Arthroscopic treatment of osteoarthritis: a bibliometric study

Introduction

Osteoarthritis (OA) is a kind of degenerative joint disease, which can cause local pain, swelling, and functional decline in the joints of patients, and seriously affect the quality of life of patients. This disease is more common in middle-aged and older adults, with the incidence and prevalence increasing with age (1,2). In the early stage of the disease, difficult-to-locate pain occurs in the joints and their surroundings, and local tenderness may be present. As the disease progresses, joint swelling, increased pain, decreased joint function, decreased joint weight, disuse atrophy of joint accessory muscles, osteoporosis, and decreased joint stability gradually appear (3-5). The main mechanism of OA involves the vascular disease of the subchondral bone causing local insufficiency of blood supply, which, in turn, leads to changes in the structure of the subchondral bone. As a consequence, the outside of the cartilage degenerates, and changes in the intra-articular environment, exudation of inflammatory mediators, synovial hyperplasia, and inflammatory manifestations of edema occur. Clinical manifestations may vary depending on the different joints involved, but issues with the knee joint and hip joint are the most common (5).

Because OA is a degenerative disease and cannot be thoroughly cured, the current principle of treatment is to control or reduce inflammation, relieve pain, and improve joint function (6,7). Treatment strategies include surgery, medication, and rehabilitation physiotherapy (6). Surgery includes open surgery and arthroscopic minimally invasive surgery, the main purpose of which is to flush and remove the diseased tissue in the joint or to reconstruct the joint to achieve partial recovery (6). Drug therapy and rehabilitation physiotherapy are mainly applied to reduce inflammation, relieve pain, and increase the function of joints and their accessory structures (6). Arthroscopy is a minimally invasive surgery using endoscopy technology in diagnosing and treatment of joint disease, and is widely used in patients with severe OA. Under arthroscopy, joint debridement, chondroplasty, and ligament lysis can be performed (8). Arthroscopic treatment of OA can not only slow down the degeneration of cartilage and the progression of the disease, but also decrease the release of inflammatory factors, reduce the pain caused by mechanical factors, and restore joint function to a certain extent. Within its long period of clinical application, arthroscopy has been able to examine and treat multiple large joints, including shoulder joints, elbow joints, wrist joints, hip joints, knee joints, and ankle joints. As OA mainly involves weight-bearing joints, arthroscopy is the most widely used approach in hip and knee joint diseases, especially the knee joint (8,9).

With the continuous development of arthroscopy in clinical practice, there has also been a corresponding enrichment in the literature in this field. It is thus necessary to analyze the current state of research related to the application of arthroscopy in OA. Some previous reviews summarized the advances and status of specific theme in the field of arthroscopic management of OA, but not overview on where these research came from or who did these work, or information about literatures (8,10). This study adopted the bibliometric method (11) to analyze the literature in the field of arthroscopic management of OA, depict the status of related research from a macroperspective, and provide references for researchers.

Methods

Literature search

Similar to other bibliometric studies (12,13), we searched for literature using the Science Citation Index Expanded (SCI-E) database in the Web of Science Core Collection (WOSCC) as the data source. Literature was searched from the earliest time included in the database to the most recent search time of this study (August 22, 2021). A topic search strategy was used, with the search terms being “osteoarthritis” and “arthroscopy”, and the intersection of the retrieval results of these 2 terms was collected.

Data analysis

The full record of the search results and the cited references was exported in text format. CiteSpace software was used to remove duplicate records. Information including annual publication status, subject distribution, country/institution distribution, journal distribution, author, and the use of keywords were then separately analyzed. Finally, burst detection was applied to analyze the annual trend in the use of keywords.

Statistical analysis

In this study, the current status of research in the field of the arthroscopic treatment of OA was analyzed. There was no comparison between groups and no analysis of influencing factors. Therefore, no P value was established. The analysis results are expressed in quantity and percentage (n, %).

Results

General information

A total of 2,862 document records were retrieved in SCI-E using the topic terms “osteoarthritis” and “arthroscopy”, 124 duplicate records were removed, and final number of documents analyzed was 2,738 (Tables 1,2, Figure 1). From Table 2 and Figure 1, it can be seen that the number of documents published in this field basically shows an increasing trend year by year. These documents have been cited 82,932 times (Figure 2), the average number of citations for each piece of literature is 30.29, the h index is 125, and the number of citations also shows a significant increase each year. Among these articles, there are 2,400 original articles, showing that research in this topic is very active. Among the other document types, there are 240 reviews, 77 proceedings papers, 70 editorial materials, 11 letters, 2 book chapters, and 1 note.

