Abstract
Background/Objective
Despite the increase in global research on open fractures, which continue to be a significant cause of morbidity and mortality, seriously affecting the health and quality of life of patients, there has not been any bibliometric research on this subject. The aim of this study was to make a holistic analysis of scientific articles published on the subject of open fractures using bibliometric methods.
Methods
Articles published on the subject of open fractures between 1980 and 2021 were downloaded from the Web of Science (WoS) database, and were analysed using various statistical methods. Network visualisation maps were used to determine international collaborations and trend topics, and citation analyses to determine the most effective studies. Spearman’s correlation coefficient was used to determine correlations, and exponential smoothing predictors to estimate the number of articles to be published in the next 5 years.
Results
A total of 1742 articles were analysed. The 3 countries making the greatest contribution to literature were the USA (591, 33.9%), UK (219, 12.5%) and Germany (132, 7.5%). The most active author was Bhandari M. (n = 22). The 3 most productive institutions were determined to be the University of California System (n = 57), University of Washington (31), and Harborview Medical Center (29). The most active journal was Injury (n = 143).
Conclusion
According to the analysis applied to identify trend topics, the topics most studied in recent years were determined to be surgical site infection, orthoplastics, intramedullary nail, Masquelet technique, BOAST, bone healing, closed reduction, classification, outcomes, and lower limb.
Keywords: Open fractures, Bibliometric analysis, Trends
Introduction
The acute treatment of open fractures has always been a priority, and the subject continues to be of importance because of the high morbidity and mortality rates originating from associated complications. Open fracture is defined as the fracture of any bone in which the fracture fragments including soft-tissue injuries are exposed to the external environment through breakage of the skin [1–4]. The extent of the trauma is related to the total amount of energy transferred through the mechanism of injury. Many different complications may occur secondary to the fracture, such as compartment syndrome, non-union, loss of function, neurovascular damage, infection, osteomyelitis, and amputation [1, 2, 4].
In 1976, Gustilo and Anderson described a classification for open fractures according to the size of the related laceration, the degree of soft-tissue injury, and the presence of contamination and vascular damage, and this classification was improved in a subsequent study [1, 2]. Thus, the severity of open fractures is commonly categorised using the modified Gustilo-Anderson classification system. The prognostic value of the modified Gustilo-Anderson classification system is helpful in determining the course of treatment, and the risk of future infection, and the incidence of limb loss is related to Gustilo type, but the high rate of inter-observer variability is a significant limitation [1–4].
The treatment of open fractures constitutes a major clinical difficulty because of the higher energy involved which caused the injury, greater local trauma, tissue necrosis, and extensive contamination [5]. To obtain the best orthopaedic outcome for patients, early appropriate treatment of open fractures in the trauma is necessary [6]. Several studies have confirmed a high rate of bacterial contamination in open fractures and have shown that infection rates decrease when effective antibiotics are started early [1, 2, 4]. An 18.6% incidence was reported for surgical site infection (SSI) after open fracture surgery [7].
Open fractures in trauma are initially treated with local irrigation, debridement and the administration of antibiotics. The early administration of intravenous antibiotics is the most important factor for the first treatment of open fractures [6]. An adequate amount of irrigation is important to prevent the development of infection by cleaning foreign bodies out of the wound site. Although early surgical debridement is considered critical, the existing limited surgical techniques have reduced surgery to a minimum in favour of early antibiotic administration. There is no clear consensus on the subjects of surgical approach, debridement, or irrigation technique [5]. The general view of the treatment of open fractures includes tetanus vaccination, ample wound irrigation, operative debridement, definitive fixation and prophylactic antibiotics.
The antibiotic regimes recommended for all degrees of fractures include first, second, and third-generation cephalosporins. Open fractures require emergency and comprehensive treatment. Prophylactic antibiotic treatment is a very important part of the method to prevent infection and the risk of osteomyelitis [1, 2, 4, 8]. In the current guidelines of the East Practice Management Guidelines Work Group, it is recommended that systemic antibiotic treatment directed at Gram-positive organisms should be started as soon as possible after the injury. It has been emphasised that the addition of high-dose penicillin is necessary in the presence of faecal or potential clostridial contamination. Despite the potential clinical and source advantages of fluoroquinolones in the guidelines, current research does not support their use as single agent treatment, and it has been reported that these agents could impair fracture healing and could cause higher infection rates in Type III open fractures [3]. It has also been stated that continuation of antibiotics for 72 h (without continuing for more than 24 h after obtaining soft-tissue coverage) after injury in Type III fractures, and once a day aminoglycoside dose when necessary for Type II and III fractures is safe and effective [3]. Negative pressure wound therapy (NPWT) in the treatment of open fractures significantly reduced the risk of infection, and shortened the wound healing process and the length of stay in hospital [9].
