |
| Annals of the Royal College of Surgeons of England | 1 | 0.39 |
| British Journal of Radiology | 1 | 0.85 |
Table 4.
Countries of origin of Top 30 articles.
| Country | Number |
|---|---|
| USA | 14 |
| England | 5 |
| Australia | 3 |
| Japan | 1 |
| Sweden | 1 |
| Scotland | 2 |
| Austria | 2 |
| Argentina | 1 |
| Switzerland | 1 |
Table 5.
Institutions with multiple contributions to Top 30 articles.
| Institution | Number |
|---|---|
| Mayo Clinic, USA | 6 |
| University of Leicester | 2 |
| University of Washington | 2 |
| Medical University of Vienna | 2 |
4. Discussion
Our study identifies the Top 30 articles published on scaphoid fractures based on the number of citations received. Bibliometric analysis papers of this type are vitally important to the orthopedic community as it provides us with valuable information regarding the authors, topics and time periods that have had a profound influence on the specialty. It chronicles the changes in knowledge over a 75-year period. In this study, citation number was chosen as the marker of influence and determinant for selection. This has been performed for numerous other surgical disciplines and orthopedic topics.3, 4, 5, 6, 7, 8, 9, 10, 11 Citation analysis, although debatable,42 allows for a measure of peer-recognition and offers insights into the readership of the article. However, the citation number does not directly correlate with study quality. Despite this, a high citation number indicates that other researchers have found an article useful and its information worthy for inclusion and further discussion in their work. This impact indicator plays an important role in the evaluation of research, and resultantly these indicators have received a lot of scrutiny from the scientific community.
The most cited paper was Management of the fractured scaphoid using a new bone screw by Herbert (1984) published in the Journal of Bone and Joint Surgery-British Volume. This paper has been cited 443 times with a mean citation number of 12.66/year. Herbert described a new and simple operative technique for providing internal fixation of scaphoid fractures using a double-threaded bone screw. This was trialed over a 4-year period with 158 operations in both acute fractures and in nonunions combined with bone grafting. The rate of union was 100% for acute fractures and 83% overall.29 Innovation in screw technology and design continues today.
The second most cited paper was by Amadio et al. (1989), Scaphoid malunions published in the Journal of Hand Surgery-American Volume. This paper was cited 252 times (8.4 citations/year). Amadio followed 45 patients with scaphoid fractures more than 6 months after union by clinical examination and tri-spiral tomography scans for a mean of 63 months. They detailed the consequences should scaphoid malunion occur. He concluded that “union alone is an insufficient criterion for success in treating scaphoid fractures”.12
A total of 9 countries contributed to the Top 30 articles with the majority originating in the USA. Almost one half of those papers from the USA originated in the Mayo Clinic. 24 papers originated from countries where English is the first language. All countries represented on the list are first world countries with a large health care expenditure.43 The Top 5 articles were published in high impact journals, with impact factors ranging from 2.09 to 4.716. Our analysis suggests that research published from a prestigious institution in an English-speaking country, and a high impact journal is most likely to achieve a higher number of citations.
Interestingly, the Top 5 articles were published in a 10-year window between 1981 and 1991, over 28 years ago. Therefore, they have had considerable time to amalgamate these high citation numbers and this appears to be a key factor in their top positions. The average mean citation number of the Top 50 articles is 5.82. When we look at the mean citation number of the Top 5 articles, all but one paper significantly outperforms this (range 12.66–5.71). This suggests that these papers are highly influential papers in the field. However, a limitation in mean citation number is that it does not represent the evolution of a papers influence over time. For example, a paper which was published three decades ago and received widespread acknowledgement and numerous citations at that time may still retain a high mean citation number despite not being referenced for many years. O’Neill (2014) suggested that the mean citation number may in fact be effective in gauging the immediacy of impact a paper has, when comparing articles from different time periods.8 There are a further number of limitations associated with this type of study recognized by the authors. The Clarivate Analytics Web of Science Collection search engine used in this study spans from 1945 to present day. Therefore, any articles published before this date will not be included in our study which likely results in some true ‘classic’ research articles being excluded. Citation analysis also brings with it some inherent flaws. It does not take account of biased citing, self-citation, formal or informal influences not cited, technical limitations of citation indices, the “Matthew effect”, in-house bias and journal bias to name a few.42 ‘Obliteration by incorporation’ may also result in true classics being cited less frequently as their material becomes integrated into the current knowledge.44 Alternative metrics, or altmetrics, evaluate the impact of scholarly materials via online metrics, with an emphasis on data arising from social media outlets, including clicks, views, shares, downloads, saves, tweets, retweets, tags, mentions, bookmarks and commentary. Altmetrics will undoubtedly provide a complimentary online dimension to traditional citation metrics, which will become another dimension whereby the reach of a journal article can be assessed.45
5. Conclusion
In conclusion, our analysis of the Top 30 articles relating to scaphoid fractures has highlighted the most influential papers in the field. These cover a broad range of topics including diagnostics, management and prognosis of scaphoid fractures. Citation number was used to measure the impact of these papers. Although this may not directly correlate with study quality, it does provide an insight to the influence which a paper has had on the scientific community. This list may prove invaluable to clinicians involved in the treatment of patients with scaphoid fractures and those actively furthering the development of the field.
ICMJE criteria for authorship
Dr. Shane Irwin: Lead author, article conception and initial drafting. Final approval and agreement to be accountable for all aspects of the work.
Mr. Andrew Hughes: Contribution to article content, critical draft revision, final approval and agreement to be accountable for all aspects of the work.
Mr. Muiris Kennedy: Contribution to article conception, critical draft revision, final approval and agreement to be accountable for all aspects of the work.
Funding
No funding was received by the authors of this case report.
Declaration of competing interest
None declared.
Acknowledgements
None.
Appendix 1.
Search strategy.
References
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