A Scientometric Analysis of the most Highly Cited Publications on Fracture Research from India: 1989-2022

Introduction

India bears a heavy burden of accidents and fractures, due to rising road traffic accidents (RTAs),^1,2 causing increased morbidity and disability, and impacting the quality of life, besides imposing a significant economic burden on the health system.³ Osteoporotic fractures are also on the rise.^4,5,6,7

There has been an increased interest in fractures as is evidenced by numerous published research, research grants, and the development of fracture-related activities. As the body of literature regarding fractures continues to grow, an analysis of the most impactful literature is justified to direct future research and pay tribute to the highest contributing work within the field.

Several publications have investigated the most influential articles on various bone fractures like calcaneus,⁸ hip,^9,10,11 proximal humerus,¹² scaphoid,¹³ and spine.^14,15,16 However, fracture research at the global and national levels has been rarely studied from a bibliometric perspective. Among global studies, Baldwin et al¹⁷ studied the 100 most cited articles in fracture surgery and identified their characteristics to determine the qualities that make an article highly cited in this field. At the national level, Dong et al¹⁸ studied the characteristics of the most-cited articles on fracture surgery by Chinese authors.

No bibliometric study has investigated, so far, the most influential articles relating to Indian fracture research. We believe that the most highly cited publications (HCPs) of fracture research will have the most historically influential impact and will also play a significant role as the basis for recent studies to build on. Therefore, we decided to undertake a comprehensive review of the most influential articles related to fracture research from India. The study aims to identify India's HCPs, examine their trends, and identify the various characteristics of fracture research between 1989 and 2022, using bibliometric methods.

Methods

The terms related to fractures were searched in the Scopus database for articles published between 1989 and 2022 for retrieving relevant output on fracture research from Indian on December 2, 2022 using the retrieval search strategy highlighted in ►Fig. 1. In all, 1,408 records on India's fracture research were retrieved, of which 126 HCPs with a total citation [TC] of ≥20 were isolated, after excluding 1,282 articles that were not HCPs.

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Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart showing the inclusion and exclusion details of the study.

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Detailed ranking and analysis of these HCPs are useful for identifying the most influential articles in guiding our decision-making. Bibliometric tools were used for this study. The main analyses include publication and citation counts, the contribution of countries, institutions, authors, funding agencies and journals, and the clustering of keywords. This study used VOSviewer for visualizing the co-occurrence analysis of keywords. (N.B.: Co-occurrence is a method to analyze text that includes a graphic visualization of potential relationships between people, organizations, countries, or other entities represented within written material.)

The most productive authors were defined as those who have contributed more than the average productivity of all the authors. The most impactful organizations were defined as organizations that have registered a higher citation per paper (CPP) than the average CPP of all the organizations. India's authors and institutions were included in this study when one of the authors or institutions in the publication were from India.

((TITLE(fracture) AND TITLE(orthoped* or orthopaed*)) AND PUBYEAR > 1988 AND PUBYEAR < 2023) OR ((TITLE(fracture) AND SRCTITLE(orthoped* or orthopaed*)) AND PUBYEAR > 1988 AND PUBYEAR < 2023) AND (LIMIT-TO (AFFILCOUNTRY,”India”))

Bibliometrics is a method of statistical analysis used to assess a particular subject's characteristics and major developmental trends based on published research publications. It is a validated method for collecting and identifying impactful studies across scientific and medical fields. Because TC count is thought to be predictive of an article's overall impact, focusing on TC count through careful analysis allows scholars to present both empirical and subjective findings related to the most influential works within a field.¹⁹

Results

Citation Life Cycle Pattern of Top 10 HCPs

In the initial years after publication, articles generally receive a small but growing number of citations until, eventually, they reach a peak from where they tend to decline (►Fig. 2). Among the top 10 HCPs, the article authored by Dhanwal et al in 2011²⁰ received the highest number of 347 citations during the study period. However, the article by Garg et al in 1993²¹ is cited 135 times.

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Fig. 2

Citation life cycle of top 10 high-cited publications.

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Most Productive and Most Impactful Authors

In all, 470 Indian authors participated in 126 HCPs, of which 411 authors published 1 article each, 43 authors published 2 articles each, 7 authors published 3 articles each, 5 authors published 4 articles each, 3 authors published 5 articles each, and 1 author published 6 articles. The top 46 authors contributed 2 to 6 articles each and together contributed 122 articles and 3,527 citations, accounting for a share of 96.83 and 75.70% in total publications and total citations, respectively. It was also observed that the top 16 authors contributed more than the average group publication productivity (2.65) of 46 authors, and 19 authors registered CPP and RCI of more than the group average (28.91 and 0.78, respectively) of the top 46 organizations. ►Table 3 presents the profile of the top 8 most productive and 8 most impactful authors. The details of the HCPs of the most productive authors (with references) are presented in ►Supplementary Table S1 (available in the online version only).