Figure 1 Annual trends in the number of publications.

Figure 2 Annual changes of citations.

Country and institution distribution of document source

CiteSpace V software was used to analyze the characteristics of the country and institution of the document source and to generate a national visualization map and an institution visualization map. A seen in Figure 3, the number of nodes in the country visualization map is 90; that is, in the 2,738 documents, there are a total of 90 countries represented. The number of connections is 362; that is, the number of times any 2 countries appear in the same document is 362 times, and this represents the cooperation between these 2 countries in this document. Similarly, the number of nodes in the organization visualization map is 753; that is, in the 2,738 documents, there are 753 organizations involved, but the number of connections between the organizations is only 629, suggesting that some studies have only 1 to 2 related institutions (Figure 4). Further analysis of the publication situation of various countries revealed that the country with the largest number of publications was the United States, followed by Germany, the United Kingdom, China, and Canada (Table 3), with the number of publications in the United States being far greater than that of any other country. The United States also ranked highest in the centrality score, reflecting the frequency of external cooperation, followed by Canada, France, the United Kingdom, and Sweden, suggesting that the United States is in a leading position in research in this field in the international arena (Table 4). The institution with the largest number of publications was the Hospital of Special Surgery (the hospital is the oldest orthopedic hospital in the United States, has an international reputation, and is ranked first in the United States for orthopedics), followed by the American Hip Institute, the Steadman Philippon Research Institute, Washington University, and the Mayo Clinic, which are all located in the United States (Table 5). Among the top 5 institutions in centrality, only McMaster University in Canada was not from the United States (Table 6). Collectively, these results clearly show that the majority of prominent research in the field of arthroscopic treatment is being produced by institutes in the United States.

Figure 3 A visualization map of countries. The circles and dots in the figure represent countries, and the curve represents that 2 countries were involved in the same research project (i.e., cooperative relationship). The larger the circle, the more extensive is the cooperation between the given countries.

Figure 4 Visualization map of institutions. The circles and dots in the figure represent organizations, and the curve represents that 2 institutions were involved in the same research project (i.e., cooperative relationship). The larger the circle, the more extensive is the cooperation between the given institutions.

Author analysis

The analysis shows that the author with the largest number of publications was Domb, who published 62 related papers. Domb previously worked at the Hospital of Special Surgery and currently practices at the American Hip Institute. The number of publications and work trajectories indicate that Domb is an influential researcher in this field. Other authors with a large number of publications are shown in Table 7 and Figure 5. However, although the number of papers published by these authors is relatively large, the centrality score reflecting cooperation did not reach 0.01, indicating that the degree of cooperation between the authors is not high. Among all authors, the top 5 authors in cocitations are Ganz, Philippon, Byrd, Beck, and Outerbridge (Table 8). Although Ganz has not published the most number papers in this field, his published works constitute the seminal research in this field. The top 5 authors in cocitation centrality are Outerbridge, Bellamy, Kellgren, Ito, and Kelly, with Outerbridge being more of an earlier researcher (Table 9, Figure 6).

Figure 5 Visualization map of coauthors.

Figure 6 Visualization map of cocitation.

Journal analysis

The 2,738 articles were retrieved from 417 journals, of which 16 published more than 30 articles each (Table 10). These 16 journals have published 1,256 related papers, accounting for 45.87% of the total literature (Table 10). Moreover, this group of journals are all top journals in orthopedics, particularly in the field of joints and arthroscopy. The most cited journal was Arthroscopy (Table 11). The journal with the highest centrality score was Instructional Course Lectures, which is a professional journal of the American Academy of Orthopaedic Surgeons (AAOS) and only publishes 1 issue a year, covering important issues in this field (Table 12).

Keyword analysis

CiteSpace V software was employed to analyze keyword usage and to generate a keyword co-occurrence visualization map (Figure 7). There are 551 nodes in the graph in Figure 7; that is, there are 551 keywords used in the literature in this field. The number of simultaneous appearances of any 2 keywords in a single document is 1993. The top 5 keywords in terms of frequency are “osteoarthritis”, “arthroscopy”, “knee”, “femoroacetabular impingement”, and “hip arthroscopy” (Table 13). The keyword for the central score is “articular cartilage”, which is consistent with the effect of arthroscopy in the treatment of OA (Table 14). We further used CiteSpace for burst detection (Figure 8) to find keywords with a high frequency of use. We found that early research mainly focused on the technical operation of arthroscopic treatment of OA, while the focus in recent years has been on long-term prognosis and risk prediction.

Figure 7 Visualization map of keywords.

