# A bibliometric analysis of clinical research on fracture-related infection

Authors: Cheng Li; Andrew L. Foster; Nicholas Hang Bao Han; Andrej Trampuz; Michael Schuetz
Journal: BioMed Research International
 (2022)

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## Abstract

Background. Infection following orthopaedic trauma surgery is increasingly recognized as one of the major research priorities with as primary goal, improving patient care. This increased interest has been anecdotally recognized through published research, research grants, and, finally, with the development of the fracture-related infection (FRI) consensus group. In 2017, the accepted consensus definition of FRI was published, which has been followed by consensus recommendations from both a surgical and medical perspective. A bibliometric analysis was performed to objectively describe the trends in published clinical research related to FRI. Methods. The terms related to FRI were searched in the Web of Science database between 2000 and 2020. The characteristics of clinical research on FRI regarding the author, country, journal, institution, scientific output, top 100 most cited articles, and trend topics were analyzed using Bibliometrix and WPS Office. Results. A total of 2597 records were eligible for inclusion in this bibliometric approach, with studies originating from 89 countries, including eight languages. The United States of America (USA) published the highest number of articles and citations. International collaborations were present between 72 countries, with the most active country being the USA. The most contributive institution was the University of California. The highest number of papers and citations were from the Injury-International Journal of the Care of the Injured and the Journal of Orthopaedic Trauma. The top 100 most cited articles were published in 27 different journals, with the number of citations ranging between 97 and 1004. The latest trend topics were related to the diagnosis of FRI. Conclusion. The present bibliometric analysis shows the research characteristics and trends of FRI from multiple perspectives. The fact that there is an increasing number of studies being published on FRI shows the agreement among scientists and clinicians that standardization with respect to this topic is very important.


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## Body

## 1. Introduction

Internal fixation of fractures has revolutionized modern orthopaedic trauma care over the last 50 years. When indicated, internal fixation of fractures can preserve native joints and provide adequate stability to facilitate bone healing without limiting the functional rehabilitation of patients with prolonged immobilization [1]. However, postoperative infections complicate operative fracture management and occur in 1−11% of cases [2–6]. The diagnosis and treatment of postoperative infections are often complex. They require a multidisciplinary approach (i.e., surgeons, infectious disease physicians, and clinical pharmacists), often result in additional surgeries and a long duration of antibiotic therapy [7, 8]. The health care system costs are immense. Trauma patients with a postoperative infection generate inpatient costs 6.5-8 times higher than their uninfected counterparts [9]. Despite adequate treatment, clinical and functional outcomes often remain poor, with high dependency rates and an inability to return to work [10].The terminology surrounding postoperative infections has been historically inconsistent, which has hampered research efforts. Terms such as infection after fracture fixation, surgical site infection, and septic nonunion (or pseudoarthrosis) were often used interchangeably but without clear criteria to define the entity [11, 12]. Therefore, in 2017, the term fracture-related infection (FRI) was defined by an international consensus group, including the AO Foundation, Orthopaedic Trauma Association, PRO IMPLANT Foundation, and European Bone and Joint Infection Society [13]. Over the course of the past decades, FRI has increasingly been recognized as a clinical research priority to improve the outcome of this sometimes devastating complication [14–16].Bibliometrics is a method of statistical analysis used to assess a particular subject’s characteristics and major developmental trends based on published research. Such an analysis has provided useful insight into the global state and trends related to different medical fields [17–21]. Anecdotally, there has been a significant increase in interest in the topic of FRI in recent years through published papers, targeted research grants, and consensus statements. However, till today, bibliometric analysis related to this topic has not been performed. The present study was aimed at describing the overview of clinical studies and trends on FRI between 2000 and 2020.


## 2. Materials and Methods

### 2.1. Data Sources and Search Strategy

Bibliometric analysis was performed using the electronic database Web of Science (Science Citation Index Expanded) for articles published between 2000 and 2020. The retrieval strategy used was for the following medical subject headings or keywords: “osteomyelitis,” “septic non-union,” “septic pseudoarthrosis,” “septic pseudarthrosis,” “infected non-union,” “infected pseudoarthrosis,” “infected pseudarthrosis,” “trauma∗,” “injur∗,” “fracture∗,” “fracture related infection,” “infection after fracture fixation,” “infections after fracture,” “infection after fracture osteosynthesis,” “post-traumatic osteitis,” “post-traumatic osteomyelitis,” “infections associated with fracture-fixation devices,” and “osteomyelitis associated with open fractures.”


### 2.2. Inclusion and Exclusion Criteria

Inclusion criteria for further analysis were based on the following: (a) article describing a clinical study on FRI in orthopaedics; and (b) review article, meta-analysis, clinical trial, or guideline.Exclusion criteria were as follows: (a) book chapters, conference proceedings, editorials, errata, or letters; (b) basic science, animal, and cadaveric studies; and (c) nonorthopaedic related fracture or infection, such as of the skull or sternum.


### 2.3. Data Extraction and Bibliometric Analysis

Data were identified and extracted by three authors individually (CL, AF, NH). All records were exported from the Web of Science database with text and excel document then imported into the software of Bibliometrix (University of Naples Federico II, Italy) and WPS Office (Kingsoft, China) to analyze the result, respectively [22]. Data analysis involves the author, article title, country, journal, h-index, institution, author keywords, language, number of citations, number of publications, and publication year. The impact factor and quartile of the journal were collected from the Journal Citation Reports 2020. The Bibliometrix software was utilized to construct data visualization of international collaborations, top 10 authors’ average output, and trend topics.


## 2.1. Data Sources and Search Strategy

Bibliometric analysis was performed using the electronic database Web of Science (Science Citation Index Expanded) for articles published between 2000 and 2020. The retrieval strategy used was for the following medical subject headings or keywords: “osteomyelitis,” “septic non-union,” “septic pseudoarthrosis,” “septic pseudarthrosis,” “infected non-union,” “infected pseudoarthrosis,” “infected pseudarthrosis,” “trauma∗,” “injur∗,” “fracture∗,” “fracture related infection,” “infection after fracture fixation,” “infections after fracture,” “infection after fracture osteosynthesis,” “post-traumatic osteitis,” “post-traumatic osteomyelitis,” “infections associated with fracture-fixation devices,” and “osteomyelitis associated with open fractures.”


## 2.2. Inclusion and Exclusion Criteria

Inclusion criteria for further analysis were based on the following: (a) article describing a clinical study on FRI in orthopaedics; and (b) review article, meta-analysis, clinical trial, or guideline.Exclusion criteria were as follows: (a) book chapters, conference proceedings, editorials, errata, or letters; (b) basic science, animal, and cadaveric studies; and (c) nonorthopaedic related fracture or infection, such as of the skull or sternum.


## 2.3. Data Extraction and Bibliometric Analysis

Data were identified and extracted by three authors individually (CL, AF, NH). All records were exported from the Web of Science database with text and excel document then imported into the software of Bibliometrix (University of Naples Federico II, Italy) and WPS Office (Kingsoft, China) to analyze the result, respectively [22]. Data analysis involves the author, article title, country, journal, h-index, institution, author keywords, language, number of citations, number of publications, and publication year. The impact factor and quartile of the journal were collected from the Journal Citation Reports 2020. The Bibliometrix software was utilized to construct data visualization of international collaborations, top 10 authors’ average output, and trend topics.