Bibliometry is the analysis of scientific publications using various statistical methods [10–12]. Bibliometric research has been conducted on a variety of topics in the field of medicine in accordance with the increase in publications in the literature [10–14]. Despite the increase in global research on open fractures, for which the incidences of infection and non-union have decreased with new treatment approaches, but which continue to be a significant cause of morbidity and mortality, seriously affecting the health and quality of life of patients, no bibliometric research can be found in literature. The aim of this study was to make a holistic analysis of scientific articles published on the subject of open fractures between 1980 and 2021 using bibliometric and statistical methods.
Materials and Methods
Search Strategy
Web of Science Core Collection (WoS by Clarivate Analytics) database was utilized for literature search. The search period was set to 1980–2021 (publications before 1980 are not available in WoS). All publications with the phrase open fracture (or open fractures) in the title were found. Reproducibility codes to allow researchers to access similar documents (search findings may change based on different access dates, access date: 13 March 2022): (Title: (“open”) or Title (“fracture*”) Timespan: 1980–2021). The search was conducted in all research areas, but studies published outside of medical research areas (Dentistry Oral Surgery Medicine, Engineering, Materials Science, Geology, Mechanics, Veterinary Sciences, Water Resources, Energy Fuels, Environmental Sciences Ecology, Zoology etc.) were excluded and not included in the analysis. VOSviewer (Version 1.6.16, Leiden University's Center for Science and Technology Studies) software was utilized for bibliometric network visualizations, citation analysis, clustering and trend topic analysis [15].
Statistical Analysis
To create a world map showing the distribution of articles by country, the Internet site https://app.datawrapper.de was used. Statistical analyses of the data were performed using SPSS vn.22.0 software (SPSS Inc., Chicago, IL, USA; Licence: Hitit University). To estimate the number of articles that could be published in the next 5 years according to past publication trends, the Exponential Smoothing Predictor was used in Microsoft Office Excel program, which takes seasonal adjustments into consideration. Before choosing the statistical test in the correlation analysis, the data were tested for normal distribution using the Kolmogorov–Smirnov test. In the correlation analyses between global publication productivity on the subject of open fractures and some economic development markers of countries (data sourced from the World Bank [16]), such as Gross Domestic Product (GDP), Gross Domestic Product per capita (GDP per capita), and Human Development Index (HDI), the Spearman correlation coefficient was examined as the data did not show normal distribution. The level of statistical significance was set as p < 0.05.
Results
From a search of the WoS database, a total of 2727 publications were identified in all research areas on the subject of open fractures in the period 1980–2021. After the exclusion of 483 articles which were not in the field of medical research, 2244 medical publications remained. These comprised 77.6% (n = 1742) Articles, 6% (n = 135) Meeting Abstracts, 4.8% (n = 107) Review Articles, 4.4% (n = 100) Letters, 3.1% (n = 70) Proceedings Papers, and the rest were other types of publications (Corrections, Notes, Book Chapters, Discussions, Book Reviews, News Items, Biographical-Items). From the total 2727 publications, bibliometric analyses were made of 1742 categorised as Article, of which 89.5% (n = 1559) were in English and the remainder were in other languages (German (120), French (n = 31), Russian (20), Spanish (5), Serbian (2), Czech (1), Turkish (1), Japanese (1), Portuguese (1), Slovenian (1)). In the 1742 articles, the h-index was 81, the average number of citations per article was 18.82, and there were 32,777 total citations (without self-citations: 25,492). The vast majority of the articles were indexed in the SCI-Expanded Index (n = 1492, 85.6%) and the Emerging Sources Citation Index (ESCI) (n = 241, 13.8%), and 0.6% (n = 9) were in the Social Sciences Citation Index (SSCI).