Table 3 Profile of top 8 most productive and 8 most impactful authors

Sl. no.	Name of the author	Affiliation of the author	Total papers	Total citations	Citations per paper	Relative citation index	Total link strength
Top 8 most productive authors
1	R. Malhotra	AIIMS, New Delhi	6	216	36.00	0.97	21
2	M.S. Dhillon	PGIMER, Chandigarh	5	181	36.20	0.98	17
3	N.K. Magu	Pt. BDS PGIMS, Rohtak	5	134	26.80	0.72	19
4	R. Singh	Pt. BDS PGIMS, Rohtak	5	139	27.80	0.75	16
5	S. Aggarwal	PGIMER, Chandigarh	4	141	35.25	0.95	12
6	S.K. Tripathi	PGIMER, Chandigarh	4	136	34.00	0.92	14
7	R.K. Sen	PGIMER, Chandigarh	4	136	34.00	0.92	14
8	R. Vaishya	Indraprastha Apollo Hospital, Delhi	4	78	19.50	0.53	12
Top 8 most impactful authors
1	U.K. Meena	SMS Medical College, Jaipur	2	102	51.00	1.38	5
2	A.P. Singh	UCMS, Delhi	2	96	48.00	1.30	6
3	P. Sancheti	Sancheti Institute of Orthopaedic Research & Rehabilitation, Pune	2	94	47.00	1.27	76
4	L. Maini	MAMC, Delhi	3	129	43.00	1.16	7
5	D. Gulati	UCMS, Delhi	2	73	36.50	0.99	6
6	M.S. Dhillon	PGIMER, Chandigarh	5	181	36.20	0.98	17
7	R. Malhotra	AIIMS, New Delhi	6	216	36.00	0.97	21
8	A.K. Singh	Mayo Institute of Medical Sciences	3	107	35.67	0.96	3

Abbreviations: AIIMS, All India Institute of Medical Sciences; BDS PGIMS, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences; MAMC, Maulana Azad Medical College; PGIMER, Postgraduate Institute of Medical Education and Research; SMS, Sawai Madho Singh; UCMS, University College of Medical Sciences.

The collaboration links among the top 46 authors were considered to be stronger compared to institutional collaboration. Among author collaboration pairs, 206 pairs have 1 collaboration link, 20 pairs have 2 collaboration links, 4 author pairs have 3 collaboration links, and 2 author pairs have 4 collaboration links. The author network collaborative map among top authors is shown in ►Fig. 3.

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Fig. 3

Authors' co-authorship network.

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Discussion

Despite a large burden of fractures in the Indian population, due to road accidents^1,2 and other causes, not much research has been done so far, especially on the prevalence of these fractures and the published literature from Indian authors on this topic. However, the research output of the Indian authors in other fields like orthopaedics^30,31,32 and arthroplasty³³ have been studied. Rupp et al³⁴ found an increase in the incidence of fractures by 14% in Germany between 2009 and 2019. They observed that the most common fractures were femoral neck fractures (120 per 100,000 persons per year), pertrochanteric femoral fractures (109 per 100,000 persons/y), and distal radius fractures (106 per 100,000 persons/y). We also noted a significantly higher incidence of fractures in the lower limb, accounting for two-thirds of fractures (65.98%), compared to the upper limb fractures. However, the publications on upper limb fractures were more impactful and received a higher CPP, as compared to the publications on lower limb fractures. In our study, the HCPs related to fractures in adults and older people were substantially more (83/126) as compared to those of adolescents and children (43/126). In a systematic analysis of global, regional, and national burden of bone fractures in 204 countries and territories between 1990 and 2019, it was suggested that strategies should be focused on decreasing the incidence and burden of fractures by screening for osteoporosis in older people, promoting diet to improve bone health, reducing the risks of falls, providing a safe environment at work, and reducing the RTA by enforcing policy reforms and road safety measures.³⁵

Using a bibliometric approach, the present study has identified and retrieved the most relevant and comparative HCPs in India's fracture research. We studied mainly the present trends and characteristics of India's fracture research by identifying the main types and subtypes of fractures and their distribution by anatomical location, sex, and population age groups. We identified the prominent collaborating countries, organizations, authors, and journals, besides significant keywords.