## 3. Results

### 3.1. Publication Output

A total of 2597 articles met the inclusion criteria using the electronic Web of Science database (Figure1). The total number of citations related to FRI is 58,690 (51,109 excluding self-citations), with an average citation frequency of 22.6 times per item. Research papers were published in eight languages. More than 94% of articles were written in English (2458), followed by German (91), French (19), Czech (16), Serbian (4), Turkish (4), Spanish (4), and Italian (1).Figure 1
Flow chart of article selection.Figure2 presents the specific amount of annual publications regarding FRI. Since 2008, the number of articles has exceeded 100 per year. The year 2019 ranked as the most productive year (253), followed by 2017 and 2018 (175 and 171, respectively).Figure 2
Number of publication outputs per year.


### 3.2. Country

For the United Kingdom (UK), publications from England, Northern Ireland, Scotland, and Wales were merged [23]. Finally, 89 countries contributed to the FRI publications (Figure 3). Of these, the USA contributed the highest number of articles (814), followed by China (318), the UK (298), and Germany (266; Table 1). The top four countries with the most contribution, each presented more than 10 articles per year between 2016 and 2020 (Figure 4).Figure 3
Global distribution and international interactions of FRI research.Table 1
The top 10 most productive countries in FRI.
CountriesRecordsTotal citationsh-indexUSA8142562980China318425634UK298938349Germany266618737Switzerland109313931India107147321France94270821Turkey82108119Canada81505534Netherlands77285427Figure 4
The annual distribution of FRI research from top 10 countries between 2000 and 2020.Intercountry collaborations were found between 72 countries (Figure3). The USA had the largest number of collaborations with other countries (46), followed by the UK (35) and France (31; Table 2). The most frequent collaborations were between the USA and Canada (40), followed by the USA and Germany (39), then Switzerland and Germany (32; Table 3).Table 2
Top countries with more than 10 collaborations.
RanksCountriesRecords1USA462United Kingdom353France314Germany285Canada256Switzerland237Netherlands218Australia209Belgium2010Austria1811South Africa1812Israel1613Norway1614Argentina1515China1516Finland1517Italy1418Denmark1319Greece1320Ireland1221Japan11Table 3
Countries with international collaborations exceeding fifteen.
FromToFrequencyUSACanada40USAGermany39SwitzerlandGermany32USAUK30USASwitzerland27BelgiumSwitzerland22USABelgium19United KingdomSwitzerland18USANetherlands18BelgiumGermany17UKBelgium16UKGermany16


### 3.3. Organizations

The top five most productive institutions are listed in Table4. The most productive organization was the University of California system (48), followed by Harvard University (45) and Vanderbilt University (44). Of the top five most productive organizations, four were based in the USA, and the remaining was from the University Hospital Leuven, Belgium.Table 4
The top five most prolific organizations in FRI.
OrganizationRecordsTotal citationsh-indexCountryUniversity of California System48280119USAHarvard University45127520USAVanderbilt University44209722USAUniversity System of Maryland4284814USAUniversity Hospital Leuven37194420Belgium


### 3.4. Authors

A total of 9,842 authors contributed to FRI-related studies. Metsemakers WJ has the highest number of publications with 32 articles, followed by Giannoudis PV (31) and Obremskey WT with 25 publications each (Table5). Figure 5 demonstrates the average output of the top 10 authors between 2000 and 2020.Table 5
The top 10 most productive authors in FRI.
AuthorRecordsTotal citationsh-indexCountryAffiliationMetsemakers WJ3289418BelgiumUniversity Hospitals LeuvenGiannoudis PV31108019UKUniversity of LeedsObremskey WT2580217USAVanderbilt UniversityMurray CK2587213USASan Antonio Military Medical CenterO’Toole RV232679USAUniversity of MarylandMcnally MA2165914UKNuffield Orthopaedic CentreMorgenstern M2063513SwitzerlandUniversity of BaselBhandari M18123114CanadaMcMaster UniversityMoriarty TF1758613SwitzerlandAO Research Institute DavosVallier HA175029USAMetroHealth SystemFigure 5
Average output of the top 10 authors on FRI-related studies between 2000 and 2020.


### 3.5. Journals

All included articles were published in 339 different journals. Injury-International Journal of the Care of the Injured had the maximum number of papers (316), followed by the Journal of Orthopaedic Trauma (220) and International Orthopaedics (105; Table6). The year of the first publication of an FRI study in the respective journal is depicted in Figure 6, with the majority appearing in 2008 and 2019 (24).Table 6
Top 10 journals ranked by the number of publications on FRI.
SourceNumber of publicationsTotal citationsh-indexImpact factorQuartile in categoryInjury-International Journal of the Care of the Injured3167352442.586Q2Journal of Orthopaedic Trauma2208016502.512Q2International Orthopaedics1051911253.075Q2Journal of Trauma and Acute Care Surgery913205343.313Q2Bone & Joint Journal853831375.082Q1Archives of Orthopaedic and Trauma Surgery761450233.067Q2Journal of Bone and Joint Surgery-American Volume726935475.284Q1Clinical Orthopaedics and Related Research682734324.176Q1Journal of Pediatric Orthopaedics631927252.324Q2Foot & Ankle International471304202.827Q2Figure 6
Year of first publication from journals on FRI.Data from the 2020 edition of journal citation reports showed 303 journals with an impact factor. The journal with the highest impact factor was The New England Journal of Medicine (74.699), followed by JAMA (Journal of the American Medical) Association (56.272), and Intensive Care Medicine (17.44; Table7).Table 7
Top 10 journals ranked by the impact factor on FRI.
SourceImpact factorQuartile in categoryNumber of publicationsTotal citationsNew England Journal of Medicine91.245Q11104JAMA (Journal of the American Medical Association)56.272Q1390Intensive Care Medicine17.440Q1123British Journal of Sports Medicine13.800Q118Bone Research13.567Q1289Biomaterials12.479Q11260Age and Ageing10.668Q1154Journal of Nuclear Medicine10.057Q11131European Journal of Nuclear Medicine and Molecular Imaging9.236Q16172Clinical Infectious Diseases9.079Q16525All of the top 10 journals with the most number of publications and impact factors were published in English. Journals with more than 10 publications in other languages included Unfallchirurg (German, 40), Revue de Chirurgie Orthopédique et Réparatrice de l’Appareil Moteur (French, 16), and Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca (Czech, 16).