Research Areas
After the Orthopedics research area (1004, 57.6%) on open fractures, the other top 10 research areas with the most research were Surgery (868, 49.8%), Emergency Medicine (238, 13.6%), Critical Care Medicine (221, 12.7%), Sport Sciences (173, 9.9%), Medicine General Internal (152, 8.7%), Pediatrics (54, 3.1%), Medicine Research Experimental (48, 2.7%), Clinical Neurology (34, 1.9%), Infectious Diseases (26, 1.4%), and Public Environmental Occupational Health (17, 1%), respectively.
Development of Publications by Year
Figure 1 shows a bar graph displaying the number of articles published each year. Figure 1 shows the results of the Exponential Smoothing prediction model utilized to predict the number of publications that may be published over the next five years. According to the estimation model results, 132 (95% confidence interval [CI]:119–145) articles could be published in 2022 and 164 (95% CI:140–189) in 2026 (Fig. 1).
Fig. 1.
Distribution of articles published on open fractures by years and estimates of the number of articles for the next 5 years
Active Countries
Figure 2 is displayed the distribution of the number of articles by country. The 15 countries with the most publications were determined to be the USA (591, 33.9%), the UK (219, 12.5%), Germany (132, 7.5%), China (113, 6.4%), India (92, 5.2%), Canada (70, 4%), Turkey (55, 3.1%), France (54, 3.1%), Switzerland (54, 3.1%), Japan (49, 2.8%), South Korea (43, 2.4%), Pakistan (31, 1.7%), Australia (30, 1.7%), Italy (26, 1.4%), and Taiwan (24, 1.3%) (Fig. 2). From the 90 countries that published articles on the subject of open fractures, cluster analysis was applied to 52 countries that produced at least 2 articles and had international collaboration between authors, and this is displayed in Fig. 3. As a consequence of the cluster analysis, 10 different clusters were formed reflecting international collaboration (Colours for Clusters, 1: red, 2: green, 3: blue, 4: yellow, 5: purple, 6: turquoise, 7: orange, 8: brown, 9: pink, 10: cherry). Figure 3 shows the international co-operation density map that was created using the scores from the calculation of the international co-operation score showing the strength of collaboration among the 52 countries (The top 10 countries with the greatest ratings in terms of global co-operation: USA = 136, England (in UK) = 77, Canada = 67, Australia = 43, Germany = 42, Switzerland = 35, Finland = 30, Belgium = 25, South Africa = 24, France = 23).
Fig. 2.
The world article productivity density map for all countries publishing articles on open fractures and the bar chart for the top 15 countries with the most articles
Fig. 3.
a Map of network visualization of cluster analysis results displaying international co-operation among countries in open fractures. Footnote: each colour represents a different Cluster. As the number of articles published by the countries increases, the area of the circles representing the countries also increases. The lines show the countries with which they cooperate. b Intensity map showing the strength of international co-operation of countries in open fractures. Footnote: the strength of the international co-operation score increases from blue to red (blue–green–yellow–red)
Correlation Analysis
A statistically significant correlation at a moderate level was determined between the number of articles on the subject of open fractures produced by countries and the HDI, GDP, and GDP per capita values (r = 0.511, p < 0.001; r = 0.677, p < 0.001; r = 0.650, p < 0.001, respectively).
Active Authors
The top 15 most active authors that contributed the most to the literature on Open fractures were determined as Bhandari M. (n = 22), Sprague S. (18), Tornetta P. (16), Khan U. (14), Giannoudis PV. (13), Itoman M. (13), Yokoyama K. (13), Petrisor B. (12), Jeray KJ. (11), Murray CK. (11), Pallister I. (11), Wenke JC. (11), Costa ML. (10), Court-brown CM. (10), and Krettek C. (10) respectively.
Active Institutions
The top 15 most active institutions that contributed the most to the literature on Open fractures were determined as University of California System (57), University of Washington (31), Harborview Medical Center (29), Harvard University (26), Mcmaster University (26), University of Maryland Baltimore (26), University of Texas System (26), United States Department of Defense (23), University of Toronto (23), Royal Infirmary of Edinburgh (22), University of Pennsylvania (22), University of Southern California (22), Pennsylvania Commonwealth System of Higher Education (21), Hannover Medical School (17), and San Antonio Military Medical Center (17), respectively.