Figure 8 Top 25 keywords with the strongest citation bursts.

Discussion

The results of this study provide an overview of the research in the field of arthroscopic treatment of OA. The number of research documents in this field and the number of citations point to a significant increase in publication over the past three decades. A large amount of research is mainly concentrated in developed countries in Europe and the United States, and several well-known research institutions and researchers in the United States have conducted the bulk of the important research, with the main research authors including Domb and others. International cooperation is also mainly led by the United States. For journals, investigators should focus on professional journals on joints and arthroscopy to get high quality research information. Keyword analysis suggests that current research focuses on the long-term prognosis and risk prediction of the arthroscopic treatment of OA.

As a minimally invasive diagnosis and treatment method, arthroscopy is widely used. With the advancement of materials science and endoscope production technology, arthroscopy has seen a greater definition in the field of view and increasing flexibility in operation. Large joints of the limbs (including the shoulder, elbow, wrist, hip, knee, and ankle) can be examined and treated (10,14-19). Arthroscopy has a wide range of indications, with slight injury and scars caused by surgery, and low risk of infection under strict aseptic conditions (20,21). The overall risk of the operation is low, repeatable, and has no obvious impact on other future operations (22,23). With arthroscopic technology, multiple operations or treatments can be performed at the same time, including joint debridement, joint cavity irrigation, meniscus resection or plasty, worn cartilage repair, and intra-articular injection (14-19). It should be noted that, as a diagnostic technique, arthroscopy can make a clear diagnosis while being minimally invasive. However, as a treatment method, for OA, arthroscopy can often only provide preservative treatment to improve the patient’s joint function and relieve pain, but cannot prevent the progression of the degenerative disease (10). Arthroscopic surgery of the knee, the most common type of arthroscopy applied, can still only clean the hyperplastic synovium and cartilage debris, and remove inflammatory factors to improve the clinical function of the knee joint, but it cannot cure knee OA nor can it prevent the progress of this kind of degenerative disease; rather, its main effect is to reduce the knee pain of patients with OA, restore joint flexion function, and improve the patients’ living standards and quality of life (24). The effect of arthroscopic debridement on the knee of OA patients with clinical symptoms of mechanical noose is the most satisfactory, especially for patients with related diseases such as synovial hyperplasia, meniscus tear, and loose bodies of cartilage. The unique advantages of debridement surgery are more obvious than are those of nonsurgical treatments (24). Degenerative cartilage fragments in the joints, inflammatory hyperplasia and edema of synovial tissue, and hyperplasia of osteophytes can be removed to the maximum extent during arthroscopic debridement. This relieves the joint noose symptoms caused by the proliferation of cartilage fragments and the proliferation of the noose. The meniscus that is damaged and torn can be trimmed and formed. It not only reduces the abrasion and degeneration speed of cartilage tissue, but also eliminates the mechanical factors that cause joint movement obstacles caused by the torn meniscus (24). Moreover, a small amount of bleeding during the operation can form a fibrin clot, which covers the surface of the cartilage to repair it, and it can also reduce the wear and tear of the cartilage surface in the short term (25). During the cleaning process, a large amount of continuous perfusion with a certain pressure of normal saline can clean the joint cavity, which can remove the degenerated cartilage debris and a large amount of inflammatory mediators in the joint cavity and flow out with the water, thereby quickly eliminating aseptic inflammation in the joint, improving the environment in the joints, and providing sufficient conditions for the normal secretion of synovial fluid in the joints. This ultimately relieves joint pain and swelling symptoms, and improves joint function (26,27). Joint debridement will cause certain trauma to the tissues in the joint. After the operation, local glucocorticoids in the joint can inhibit inflammation, ameliorate synovial congestion, and reduce vascular permeability, thereby reducing joint effusion (28,29). Joint debridement surgery with simultaneous supplementation of sodium hyaluronate can protect the tissue structure in the joint cavity, induce synovial cells to secrete endogenous sodium hyaluronate, and bind glycoproteins, thereby reducing the need for further verification and increasing the therapeutic effect (30). However, compared with drug treatment, which can only alleviate the joint pain partly, arthroscopic treatment can reduce the pain more quickly and deeply.

The results of this study clearly show that the United States is leading the research into the role of arthroscopy in joint diseases, with the Hospital of Special Surgery, the American Hip Institute, the Steadman Philippon Research Institute, Washington University, and the Mayo Clinic being the flagship institutions. In the field of orthopedics, especially joint surgery, the USA is a world leader, with the abovementioned institutions being the central nodes of cooperation in this field. If researchers wish to exchange experiences or seek cooperation with experienced institutions, they can consider these institutions. However, the analysis of the authors shows that the degree of cooperation between researchers is not high (the centrality scores did not reach 0.01). Although the degree of cooperation between institutions is relatively high, there are many researchers in each institution, and different topics are completed by different researchers who may belong to the same research institution; thus, the centrality score of the institution may be high but that of the researchers may be low.