### 3.6. Top 100 Most Cited Articles

The number of citations for the top 100 most cited articles was defined according to the number of citations, with citations ranging between 97 and 1004 (Table8). All included studies were published in 27 different journals, with most publications in the Journal of Orthopaedic Trauma (24), followed by Journal of Bone and Joint Surgery-American Volume (21), and Injury-International Journal of the Care of the Injured (9).Table 8
The top 100 most cited articles on FRI.
First authorsArticle titleJournalsTotal citationsYearGovender, SRecombinant human bone morphogenetic protein-2 for treatment of open tibial fractures - a prospective, controlled, randomized study of four hundred and fifty patientsJournal of Bone and Joint Surgery-American Volume10042002Mckee, MDNonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures - a multicenter, randomized clinical trialJournal of Bone and Joint Surgery-American Volume5172007Bhandari, MInternal fixation compared with arthroplasty for displaced fractures of the femoral neck - a meta-analysisJournal of Bone and Joint Surgery-American Volume3462003Gopal, SFix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibiaBone & Joint Journal3322000Trampuz, ADiagnosis and treatment of infections associated with fracture-fixation devicesInjury-International Journal of the Care of the Injured2912006Jamsen, ERisk factors for infection after knee arthroplasty a register-based analysis of 43,149 casesJournal of Bone and Joint Surgery-American Volume2772009Flynn, JMTitanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complicationsJournal of Pediatric Orthopaedics2702001Widmer, AFNew developments in diagnosis and treatment of infection in orthopedic implantsClinical Infectious Diseases2632001Rokkanen, PUBioabsorbable fixation in orthopaedic surgery and traumatologyBiomaterials2602000Castillo, RCImpact of smoking on fracture healing and risk of complications in limb-threatening open tibia fracturesJournal of Orthopaedic Trauma2392005SooHoo, NFComplication rates following open reduction and internal fixation of ankle fracturesJournal of Bone and Joint Surgery-American Volume2192009Barei, DPComplications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision techniqueJournal of Orthopaedic Trauma2172004Fankhauser, FA new locking plate for unstable fractures of the proximal humerusClinical Orthopaedics and Related Research2122005Pape, HCChanges in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgeryJournal of Trauma-Injury Infection and Critical Care2102002Yazar, SOne-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremitiesPlastic and Reconstructive Surgery2052004Hak, DJDelayed union and nonunions: epidemiology, clinical issues, and financial aspectsInjury-International Journal of the Care of the Injured2022014Moro, JKArthroplasty with a metal radial head for unreconstructible fractures of the radial headJournal of Bone and Joint Surgery-American Volume2012001Stannard, JPNegative pressure wound therapy after severe open fractures: a prospective randomized studyJournal of Orthopaedic Trauma2002009Sproul, RCA systematic review of locking plate fixation of proximal humerus fracturesInjury-International Journal of the Care of the Injured1972011Schmidmaier, GProphylaxis and treatment of implant-related infections by antibiotic-coated implants: a reviewInjury-International Journal of the Care of the Injured1942006Bhandari, MTreatment of open fractures of the shaft of the tibia - a systematic overview and meta-analysisBone & Joint Journal1882001O’Neill, KRReduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powderSpine Journal1872011Zalavras, CGLocal antibiotic therapy in the treatment of open fractures and osteomyelitisClinical Orthopaedics and Related Research1862004Kregor, PJTreatment of distal femur fractures using the less invasive stabilization system - surgical experience and early clinical results in 103 fracturesJournal of Orthopaedic Trauma1852004Johnson, ENInfectious complications of open type III tibial fractures among combat casualtiesClinical Infectious Diseases1842007Robinson, CMAdult distal humeral metaphyseal fractures: epidemiology and results of treatmentJournal of Orthopaedic Trauma1772003Koval, KJFractures of the distal part of the radiusJournal of Bone and Joint Surgery-American Volume1742008Yazar, SOutcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fracturesPlastic and Reconstructive Surgery1742006Egol, KAStaged management of high-energy proximal tibia fractures (OTA types 41) - the results of a prospective, standardized protocolJournal of Orthopaedic Trauma1732005Harris, AMComplications following limb-threatening lower extremity traumaJournal of Orthopaedic Trauma1692009Nowotarski, PJConversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patientsJournal of Bone and Joint Surgery-American Volume1692000Karger, CTreatment of posttraumatic bone defects by the induced membrane techniqueOrthopaedics & Traumatology-Surgery & Research1632012Chapman, JRRandomized prospective study of humeral shaft fracture fixation: intramedullary nails versus platesJournal of Orthopaedic Trauma1622000Arciola, CREtiology of implant orthopedic infections: a survey on 1027 clinical isolatesInternational Journal of Artificial Organs1612005Vallier, HARandomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fracturesJournal of Orthopaedic Trauma1582011Im, GIDistal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixationJournal of Trauma-Injury Infection and Critical Care1572005Swiontkowski, MFRecombinant human bone morphogenetic protein-2 in open tibial fractures - a subgroup analysis of data combined from two prospective randomized studiesJournal of Bone and Joint Surgery-American Volume1562006Blauth, MSurgical options for the treatment of severe tibial pilon fractures: a study of three techniquesJournal of Orthopaedic Trauma1552001Stafford, PRReamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 casesInjury-International Journal of the Care of the Injured1542010Rechtine, GRPostoperative wound infection after instrumentation of thoracic and lumbar fracturesJournal of Orthopaedic Trauma1512001Minami, AVascularised fibular grafts - an experience of 102 patientsBone & Joint Journal1502000Barei, DPFunctional outcomes of severe bicondylar plateau fractures treated with dual incisions and medial and lateral platesJournal of Bone and Joint Surgery-American Volume1482006Prokuski, LProphylactic antibiotics in orthopaedic surgeryJournal of the American Academy of Orthopaedic Surgeons1462008Nork, SEIntramedullary nailing of distal metaphyseal tibial fracturesJournal of Bone and Joint Surgery-American Volume1452005Skaggs, DLLateral-entry pin fixation in the management of supracondylar fractures in childrenJournal of Bone and Joint Surgery-American Volume1452004Pollak, ANThe relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity traumaJournal of Bone and Joint Surgery-American Volume1432010Rodriguez-Merchan, ECNonunion: general principles and experimental dataClinical Orthopaedics and Related Research1422004Patzakis, MJChronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management conceptsJournal of the American Academy of Orthopaedic Surgeons1412005McKee, MDThe use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trialJournal of Orthopaedic Trauma1412002Harley, BJThe effect of time to definitive treatment on the rate of nonunion and infection in open fracturesJournal of Orthopaedic Trauma1402002Ricci, WMLocked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplastyJournal of Orthopaedic Trauma1392006Naique, SBManagement of severe open tibial fractures - the need for combined orthopaedic and plastic surgical treatment in specialist centresBone & Joint Journal1382006Mehlman, CTThe effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in childrenJournal of Bone and Joint Surgery-American Volume1382001Edwards, CEarly infection after hip fracture surgery - risk factors, costs and outcomeBone & Joint Journal1372008Knop, CLate results of thoracolumbar fractures after posterior instrumentation and transpedicular bone graftingSpine1372001Sebastia-Forcada, EReverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective studyJournal of Shoulder and Elbow Surgery1362014Benirschke, SKWound healing complications in closed and open calcaneal fracturesJournal of Orthopaedic Trauma1322004Filippi, LUsefulness of hybrid SPECT/CT in Tc-99 m-HMPAO-labeled leukocyte scintigraphy for bone and joint infectionsJournal of Nuclear Medicine1312006Anglen, JOComparison of soap and antibiotic solutions for irrigation of lower-limb openfracture wounds - a prospective, randomized studyJournal of Bone and Joint Surgery-American Volume1312005Leung, KSComplex tibial fracture outcomes following treatment with low-intensity pulsed ultrasoundUltrasound in Medicine and Biology1312004Herrera, DATreatment of acute distal femur fractures above a total knee arthroplasty - systematic review of 415 cases (1981-2006)Acta Orthopaedica1282008Narayanan, UGComplications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid themJournal of Pediatric Orthopaedics1282004Harvey, EJMorbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approachFoot & Ankle International1282001Jost, BLocking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcomeJournal of Shoulder and Elbow Surgery1272013Kettler, MTreatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fracturesUnfallchirurg1272006Cassidy, CNorian SRS cement compared with conventional fixation in distal radial fractures - a randomized studyJournal of Bone and Joint Surgery-American Volume1272003Sirkin, MA staged protocol for soft tissue management in the treatment of complex pilon fracturesJournal of Orthopaedic Trauma1242004Metsemakers, WJInfection after fracture fixation: current surgical and microbiological conceptsInjury-International Journal of the Care of the Injured1212018Stulik, JMinimally-invasive treatment of intra-articular fractures of the calcaneumBone & Joint Journal1192006Khatod, MOutcomes in open tibia fractures: relationship between delay in treatment and infectionJournal of Trauma-Injury Infection and Critical Care1192003Cole, PATreatment of proximal tibia fractures using the less invasive stabilization system - surgical experience and early clinical results in 77 fracturesJournal of Orthopaedic Trauma1172004Springer, BDTreatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revisionJournal of Bone and Joint Surgery-American Volume1172003Metsemakers, WJFracture-related infection: a consensus on definition from an international expert groupInjury-International Journal of the Care of the Injured1162018Gosling, TSingle lateral locked screw plating of bicondylar tibial plateau fracturesClinical Orthopaedics and Related Research1162005Takeuchi, RFractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fractureArthroscopy-the Journal of Arthroscopic and Related Surgery1152012Canadian Orthopaedic Trauma SocietyOpen reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures - results of a multicenter, prospective, randomized clinical trialJournal of Bone and Joint Surgery-American Volume1132006Yun, HCOsteomyelitis in military personnel wounded in Iraq and AfghanistanJournal of Trauma-Injury Infection and Critical Care1112008Taeger, GDamage control orthopedics in patients with multiple injuries is effective, time saving, and safeJournal of Trauma-Injury Infection and Critical Care1112005Parsons, BSurgical management of chronic osteomyelitisAmerican Journal of Surgery1112004Lack, WDType III open tibia fractures: immediate antibiotic prophylaxis minimizes infectionJournal of Orthopaedic Trauma1092015Borg, TPercutaneous plating of distal tibial fractures preliminary results in 21 patientsInjury-International Journal of the Care of the Injured1082004Parameswaran, ADPin tract infection with contemporary external fixation: how much of a problem?Journal of Orthopaedic Trauma1082003Suk, SIAnterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fractureSpine1062003Misra, AComplex proximal humeral fractures in adults - a systematic review of managementInjury-International Journal of the Care of the Injured1062001Bhandari, MA trial of wound irrigation in the initial management of open fracture woundsNew England Journal of Medicine1042015Aro, HTRecombinant human bone morphogenetic protein-2: a randomized trial in open tibial fractures treated with reamed nail fixationJournal of Bone and Joint Surgery-American Volume1042011Ferran, NALocked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trialJournal of Shoulder and Elbow Surgery1042010Rozbruch, SRSimultaneous treatment of tibial bone and soft-tissue defects with the ilizarov methodJournal of Orthopaedic Trauma1042006Karunakar, MABody mass index as a predictor of complications after operative treatment of acetabular fracturesJournal of Bone and Joint Surgery-American Volume1042005Feldman, DSCorrection of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor spatial frameJournal of Orthopaedic Trauma1042003Edlund, ADelirium before and after operation for femoral neck fractureJournal of the American Geriatrics Society1042001Richards, JERelationship of hyperglycemia and surgical-site infection in orthopaedic surgeryJournal of Bone and Joint Surgery-American Volume1022012Gjertsen, JEMore re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck. An observational study of 11 116 hemiarthroplasties from a national registerBone & Joint Journal1012012Nasell, HThe impact of smoking on complications after operatively treated ankle fractures-a follow-Up study of 906 patientsJournal of Orthopaedic Trauma1002011Lau, TWWound complication of minimally invasive plate osteosynthesis in distal tibia fracturesInternational Orthopaedics1002008Fuchs, TThe use of gentamicin-coated nails in the tibia: preliminary results of a prospective studyArchives of Orthopaedic and Trauma Surgery992011Flynn, JMManagement of pediatric femoral shaft fracturesJournal of the American Academy of Orthopaedic Surgeons992004Malik, MHAFactors affecting rates of infection and nonunion in intramedullary nailingBone & Joint Journal992004Collinge, CAnterior-inferior plate fixation of middle-third fractures and nonunions of the clavicleJournal of Orthopaedic Trauma982006Mckee, MDA prospective, randomized clinical trial comparing an antibiotic-impregnated bioabsorbable bone substitute with standard antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis and infected nonunionJournal of Orthopaedic Trauma972010