Active Journals
The 1742 articles on the subject of open fractures were published in 374 different journals. Of these, the leading 63 journals making the greatest contribution to literature publishing 6 or more articles, the overall number of citations the journals received as well as the average number of citations per article are shown in Table 1.
Table 1.
The 63 most active journals that have published 6 or more articles on open fractures
| Journals | RC | C | AC | Journals | RC | C | AC |
|---|---|---|---|---|---|---|---|
| Injury-International Journal of the Care of the Injured | 143 | 2489 | 17.4 | Pakistan Journal of Medical & Health Sciences | 10 | 3 | 0.3 |
| Journal of Orthopaedic Trauma | 141 | 4345 | 30.8 | Surgical Infections | 10 | 52 | 5.2 |
| Clinical Orthopaedics and Related Research | 81 | 2741 | 33.8 | Annals of the Royal College of Surgeons of England | 9 | 139 | 15.4 |
| Journal of Trauma-Injury Infection and Critical Care | 58 | 3409 | 58.8 | Journal of Pediatric Orthopaedics-Part B | 9 | 33 | 3.7 |
| Journal of Bone and Joint Surgery-American Volume | 46 | 4367 | 94.9 | Orthopade | 9 | 50 | 5.6 |
| Unfallchirurg | 40 | 559 | 14.0 | Revue de Chirurgie Orthopedique et Reparatrice de L Appareil Moteur | 9 | 40 | 4.4 |
| International Orthopaedics | 35 | 484 | 13.8 | Acta Orthopaedica Scandinavica | 8 | 120 | 15.0 |
| Journal of Bone and Joint Surgery-British Volume | 34 | 2383 | 70.1 | Annals of Plastic Surgery | 8 | 121 | 15.1 |
| Archives of Orthopaedic and Trauma Surgery | 31 | 415 | 13.4 | Arthroscopy-The Journal of Arthroscopic and Related Surgery | 8 | 139 | 17.4 |
| Journal of Pediatric Orthopaedics | 31 | 520 | 16.8 | Journal of Orthopaedic Science | 8 | 38 | 4.8 |
| Orthopedics | 30 | 418 | 13.9 | Journal of Orthopaedic Surgery | 8 | 63 | 7.9 |
| Journal of Foot & Ankle Surgery | 24 | 160 | 6.7 | Malaysian Orthopaedic Journal | 8 | 21 | 2.6 |
| Bone & Joint Journal | 23 | 394 | 17.1 | Pakistan Journal of Medical Sciences | 8 | 40 | 5.0 |
| Indian Journal of Orthopaedics | 22 | 146 | 6.6 | Acta Orthopaedica Belgica | 7 | 26 | 3.7 |
| Plastic and Reconstructive Surgery | 21 | 1541 | 73.4 | Cureus | 7 | 7 | 1.0 |
| Journal of Hand Surgery-American Volume | 20 | 481 | 24.1 | Current Orthopaedic Practice | 7 | 7 | 1.0 |
| Zentralblatt fur Chirurgie | 17 | 54 | 3.2 | Journal Of Craniofacial Surgery | 7 | 55 | 7.9 |
| European Journal of Trauma and Emergency Surgery | 16 | 90 | 5.6 | Journal of Reconstructive Microsurgery | 7 | 47 | 6.7 |
| Helvetica Chirurgica Acta | 16 | 15 | 0.9 | Langenbecks Archiv fur Chirurgie | 7 | 9 | 1.3 |
| Journal of Orthopaedic Surgery and Research | 15 | 66 | 4.4 | Medicine | 7 | 10 | 1.4 |
| Journal of Trauma and Acute Care Surgery | 15 | 320 | 21.3 | Microsurgery | 7 | 95 | 13.6 |
| Orthopedic Clinics of North America | 15 | 336 | 22.4 | Trauma und Berufskrankheit | 7 | 1 | 0.1 |
| Foot & Ankle International | 14 | 238 | 17.0 | Ulusal Travma ve Acil Cerrahi Dergisi-Turkish Journal of Trauma & Emergency Surgery | 7 | 30 | 4.3 |
| European Journal of Orthopaedic Surgery and Traumatology | 13 | 26 | 2.0 | Vestnik Khirurgii Imeni I I Grekova | 7 | 1 | 0.1 |
| Strategies in Trauma and Limb Reconstruction | 12 | 88 | 7.3 | BMJ Case Reports | 6 | 0 | 0.0 |
| International Journal of Clinical and Experimental Medicine | 12 | 15 | 1.3 | Hand Clinics | 6 | 43 | 7.2 |
| BMC Musculoskeletal Disorders | 11 | 187 | 17.0 | Journal of Plastic Reconstructive and Aesthetic Surgery | 6 | 87 | 14.5 |
| Journal of Orthopaedic Research | 11 | 354 | 32.2 | Journal of Shoulder and Elbow Surgery | 6 | 84 | 14.0 |
| Knee Surgery Sports Traumatology Arthroscopy | 11 | 267 | 24.3 | Journal of the Pakistan Medical Association | 6 | 3 | 0.5 |
| Chirurg | 10 | 66 | 6.6 | Khirurgiya | 6 | 1 | 0.2 |
| Journal of Evolution of Medical and Dental Sciences-JEMDS | 10 | 7 | 0.7 | Unfallheilkunde-Traumatology | 6 | 284 | 47.3 |