Vaishya et al reported that India's publications in orthopaedics grew at a rate of 20.8% annually in the last two decades, and 10.4% of Indian studies received external funding and 16.3% were international collaborations.³⁰ Karlapudi et al³¹ found New Delhi to be the epicenter of publications related to orthopaedics, similar to our findings related to fractures. Vaish et al³² found that in Indian HCPs related to orthopaedics 24.58% publications received external funding and 36.87% publications were an international collaboration. This is higher than our findings according to which there was external funding in 1.59% publications and international collaboration in 15.08% publications, signifying a lower interest in the fracture research from India. We concur with the views that national and international collaboration in research helps in exchanging ideas, provides better-quality results, and may provide access to external funding for research.^36,37

The leading teaching government institutions of India were the most productive and impactful organizations in fracture research, with AIIMS, New Delhi, PGIMER, Chandigarh, and Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (Pt. BD Sharma PGIMS), Rohtak, being the most productive organizations. The MAMC, Delhi, JIPMER, Pondicherry, and Sancheti Institute of Orthopaedic Research & Rehabilitation, Pune, were the most impactful organizations, receiving the highest CPP. The top three organizations reporting the highest collaboration linkages and intensity with other Indian and foreign organizations were the following: PGIMER, Chandigarh, and Sancheti Institute of Orthopaedic Research & Rehabilitation, Pune (n = 13 linkages each) and AIIMS, New Delhi (n = 11 linkages).

Among the authors, R. Malhotra, M.S. Dhillon, and N.K. Magu were the most productive authors with 6, 5, and 5 articles, respectively, and U.K. Meena, A.P. Singh, and P. Sancheti registered the highest CPP (►Supplementary Table S1, available in the online version only). The authors reporting the highest collaborative linkages were P. Sancheti (76 linkages), R. Malhotra (21 linkages), M.S. Dhillon (17 linkages), and R. Singh (17 linkages). Among journals, the Indian Journal of Orthopaedics, International Orthopaedics, Hong Kong Journal of Orthopaedic Surgery, and Journal of Orthopaedics & Traumatology were the most productive journals (with 11–22 articles). The Proceedings of the National Academy of Sciences of USA, The Lancet, Acta Orthopaedica, and Journal of Pediatric Orthopaedics: Part B registered a comparatively higher CPP, and all these journals have a higher impact factor.

There are a few limitations to the present study. Only a single database of Scopus was searched, and other databases and sources (e.g., Web of Science) were not included in this bibliometric analysis. Therefore, some potential information may have been missed due to the noninclusion of some of the publications in the Scopus database. However, the use of multiple databases may lead to other difficulties in merging existing data in different databases available in different formats. In addition, there are chances that funding-related information may not be complete, an author's name may be similar to some other author's name, etc. We acknowledge that bibliometric studies do not involve clinical data of the patients; however, this is a well-established research method of evaluation of scientific contents. These studies are also valuable and useful as supporting tools for decision-making in setting research priorities, tracking the evolution of science and technology, funding allocation, and rewarding scientific excellence, among others.³⁸ We believe that bibliometrics is an objective and quantitative way of measuring research impact. The methodology is reproducible, transparent, and scalable, and one can assess the bibliometrics on an individual, institutional, national, or international level. On the negative side, the metrics can be exploited by researchers and journals to artificially boost bibliometric scores.

Conclusion

In this bibliometric study, we identified from the Scopus database 126 HCPs (≥20 citations) on Indian fracture research published during 1989 to 2022. Delhi was the epicenter of research and publication activities on the topic. The most productive organization were AIIMS, New Delhi, and PGIMER, Chandigarh, whereas the most impactful organizations were MAMC, New Delhi, and JIPMER, Pondicherry. The most productive authors were R. Malhotra and M.S. Dhillon, and the most impactful authors were U.K. Meena and A.P. Singh. Indian Journal of Orthopaedics and International Orthopaedics published the maximum number of HCPs, but the most impactful publications were from Proceedings of the National Academy of Sciences of USA and The Lancet, with an impact factor of 12.799 and 202.7, respectively.

To diversify India's research on fractures, there is an urgent need to develop a national registry and expand international collaboration, which will help improve both research output and research impact and quality. These research topics are expected to continue to be the hotspots and focus of research. Citation number–based identification of important articles will help current practitioners gain insight into the past and current trends in their respective fields and provide the foundation for further investigations.