### 3.7. Trend Topics

Trend topics were identified by author keywords in Bibliometrix. Parameter values were set to a minimum number of keyword occurrences more than 20 times. The first keywords were presented until 2010, and 36 keywords met the threshold (Figure7). The top three most frequently used keywords were “infection,” “fracture,” and “complications.” The earliest keywords were “external fixation,” “children,” and “humerus.” The keywords “fracture-related infection,” “diagnosis,” and “risk factor” were the top three latest emerging trend topics of FRI research.Figure 7
Trend topics of FRI according to author keywords.


## 3.1. Publication Output

A total of 2597 articles met the inclusion criteria using the electronic Web of Science database (Figure1). The total number of citations related to FRI is 58,690 (51,109 excluding self-citations), with an average citation frequency of 22.6 times per item. Research papers were published in eight languages. More than 94% of articles were written in English (2458), followed by German (91), French (19), Czech (16), Serbian (4), Turkish (4), Spanish (4), and Italian (1).Figure 1
Flow chart of article selection.Figure2 presents the specific amount of annual publications regarding FRI. Since 2008, the number of articles has exceeded 100 per year. The year 2019 ranked as the most productive year (253), followed by 2017 and 2018 (175 and 171, respectively).Figure 2
Number of publication outputs per year.


## 3.2. Country

For the United Kingdom (UK), publications from England, Northern Ireland, Scotland, and Wales were merged [23]. Finally, 89 countries contributed to the FRI publications (Figure 3). Of these, the USA contributed the highest number of articles (814), followed by China (318), the UK (298), and Germany (266; Table 1). The top four countries with the most contribution, each presented more than 10 articles per year between 2016 and 2020 (Figure 4).Figure 3
Global distribution and international interactions of FRI research.Table 1
The top 10 most productive countries in FRI.
CountriesRecordsTotal citationsh-indexUSA8142562980China318425634UK298938349Germany266618737Switzerland109313931India107147321France94270821Turkey82108119Canada81505534Netherlands77285427Figure 4
The annual distribution of FRI research from top 10 countries between 2000 and 2020.Intercountry collaborations were found between 72 countries (Figure3). The USA had the largest number of collaborations with other countries (46), followed by the UK (35) and France (31; Table 2). The most frequent collaborations were between the USA and Canada (40), followed by the USA and Germany (39), then Switzerland and Germany (32; Table 3).Table 2
Top countries with more than 10 collaborations.
RanksCountriesRecords1USA462United Kingdom353France314Germany285Canada256Switzerland237Netherlands218Australia209Belgium2010Austria1811South Africa1812Israel1613Norway1614Argentina1515China1516Finland1517Italy1418Denmark1319Greece1320Ireland1221Japan11Table 3
Countries with international collaborations exceeding fifteen.
FromToFrequencyUSACanada40USAGermany39SwitzerlandGermany32USAUK30USASwitzerland27BelgiumSwitzerland22USABelgium19United KingdomSwitzerland18USANetherlands18BelgiumGermany17UKBelgium16UKGermany16


## 3.3. Organizations

The top five most productive institutions are listed in Table4. The most productive organization was the University of California system (48), followed by Harvard University (45) and Vanderbilt University (44). Of the top five most productive organizations, four were based in the USA, and the remaining was from the University Hospital Leuven, Belgium.Table 4
The top five most prolific organizations in FRI.
OrganizationRecordsTotal citationsh-indexCountryUniversity of California System48280119USAHarvard University45127520USAVanderbilt University44209722USAUniversity System of Maryland4284814USAUniversity Hospital Leuven37194420Belgium


## 3.4. Authors

A total of 9,842 authors contributed to FRI-related studies. Metsemakers WJ has the highest number of publications with 32 articles, followed by Giannoudis PV (31) and Obremskey WT with 25 publications each (Table5). Figure 5 demonstrates the average output of the top 10 authors between 2000 and 2020.Table 5
The top 10 most productive authors in FRI.
AuthorRecordsTotal citationsh-indexCountryAffiliationMetsemakers WJ3289418BelgiumUniversity Hospitals LeuvenGiannoudis PV31108019UKUniversity of LeedsObremskey WT2580217USAVanderbilt UniversityMurray CK2587213USASan Antonio Military Medical CenterO’Toole RV232679USAUniversity of MarylandMcnally MA2165914UKNuffield Orthopaedic CentreMorgenstern M2063513SwitzerlandUniversity of BaselBhandari M18123114CanadaMcMaster UniversityMoriarty TF1758613SwitzerlandAO Research Institute DavosVallier HA175029USAMetroHealth SystemFigure 5
Average output of the top 10 authors on FRI-related studies between 2000 and 2020.


## 3.5. Journals

All included articles were published in 339 different journals. Injury-International Journal of the Care of the Injured had the maximum number of papers (316), followed by the Journal of Orthopaedic Trauma (220) and International Orthopaedics (105; Table6). The year of the first publication of an FRI study in the respective journal is depicted in Figure 6, with the majority appearing in 2008 and 2019 (24).Table 6
Top 10 journals ranked by the number of publications on FRI.
SourceNumber of publicationsTotal citationsh-indexImpact factorQuartile in categoryInjury-International Journal of the Care of the Injured3167352442.586Q2Journal of Orthopaedic Trauma2208016502.512Q2International Orthopaedics1051911253.075Q2Journal of Trauma and Acute Care Surgery913205343.313Q2Bone & Joint Journal853831375.082Q1Archives of Orthopaedic and Trauma Surgery761450233.067Q2Journal of Bone and Joint Surgery-American Volume726935475.284Q1Clinical Orthopaedics and Related Research682734324.176Q1Journal of Pediatric Orthopaedics631927252.324Q2Foot & Ankle International471304202.827Q2Figure 6
Year of first publication from journals on FRI.Data from the 2020 edition of journal citation reports showed 303 journals with an impact factor. The journal with the highest impact factor was The New England Journal of Medicine (74.699), followed by JAMA (Journal of the American Medical) Association (56.272), and Intensive Care Medicine (17.44; Table7).Table 7
Top 10 journals ranked by the impact factor on FRI.
SourceImpact factorQuartile in categoryNumber of publicationsTotal citationsNew England Journal of Medicine91.245Q11104JAMA (Journal of the American Medical Association)56.272Q1390Intensive Care Medicine17.440Q1123British Journal of Sports Medicine13.800Q118Bone Research13.567Q1289Biomaterials12.479Q11260Age and Ageing10.668Q1154Journal of Nuclear Medicine10.057Q11131European Journal of Nuclear Medicine and Molecular Imaging9.236Q16172Clinical Infectious Diseases9.079Q16525All of the top 10 journals with the most number of publications and impact factors were published in English. Journals with more than 10 publications in other languages included Unfallchirurg (German, 40), Revue de Chirurgie Orthopédique et Réparatrice de l’Appareil Moteur (French, 16), and Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca (Czech, 16).