| Orthopaedics & Traumatology-Surgery & Research | 10 | 83 | 8.3 |
RC record count, C number of citation, AC average citation per document
Citation Analysis
The 20 articles with the highest number of citations (> 190 citations: based on the total number of citations), out of the 1742 articles published on the topic of open fractures, are shown in Table 2. The average number of citations per year for the articles is displayed in the last column of Table 2.
Table 2.
The top 20 most cited articles with more than 190 citations on open fractures
| No. | Article | Author | Journal | PY | TC | AC |
|---|---|---|---|---|---|---|
| 1 | Problems in the management of type-III (severe) open fractures—a new classification of type-III open fractures | Gustilo RB. et al | Journal of Trauma-Injury Infection and Critical Care | 1984 | 1447 | 37.1 |
| 2 | Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures—A prospective, controlled, randomized study of four hundred and fifty patients | Govender S. et al | Journal of Bone and Joint Surgery-American Volume | 2002 | 1018 | 48.48 |
| 3 | Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia | Gopal S. et al | Journal of Bone and Joint Surgery-British Volume | 2000 | 344 | 14.96 |
| 4 | Management of open tibial fractures | Byrd HS. et al | Plastic and Reconstructive Surgery | 1985 | 293 | 7.71 |
| 5 | Vacuum sealing for treatment of soft-tissue injury in open fractures | Fleischmann W. et al | Unfallchirurg | 1993 | 287 | 9.57 |
| 6 | Factors influencing infection-rate in open fracture wounds | Patzakis MJ. and Wilkins J | Clinical Orthopaedics and Related Research | 1989 | 280 | 8.24 |
| 7 | Severe open fractures of the tibia | Caudle RJ. and Stern PJ | Journal of Bone and Joint Surgery-American Volume | 1987 | 260 | 7.22 |
| 8 | A new classification of soft-tissue damage in open and closed fractures | Tscherne H. and Oestern HJ | Unfallheilkunde-Traumatology | 1982 | 251 | 6.12 |
| 9 | Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures | Castillo RC. et al | Journal of Orthopaedic Trauma | 2005 | 246 | 13.67 |
| 10 | Closed intramedullary tibial nailing—its use in closed and type-I open fractures | Court-brown CM. et al | Journal of Bone and Joint Surgery-British Volume | 1990 | 245 | 7.42 |
| 11 | Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft—A prospective, randomized study | Keating JF. et al | Journal of Bone and Joint Surgery-American Volume | 1997 | 213 | 8.19 |
| 12 | Treatment of grade-IIIb open tibial fractures—a prospective randomized comparison of external fixation and non-reamed locked nailing | Tornetta P. et al | Journal of Bone and Joint Surgery-British Volume | 1994 | 208 | 7.17 |
| 13 | Lower extremity trauma: Trends in the management of soft-tissue reconstruction of open tibia-fibula fractures | Parrett BM. et al | Plastic and Reconstructive Surgery | 2006 | 206 | 12.12 |
| 14 | Negative pressure wound therapy after severe open fractures: a prospective randomized study | Stannard JP. et al | Journal of Orthopaedic Trauma | 2009 | 205 | 14.64 |
| 15 | The management of open tibial fractures with associated soft-tissue loss—external pin fixation with early flap coverage | Byrd HS. et al | Plastic and Reconstructive Surgery | 1981 | 198 | 4.71 |
| 16 | Local antibiotic therapy in the treatment of open fractures and osteomyelitis | Zalavras CG. et al | Clinical Orthopaedics and Related Research | 2004 | 197 | 10.37 |
| 17 | Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming | Whittle AP. et al | Journal of Bone and Joint Surgery-American Volume | 1992 | 197 | 6.35 |
| 18 | Open tibial fractures with associated vascular injuries—prognosis for limb salvage | Lange RH. et al | Journal of Trauma-Injury Infection and Critical Care | 1985 | 197 | 5.18 |
| 19 | Treatment of open fractures of the shaft of the tibia—a systematic overview and meta-analysis | Bhandari M. et al | Journal of Bone and Joint Surgery-British Volume | 2001 | 195 | 8.86 |
| 20 | Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures—timing of coverage and long-term functional results | Francel TJ. et al | Plastic and Reconstructive Surgery | 1992 | 191 | 6.16 |
PY publication year, TC total citation, AC average citations per year
Co-citation Analysis
There were a total of 20,036 publication listed in the references section of the 1742 articles published on the topic of open fractures. Among these publications, the 7 most effective articles with the most co-citations receiving more than 100 citations were by Gustilo and Anderson (1976), (Number of co-citation: NC = 525), Gustilo et al. (1984), (NC = 391), Patzakis and Wilkins (1989), (NC = 126), Gopal et al. (2000), (NC = 125), Godina (1986), (NC = 123), Gustilo et al. (1990), (NC = 115), and Patzakis et al. (1974), (NC = 110), respectively [1, 2, 17–21].
Trend Topics
In all of the 1742 papers published on the topic of open fractures, a total of 2474 different key words were utilized. The 99 different key words used in at least 6 different articles are shown in Table 3. The cluster network visualisation map showing the results of the cluster analysis applied to these keywords is displayed in Fig. 4. As a result of the cluster analysis, 8 different clusters were formed (Colours for Clusters, 1: red, 2: green, 3: blue, 4: yellow, 5: purple, 6: turquoise, 7: orange, 8: brown). Figure 5 is displayed the trend network visualisation map created to determine the trend topics. The most frequently cited topics are shown on the citation network visualisation map in Fig. 6.
Table 3.
The 99 most frequently used keywords in articles on open fractures
| Keywords | Number of uses | Keywords | Number of uses | Keywords | Number of uses |
|---|---|---|---|---|---|
| Open fracture | 248 | Tibial fracture | 14 | Outcomes | 8 |
| Open fractures | 107 | Ankle | 13 | Polytrauma | 8 |
| Infection | 100 | Calcaneus | 13 | Wounds | 8 |
| Tibia | 76 | Deep infection | 13 | Ankle fractures | 7 |
| Trauma | 76 | Open tibia fracture | 13 | Bone healing | 7 |
| Fracture | 66 | ORIF | 13 | Bone loss | 7 |
| Open | 46 | Surgical site infection | 13 | Free flap | 7 |
| External fixation | 43 | Antibiotic prophylaxis | 12 | Ilizarov | 7 |
| Debridement | 32 | Femur | 12 | Intramedullary nail | 7 |
| External fixator | 32 | Fracture healing | 12 | Injury | 7 |
| Open tibial fracture | 31 | Minimally invasive surgery | 12 | Pilon fracture | 7 |
| Complications | 30 | Osteosynthesis | 12 | Taylor spatial frame | 7 |
| Antibiotics | 27 | Orthoplastic | 11 | Tibial shaft fracture | 7 |
| Fractures | 26 | Osteoporosis | 11 | Boast | 6 |
| Tibia fracture | 26 | Dislocation | 10 | Bone | 6 |
| Limb salvage | 25 | Negative pressure wound therapy | 10 | Child | 6 |
| Osteomyelitis | 24 | Open pelvic fracture | 10 | Delay | 6 |
| Amputation | 23 | Open tibia fractures | 10 | Elderly | 6 |
| Intramedullary nailing | 23 | Pelvic fracture | 10 | Fixation | 6 |
| Internal fixation | 21 | Reconstruction | 10 | Forearm | 6 |
| Children | 20 | External fixators | 9 | Fractures, open | 6 |
| Non-union | 20 | Humerus | 9 | Gentamicin | 6 |
| Surgery | 18 | Lower extremity | 9 | Locking plate | 6 |
| Epidemiology | 17 | Quality of life | 9 | Management | 6 |
| Lower limb | 17 | Classification | 8 | Non-union | 6 |
| Outcome | 17 | Closed reduction | 8 | Orthopaedics | 6 |
| Pediatric | 17 | Complication | 8 | Percutaneous | 6 |
| Fracture fixation | 15 | Flap | 8 | Soft tissue | 6 |
| Open tibial fractures | 15 | Functional outcome | 8 | Spine | 6 |
| Tibial fractures | 15 | Kyphoplasty | 8 | Tibia fractures | 6 |
| Treatment | 15 | Masquelet technique | 8 | Union | 6 |
| Bone defect | 14 | Mortality | 8 | Vascular injury | 6 |
| Open reduction | 14 | Open pelvic fractures | 8 | Wound infection | 6 |
Fig. 4.