## 3.6. Top 100 Most Cited Articles

The number of citations for the top 100 most cited articles was defined according to the number of citations, with citations ranging between 97 and 1004 (Table8). All included studies were published in 27 different journals, with most publications in the Journal of Orthopaedic Trauma (24), followed by Journal of Bone and Joint Surgery-American Volume (21), and Injury-International Journal of the Care of the Injured (9).Table 8
The top 100 most cited articles on FRI.
First authorsArticle titleJournalsTotal citationsYearGovender, SRecombinant human bone morphogenetic protein-2 for treatment of open tibial fractures - a prospective, controlled, randomized study of four hundred and fifty patientsJournal of Bone and Joint Surgery-American Volume10042002Mckee, MDNonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures - a multicenter, randomized clinical trialJournal of Bone and Joint Surgery-American Volume5172007Bhandari, MInternal fixation compared with arthroplasty for displaced fractures of the femoral neck - a meta-analysisJournal of Bone and Joint Surgery-American Volume3462003Gopal, SFix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibiaBone & Joint Journal3322000Trampuz, ADiagnosis and treatment of infections associated with fracture-fixation devicesInjury-International Journal of the Care of the Injured2912006Jamsen, ERisk factors for infection after knee arthroplasty a register-based analysis of 43,149 casesJournal of Bone and Joint Surgery-American Volume2772009Flynn, JMTitanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complicationsJournal of Pediatric Orthopaedics2702001Widmer, AFNew developments in diagnosis and treatment of infection in orthopedic implantsClinical Infectious Diseases2632001Rokkanen, PUBioabsorbable fixation in orthopaedic surgery and traumatologyBiomaterials2602000Castillo, RCImpact of smoking on fracture healing and risk of complications in limb-threatening open tibia fracturesJournal of Orthopaedic Trauma2392005SooHoo, NFComplication rates following open reduction and internal fixation of ankle fracturesJournal of Bone and Joint Surgery-American Volume2192009Barei, DPComplications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision techniqueJournal of Orthopaedic Trauma2172004Fankhauser, FA new locking plate for unstable fractures of the proximal humerusClinical Orthopaedics and Related Research2122005Pape, HCChanges in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgeryJournal of Trauma-Injury Infection and Critical Care2102002Yazar, SOne-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremitiesPlastic and Reconstructive Surgery2052004Hak, DJDelayed union and nonunions: epidemiology, clinical issues, and financial aspectsInjury-International Journal of the Care of the Injured2022014Moro, JKArthroplasty with a metal radial head for unreconstructible fractures of the radial headJournal of Bone and Joint Surgery-American Volume2012001Stannard, JPNegative pressure wound therapy after severe open fractures: a prospective randomized studyJournal of Orthopaedic Trauma2002009Sproul, RCA systematic review of locking plate fixation of proximal humerus fracturesInjury-International Journal of the Care of the Injured1972011Schmidmaier, GProphylaxis and treatment of implant-related infections by antibiotic-coated implants: a reviewInjury-International Journal of the Care of the Injured1942006Bhandari, MTreatment of open fractures of the shaft of the tibia - a systematic overview and meta-analysisBone & Joint Journal1882001O’Neill, KRReduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powderSpine Journal1872011Zalavras, CGLocal antibiotic therapy in the treatment of open fractures and osteomyelitisClinical Orthopaedics and Related Research1862004Kregor, PJTreatment of distal femur fractures using the less invasive stabilization system - surgical experience and early clinical results in 103 fracturesJournal of Orthopaedic Trauma1852004Johnson, ENInfectious complications of open type III tibial fractures among combat casualtiesClinical Infectious Diseases1842007Robinson, CMAdult distal humeral metaphyseal fractures: epidemiology and results of treatmentJournal of Orthopaedic Trauma1772003Koval, KJFractures of the distal part of the radiusJournal of Bone and Joint Surgery-American Volume1742008Yazar, SOutcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fracturesPlastic and Reconstructive Surgery1742006Egol, KAStaged management of high-energy proximal tibia fractures (OTA types 41) - the results of a prospective, standardized protocolJournal of Orthopaedic Trauma1732005Harris, AMComplications following limb-threatening lower extremity traumaJournal of Orthopaedic Trauma1692009Nowotarski, PJConversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patientsJournal of Bone and Joint Surgery-American Volume1692000Karger, CTreatment of posttraumatic bone defects by the induced membrane techniqueOrthopaedics & Traumatology-Surgery & Research1632012Chapman, JRRandomized prospective study of humeral shaft fracture fixation: intramedullary nails versus platesJournal of Orthopaedic Trauma1622000Arciola, CREtiology of implant orthopedic infections: a survey on 1027 clinical isolatesInternational Journal of Artificial Organs1612005Vallier, HARandomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fracturesJournal of Orthopaedic Trauma1582011Im, GIDistal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixationJournal of Trauma-Injury Infection and Critical Care1572005Swiontkowski, MFRecombinant human bone morphogenetic protein-2 in open tibial fractures - a subgroup analysis of data combined from two prospective randomized studiesJournal of Bone and Joint Surgery-American Volume1562006Blauth, MSurgical options for the treatment of severe tibial pilon fractures: a study of three techniquesJournal of Orthopaedic Trauma1552001Stafford, PRReamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 casesInjury-International Journal of the Care of the Injured1542010Rechtine, GRPostoperative wound infection after instrumentation of thoracic and lumbar fracturesJournal of Orthopaedic Trauma1512001Minami, AVascularised fibular grafts - an experience of 102 patientsBone & Joint Journal1502000Barei, DPFunctional outcomes of severe bicondylar plateau fractures treated with dual incisions and medial and lateral platesJournal of Bone and Joint Surgery-American Volume1482006Prokuski, LProphylactic antibiotics in orthopaedic surgeryJournal of the American Academy of Orthopaedic Surgeons1462008Nork, SEIntramedullary nailing of distal metaphyseal tibial fracturesJournal of Bone and Joint Surgery-American Volume1452005Skaggs, DLLateral-entry pin fixation in the management of supracondylar fractures in childrenJournal of Bone and Joint Surgery-American Volume1452004Pollak, ANThe relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity traumaJournal of Bone and Joint Surgery-American Volume1432010Rodriguez-Merchan, ECNonunion: general principles and experimental dataClinical Orthopaedics and Related Research1422004Patzakis, MJChronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management conceptsJournal of the American Academy of Orthopaedic Surgeons1412005McKee, MDThe use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trialJournal of Orthopaedic Trauma1412002Harley, BJThe effect of time to definitive treatment on the rate of nonunion and infection in open fracturesJournal of Orthopaedic Trauma1402002Ricci, WMLocked plates combined with minimally invasive insertion technique for the treatment of periprosthetic supracondylar femur fractures above a total knee arthroplastyJournal of Orthopaedic Trauma1392006Naique, SBManagement of severe open tibial fractures - the need for combined orthopaedic and plastic surgical treatment in specialist centresBone & Joint Journal1382006Mehlman, CTThe effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in childrenJournal of Bone and Joint Surgery-American Volume1382001Edwards, CEarly infection after hip fracture surgery - risk factors, costs and outcomeBone & Joint Journal1372008Knop, CLate results of thoracolumbar fractures after posterior instrumentation and transpedicular bone graftingSpine1372001Sebastia-Forcada, EReverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective studyJournal of Shoulder and Elbow Surgery1362014Benirschke, SKWound healing complications in closed and open calcaneal fracturesJournal of Orthopaedic Trauma1322004Filippi, LUsefulness of hybrid SPECT/CT in Tc-99 m-HMPAO-labeled leukocyte scintigraphy for bone and joint infectionsJournal of Nuclear Medicine1312006Anglen, JOComparison of soap and antibiotic solutions for irrigation of lower-limb openfracture wounds - a prospective, randomized studyJournal of Bone and Joint Surgery-American Volume1312005Leung, KSComplex tibial fracture outcomes following treatment with low-intensity pulsed ultrasoundUltrasound in Medicine and Biology1312004Herrera, DATreatment of acute distal femur fractures above a total knee arthroplasty - systematic review of 415 cases (1981-2006)Acta Orthopaedica1282008Narayanan, UGComplications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid themJournal of Pediatric Orthopaedics1282004Harvey, EJMorbidity associated with ORIF of intra-articular calcaneus fractures using a lateral approachFoot & Ankle International1282001Jost, BLocking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcomeJournal of Shoulder and Elbow Surgery1272013Kettler, MTreatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fracturesUnfallchirurg1272006Cassidy, CNorian SRS cement compared with conventional fixation in distal radial fractures - a randomized studyJournal of Bone and Joint Surgery-American Volume1272003Sirkin, MA staged protocol for soft tissue management in the treatment of complex pilon fracturesJournal of Orthopaedic Trauma1242004Metsemakers, WJInfection after fracture fixation: current surgical and microbiological conceptsInjury-International Journal of the Care of the Injured1212018Stulik, JMinimally-invasive treatment of intra-articular fractures of the calcaneumBone & Joint Journal1192006Khatod, MOutcomes in open tibia fractures: relationship between delay in treatment and infectionJournal of Trauma-Injury Infection and Critical Care1192003Cole, PATreatment of proximal tibia fractures using the less invasive stabilization system - surgical experience and early clinical results in 77 fracturesJournal of Orthopaedic Trauma1172004Springer, BDTreatment of periprosthetic femoral fractures following total hip arthroplasty with femoral component revisionJournal of Bone and Joint Surgery-American Volume1172003Metsemakers, WJFracture-related infection: a consensus on definition from an international expert groupInjury-International Journal of the Care of the Injured1162018Gosling, TSingle lateral locked screw plating of bicondylar tibial plateau fracturesClinical Orthopaedics and Related Research1162005Takeuchi, RFractures around the lateral cortical hinge after a medial opening-wedge high tibial osteotomy: a new classification of lateral hinge fractureArthroscopy-the Journal of Arthroscopic and Related Surgery1152012Canadian Orthopaedic Trauma SocietyOpen reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures - results of a multicenter, prospective, randomized clinical trialJournal of Bone and Joint Surgery-American Volume1132006Yun, HCOsteomyelitis in military personnel wounded in Iraq and AfghanistanJournal of Trauma-Injury Infection and Critical Care1112008Taeger, GDamage control orthopedics in patients with multiple injuries is effective, time saving, and safeJournal of Trauma-Injury Infection and Critical Care1112005Parsons, BSurgical management of chronic osteomyelitisAmerican Journal of Surgery1112004Lack, WDType III open tibia fractures: immediate antibiotic prophylaxis minimizes infectionJournal of Orthopaedic Trauma1092015Borg, TPercutaneous plating of distal tibial fractures preliminary results in 21 patientsInjury-International Journal of the Care of the Injured1082004Parameswaran, ADPin tract infection with contemporary external fixation: how much of a problem?Journal of Orthopaedic Trauma1082003Suk, SIAnterior-posterior surgery versus posterior closing wedge osteotomy in posttraumatic kyphosis with neurologic compromised osteoporotic fractureSpine1062003Misra, AComplex proximal humeral fractures in adults - a systematic review of managementInjury-International Journal of the Care of the Injured1062001Bhandari, MA trial of wound irrigation in the initial management of open fracture woundsNew England Journal of Medicine1042015Aro, HTRecombinant human bone morphogenetic protein-2: a randomized trial in open tibial fractures treated with reamed nail fixationJournal of Bone and Joint Surgery-American Volume1042011Ferran, NALocked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trialJournal of Shoulder and Elbow Surgery1042010Rozbruch, SRSimultaneous treatment of tibial bone and soft-tissue defects with the ilizarov methodJournal of Orthopaedic Trauma1042006Karunakar, MABody mass index as a predictor of complications after operative treatment of acetabular fracturesJournal of Bone and Joint Surgery-American Volume1042005Feldman, DSCorrection of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor spatial frameJournal of Orthopaedic Trauma1042003Edlund, ADelirium before and after operation for femoral neck fractureJournal of the American Geriatrics Society1042001Richards, JERelationship of hyperglycemia and surgical-site infection in orthopaedic surgeryJournal of Bone and Joint Surgery-American Volume1022012Gjertsen, JEMore re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck. An observational study of 11 116 hemiarthroplasties from a national registerBone & Joint Journal1012012Nasell, HThe impact of smoking on complications after operatively treated ankle fractures-a follow-Up study of 906 patientsJournal of Orthopaedic Trauma1002011Lau, TWWound complication of minimally invasive plate osteosynthesis in distal tibia fracturesInternational Orthopaedics1002008Fuchs, TThe use of gentamicin-coated nails in the tibia: preliminary results of a prospective studyArchives of Orthopaedic and Trauma Surgery992011Flynn, JMManagement of pediatric femoral shaft fracturesJournal of the American Academy of Orthopaedic Surgeons992004Malik, MHAFactors affecting rates of infection and nonunion in intramedullary nailingBone & Joint Journal992004Collinge, CAnterior-inferior plate fixation of middle-third fractures and nonunions of the clavicleJournal of Orthopaedic Trauma982006Mckee, MDA prospective, randomized clinical trial comparing an antibiotic-impregnated bioabsorbable bone substitute with standard antibiotic-impregnated cement beads in the treatment of chronic osteomyelitis and infected nonunionJournal of Orthopaedic Trauma972010