Network visualization map for cluster analysis based on keyword analysis conducted to reveal clustering of open fractures. Footnote: each colour represents a different cluster. Similar keywords are coloured together in a cluster. The greater the number of times the keyword is used in articles, the larger the area of the circle it represents
Fig. 5.
Network visualization map based on keyword analysis to reveal past and current trends in open fractures. Footnote: the indicator in the figure's lower right corner changes from blue to red as the keyword becomes more current (blue–green–yellow–red). The area of the circle that a keyword represents grows as its frequency in articles increases
Fig. 6.
Network visualization map based on keyword analysis conducted to reveal the most cited topics in open fractures. Footnote: the amount of citations for the issue increases from blue to red in the indicator in the lower right corner of the figure (blue–green–yellow–red). The area of the circle that a keyword represents grows as its frequency in articles increases
Discussion
When the trends on the subject of open fractures were evaluated according to years, 3 different trend periods were determined. In the first period of 1980–2006, an average of 22 articles per year (10–32) were published. In the second period of 2007–2013, this was an average of 52 (41–63) articles per year, and in the third period of 2014–2021, an average of 100 (74–132) articles were published per year. When the potential number of papers to be published over the following five years was assessed using the exponential smoothing predictor based on time series taking seasonal adjustment into consideration, it can be said that the number of articles predicted to be published on the subject of open fractures will increase with an exponential trend.
Looking at the distribution of publications of the countries, it was determined that 11 of the 15 most active countries that made the greatest contribution to the literature were developed countries (USA, UK, Germany, Canada, France, Switzerland, Japan, South Korea, Australia, Italy, and Taiwan). Although 3 of the 15 most active countries are classified as developing countries (China, India, Turkey), they are countries with large economies. Only Pakistan is an underdeveloped country in the 15 most active countries. When the results of the correlation analyses were evaluated, a statistically significant positive correlation at a moderate level was determined between the number of articles on the subject of open fractures produced by countries and the GDP, GDP per capita, and HDI values, showing that economic size and the level of development of a country are effective factors in article productivity [10–14].
A density map was formed according to the International Co-operation Scores and the 10 countries with the most intense collaboration were determined to be the USA, England, Canada, Australia, Germany, Switzerland, Finland, Belgium, South Africa, and France. When co-operation between authors was examined, although some global international collaboration was seen to be effective, regional international collaboration based on neighbouring geography was observed to be more common in article production (Countries in the same cluster and in similar geographic regions: (Argentina, Brazil, Mexico, Colombia), (Norway, Netherlands, North Ireland) (Canada, Denmark) (Austria, Belgium, Germany), (China, South Korea, Japan, Nepal, Indonesia), (England, Wales, Scotland, Czech republic), (France, Senegal, Morocco). Some of the countries in the same cluster and in different geographical regions: (USA, New Zealand, Italy, Egypt, Kenya, Tanzania), (Finland, Romania, South Africa, Spain, United Arab Emirates), (Australia, India, Saudi Arabia, Pakistan, Sweden, Singapore).
The journals publishing the most articles on the subject of open fractures were found to be the Injury-International Journal of the Care of the Injured, Journal of Orthopaedic Trauma, Clinical Orthopaedics and Related Research, Journal of Trauma-Injury Infection and Critical Care, Journal of Bone and Joint Surgery-American Volume, Unfallchirurg, International Orthopaedics, and the Journal of Bone and Joint Surgery-British Volume. It can be recommended that authors in the process of research or wishing to publish an article on the subject of open fractures consider the journals listed in Table 1.