## 3.7. Trend Topics

Trend topics were identified by author keywords in Bibliometrix. Parameter values were set to a minimum number of keyword occurrences more than 20 times. The first keywords were presented until 2010, and 36 keywords met the threshold (Figure7). The top three most frequently used keywords were “infection,” “fracture,” and “complications.” The earliest keywords were “external fixation,” “children,” and “humerus.” The keywords “fracture-related infection,” “diagnosis,” and “risk factor” were the top three latest emerging trend topics of FRI research.Figure 7
Trend topics of FRI according to author keywords.


## 4. Discussion

The current bibliometric study comprised a comprehensive analysis of the scientific output related to FRI, exploring characteristics from publications, languages, countries, institutions, authors, journals, most cited articles, and trend topics. In the current report, we provide scholars with essential references and suggestions for further investigation on FRI.


### 4.1. Global Publishing Trends

Although some research papers evaluated orthopaedic-related infection using bibliometrics [24, 25], to the best of our knowledge, this is the first article to fully assess clinical research on FRI. Our analysis shows that the number of related publications exhibited a significant increasing trend from 2000 to 2020. Of all languages, English was the main international scholarly language in this field. In addition, 65% of studies in languages other than English was in German. Several bibliometric analyses of medicine-related research also noted that German was the most common second language following English [19, 26].


### 4.2. Country

Half of the top 10 contributing countries on FRI studies originated from Europe, with the remaining coming from Asia and North America. The UK had the highest number of publications and academic influence in Europe, China in Asia, and the USA in North America. The annual distribution of FRI research from the top 10 countries displayed the USA ranked first in the top 10 largest contribution countries annually between 2000 and 2019. Interestingly, the UK and Germany persistently remained at around second and third place from 2003 to 2012 (Figure4). China was ranked second between 2013 and 2019 and first in 2020. This result may suggest a great potential for the development of FRI research in China.In 72 of 89 countries involved in international collaborations, the USA had the highest number of research collaborations with other countries. Most of the international collaborations were between North America and European countries. A greater international collaboration should be widely established in the future.


### 4.3. Organizations and Authors

Among the institutions, four of the top five highest contributing countries originated from the USA. The University of California from the USA was the most productive institution globally in clinical studies focusing on FRI. Scholars from Europe and North America demonstrated a dominant position. The publications on the diagnosis and treatment principles of FRI also proved that most members of the FRI consensus group originated from Euro-American countries [27, 28]. In addition, half of the top 10 most productive authors on FRI were involved in the FRI consensus group [13]. Metsemakers WJ, from the University Hospitals Leuven, contributed most to clinic research of FRI. Regarding the top 10 author productions over time, most authors showed increased stability and persistence for a longer duration between 2016 and 2020. The list of top 10 most productive authors in FRI may provide a valuable reference for future scientific conference invitations for FRI experts.


### 4.4. Journals

Of the top 10 journals with the largest number of papers, Injury-International Journal of the Care of the Injured had the highest number of relevant publications, whereas Journal of Orthopaedic Trauma was the most academic influential journal on FRI. Compared with the bibliometric study, which excludes non-English literature [29, 30], the present bibliometric research also provides more valuable journal information to non-English speaking countries. Hence, scholars will most likely benefit from journal information to further subscribe or track the most relevant journal and also submit clinical research of FRI manuscripts as a reference. Figures on the first publications indicated that an increasing number of journals are interested in FRI research, with the highest values attained in 2008 and 2019.


### 4.5. Most Cited Documents

The number of citations is a traditional indicator for the assessment of the value of a certain study. Our study displays the top 100 most impactful studies on FRI and provides a resource for clinical scientists. Of all publications, the most cited research paper was published by Govender et al. [31]. The authors found that an implant containing 1.50 mg/mL of recombinant human bone morphogenetic protein-2 in the treatment of open tibial fractures could reduce the incidence of postsurgical infections. The most cited review article was published by Trampuz and Zimmerli [32]. The authors summarized the pathogenesis, classification, diagnosis, and treatment of infections associated with fracture-fixation devices.


### 4.6. Trend Topics

Trend topics were identified from author keywords. In terms of the surgical site, scholars placed a greater interest in infection after humeral fractures, followed by the location of femur and tibia, with a current focus on ankle fractures [33–39]. Furthermore, research topics and concepts also altered over the course of the years. With the introduction of the FRI consensus group, the term “fracture-related infection” became the standard, with more recent topics primarily focusing on risk factors and diagnostic criteria of FRI [15, 40–43]. Prior to this, researchers focused on the treatment of FRI [44–46], with a focus on debridement, bone transfer, and antibiotic treatment. In addition, with the publication of the consensus definition of FRI, this concept appears to be gradually gaining ground in the scientific literature.


### 4.7. Limitations

There are several limitations to the present study. First, only a single database was searched, with other databases and sources not included in the bibliometric analysis. Therefore, some potentially valuable information may have been missed [47]. Second, the FRI-related terms of the search strategy were based on the literature and personal experience; nonetheless, some literature may have been overlooked. Third, conference proceedings were also removed from this bibliometric analysis, due to the potential of being published on two occasions, as a conference abstract and also as a full journal article [48, 49]. Fourth, the number of citations is commonly used to assess the publication quality in bibliometric analysis. To discover high academic impact publications in the clinical research of FRI, we listed the top 100 most cited articles. However, self-citation, publication date, and controversial articles all likely had an impact on the number of citations [21].


## 4.1. Global Publishing Trends

Although some research papers evaluated orthopaedic-related infection using bibliometrics [24, 25], to the best of our knowledge, this is the first article to fully assess clinical research on FRI. Our analysis shows that the number of related publications exhibited a significant increasing trend from 2000 to 2020. Of all languages, English was the main international scholarly language in this field. In addition, 65% of studies in languages other than English was in German. Several bibliometric analyses of medicine-related research also noted that German was the most common second language following English [19, 26].


## 4.2. Country

Half of the top 10 contributing countries on FRI studies originated from Europe, with the remaining coming from Asia and North America. The UK had the highest number of publications and academic influence in Europe, China in Asia, and the USA in North America. The annual distribution of FRI research from the top 10 countries displayed the USA ranked first in the top 10 largest contribution countries annually between 2000 and 2019. Interestingly, the UK and Germany persistently remained at around second and third place from 2003 to 2012 (Figure4). China was ranked second between 2013 and 2019 and first in 2020. This result may suggest a great potential for the development of FRI research in China.In 72 of 89 countries involved in international collaborations, the USA had the highest number of research collaborations with other countries. Most of the international collaborations were between North America and European countries. A greater international collaboration should be widely established in the future.


## 4.3. Organizations and Authors

Among the institutions, four of the top five highest contributing countries originated from the USA. The University of California from the USA was the most productive institution globally in clinical studies focusing on FRI. Scholars from Europe and North America demonstrated a dominant position. The publications on the diagnosis and treatment principles of FRI also proved that most members of the FRI consensus group originated from Euro-American countries [27, 28]. In addition, half of the top 10 most productive authors on FRI were involved in the FRI consensus group [13]. Metsemakers WJ, from the University Hospitals Leuven, contributed most to clinic research of FRI. Regarding the top 10 author productions over time, most authors showed increased stability and persistence for a longer duration between 2016 and 2020. The list of top 10 most productive authors in FRI may provide a valuable reference for future scientific conference invitations for FRI experts.


## 4.4. Journals

Of the top 10 journals with the largest number of papers, Injury-International Journal of the Care of the Injured had the highest number of relevant publications, whereas Journal of Orthopaedic Trauma was the most academic influential journal on FRI. Compared with the bibliometric study, which excludes non-English literature [29, 30], the present bibliometric research also provides more valuable journal information to non-English speaking countries. Hence, scholars will most likely benefit from journal information to further subscribe or track the most relevant journal and also submit clinical research of FRI manuscripts as a reference. Figures on the first publications indicated that an increasing number of journals are interested in FRI research, with the highest values attained in 2008 and 2019.


## 4.5. Most Cited Documents

The number of citations is a traditional indicator for the assessment of the value of a certain study. Our study displays the top 100 most impactful studies on FRI and provides a resource for clinical scientists. Of all publications, the most cited research paper was published by Govender et al. [31]. The authors found that an implant containing 1.50 mg/mL of recombinant human bone morphogenetic protein-2 in the treatment of open tibial fractures could reduce the incidence of postsurgical infections. The most cited review article was published by Trampuz and Zimmerli [32]. The authors summarized the pathogenesis, classification, diagnosis, and treatment of infections associated with fracture-fixation devices.


## 4.6. Trend Topics

Trend topics were identified from author keywords. In terms of the surgical site, scholars placed a greater interest in infection after humeral fractures, followed by the location of femur and tibia, with a current focus on ankle fractures [33–39]. Furthermore, research topics and concepts also altered over the course of the years. With the introduction of the FRI consensus group, the term “fracture-related infection” became the standard, with more recent topics primarily focusing on risk factors and diagnostic criteria of FRI [15, 40–43]. Prior to this, researchers focused on the treatment of FRI [44–46], with a focus on debridement, bone transfer, and antibiotic treatment. In addition, with the publication of the consensus definition of FRI, this concept appears to be gradually gaining ground in the scientific literature.


## 4.7. Limitations

There are several limitations to the present study. First, only a single database was searched, with other databases and sources not included in the bibliometric analysis. Therefore, some potentially valuable information may have been missed [47]. Second, the FRI-related terms of the search strategy were based on the literature and personal experience; nonetheless, some literature may have been overlooked. Third, conference proceedings were also removed from this bibliometric analysis, due to the potential of being published on two occasions, as a conference abstract and also as a full journal article [48, 49]. Fourth, the number of citations is commonly used to assess the publication quality in bibliometric analysis. To discover high academic impact publications in the clinical research of FRI, we listed the top 100 most cited articles. However, self-citation, publication date, and controversial articles all likely had an impact on the number of citations [21].


## 5. Conclusions

The number of articles on FRI showed an increasing trend over the last 21 years. English was the primary language used for academic exchange on the topic of FRI, followed by German. In addition, the USA has the most number and impactful publications, as well as international collaborations. China has great development potential in this field. A broader international collaboration on FRI is required in the future. The most relevant and academic influential journals on FRI are the Injury-International Journal of the Care of the Injured and the Journal of Orthopaedic Trauma, respectively. The definition of FRI will most likely become validated and widely available in clinical practice.



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