When the citation analyses of the journals were assessed, the most influential journals based on the average number of citations per published paper were the Journal of Bone and Joint Surgery-American Volume (Average Citation Per Article, AC = 94.9), Plastic and Reconstructive Surgery (AC = 73.4), Journal of Bone and Joint Surgery-British Volume (AC = 70.1), Journal of Trauma-Injury Infection and Critical Care (AC = 58.8), Unfallheilkunde-Traumatology (AC = 47.3), Clinical Orthopaedics and Related Research (AC = 33.8), Journal of Orthopaedic Research (AC = 32.2), and the Journal of Orthopaedic Trauma (AC = 30.8). In order for their published studies to have more impact, researchers should first consider these journals.
In the evaluations according to the overall number of citations received by an article, the 3 most effective studies receiving the most citations were determined to be “Problems in the management of Type-III (severe) open fractures—a new classification of Type-III open fractures” published by Gustilo et al. (1984) in the Journal of Trauma-Injury Infection and Critical Care [2], “Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures—a prospective, controlled, randomized study of four hundred and fifty patients” by Govender et al. (2002) published in the Journal of Bone and Joint Surgery-American Volume [22], and “Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia” by Gopal et al. (2000) published in the Journal of Bone and Joint Surgery-British Volume [18].
When the articles under consideration were ranked by the average number of citations received each year, the most effective article was by Govender et al. (2002) [22], followed by Gustilo et al. (1984) [2], and the article entitled “Type III Open Tibia Fractures: Immediate Antibiotic Prophylaxis Minimizes Infection” published by Lack et al. (2015) in the Journal of Orthopaedic Trauma [23]. According to the number of co-citations, the most effective articles were determined to be those by Gustilo and Anderson (1976), Gustilo et al. (1984), Patzakis and Wilkins (1989), Gopal et al. (2000), Godina (1986), Gustilo et al. (1990), and Patzakis et al. (1974) [1, 2, 17–21]. It is suggested that orthopaedists and traumatologists who are interested in this subject first study these papers.
In the evaluation of the key word analysis findings, there were seen to be 8 different main clusters formed of the open fracture subjects as a result of cluster analysis. The most cited key words were determined to be osteomyelitis, tibial shaft fracture, union and non-union, negative pressure wound therapy, fracture healing, open pelvic fractures, infection, deep infection, internal fixation, calcaneus, and tibia fracture. The analysis used to identify trend topics revealed that the most frequently researched topics in recent years were surgical site infection, orthoplastics, intramedullary nail, Masquelet technique, BOAST, bone healing, closed reduction, classification, outcomes, and lower limb.
From a scan of literature on the subject of open fractures, no bibliometric study was found on this subject. In addition to citation analyses, the use in this research of several statistical approaches such as trend key word analysis, cluster analysis and correlation analyses, and that this is the first bibliometric study on this subject can be said to be the strengths of this research. A limitation could be considered to be that only the WoS database was used, but the WoS database indexes article content from more influential journals (only journals indexed in SCI-expanded, ESCI, and SSCI) compared to the Scopus database [10, 12, 13]. The PubMed database was not selected as citation and co-citation analyses could not be made. The fact that some journals from the developing world (where open fractures and sequels related to delayed or inadequate treatment of the same are likely to be more common), which are not included in WoS but indexed in other databases, were not included in the analysis in our study might lead to bias in favour of more developed countries.
Conclusion
In this extensive bibliometric study on the subject of open fractures, the findings are presented of the statistical analysis of 1742 articles published from 1980 to date. According to the analysis applied to identify trend topics, the topics most studied in recent years were determined to be surgical site infection, orthoplastics, intramedullary nail, Masquelet technique, BOAST, bone healing, closed reduction, classification, outcomes, and lower limb. For orthopaedists interested in the global implications of open fractures, this study can be regarded as a helpful resource.
Funding
The study had no funding source.
Declarations
Conflict of interest
Authors declare that they have no conflict of interest.
Ethical Approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed Consent
For this type of study formal consent is not required.
Footnotes
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Contributor Information
Taner Alıç, Email: taneralic@gmail.com.
Ercan Hassa, Email: dr.ercanhassa@gmail.com.
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