Our study also found that important research institutions have a large number of research results in the field of arthroscopy diagnosis and treatment, which deserves close attention. When doing literature search, we can take those top institutions and authors in our results as search targets. Since arthroscopy is relatively professional, the research results in this field are all published in orthopedics or joint professional journals. For high quality of literature investigating, we can pay more attention on the top journals in our analysis results, including Arthroscopy, American Journal of Sports Medicine, Knee Surgery, Sports Traumatology, Arthroscopy, Osteoarthritis and Cartilage, and Clinical Orthopaedics and Related Research. Keyword analysis results show that knee joints and hip joints are the focus of arthroscopic research and that there are relatively few studies on other joints. This may be due to the limitation of arthroscopic technology, the high complexity of other joints, and the low incidence of OA in other joints; research into other joints can be appropriately increased in the future.

Using the SCI-E citation database, this study analyzed the current status of research on arthroscopy in the field of OA, summarized the main research sources in this field, revealed some issues that researchers should pay attention to, and used keyword analysis to track the changes in research interest in this field. These finding may be valuable for researchers in this field in determining research directions, carrying out cooperative projects, and exchanging experiences.

Some limitations to this study should also be noted. First, an in-depth analysis of the relative strengths and specialties that different research institutions and researchers in this field possess was not undertaken in this study. Second, we were not able to extensively examine the current issues in this field that have yet to be resolved. This may require additional systematic reviews or meta-analyses.

Acknowledgments

Funding: This study was supported by Jinzhou Medical University School-Enterprise Cooperation Fund Project (No. 2020002).

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/apm-21-3548). YL, JC, LK, and HZ report that they received funding support from Jinzhou Medical University School-Enterprise Cooperation Fund Project (No. 2020002). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet 2019;393:1745-59. [PubMed]
2. Vina ER, Kwoh CK. Epidemiology of osteoarthritis: literature update. Curr Opin Rheumatol 2018;30:160-7. [Crossref] [PubMed]
3. Nelson AE. Osteoarthritis year in review 2017: clinical. Osteoarthritis Cartilage 2018;26:319-25. [Crossref] [PubMed]
4. Martel-Pelletier J, Barr AJ, Cicuttini FM, et al. Osteoarthritis. Nat Rev Dis Primers 2016;2:16072. [Crossref] [PubMed]
5. Xia B. Osteoarthritis pathogenesis: a review of molecular mechanisms. Calcif Tissue Int 2014;95:495-505. [Crossref] [PubMed]
6. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken) 2020;72:149-62. [Crossref] [PubMed]
7. Dieppe PA, Lohmander LS. Pathogenesis and management of pain in osteoarthritis. Lancet 2005;365:965-73. [Crossref] [PubMed]
8. Khan M, Khanna V, Adili A, et al. Knee osteoarthritis: when arthroscopy can help. Pol Arch Intern Med 2018;128:121-5. [PubMed]
9. Casp A, Gwathmey FW. Hip Arthroscopy: Common Problems and Solutions. Clin Sports Med 2018;37:245-63. [Crossref] [PubMed]
10. Cooper ID. Bibliometrics basics. J Med Libr Assoc 2015;103:217-8. [Crossref] [PubMed]
11. Brandt JS, Hadaya O, Schuster M, et al. A Bibliometric Analysis of Top-Cited Journal Articles in Obstetrics and Gynecology. JAMA Netw Open 2019;2:e1918007. [Crossref] [PubMed]
12. Devos P, Menard J. Bibliometric analysis of research relating to hypertension reported over the period 1997-2016. J Hypertens 2019;37:2116-22. [Crossref] [PubMed]
13. Pitta M, Davis W 3rd, Argintar EH. Arthroscopic Management of Osteoarthritis. J Am Acad Orthop Surg 2016;24:74-82. [Crossref] [PubMed]
14. Paxton ES, Backus J, Keener J, et al. Shoulder arthroscopy: basic principles of positioning, anesthesia, and portal anatomy. J Am Acad Orthop Surg 2013;21:332-42. [PubMed]
15. Adams JE, King GJ, Steinmann SP, et al. Elbow arthroscopy: indications, techniques, outcomes, and complications. Instr Course Lect 2015;64:215-24. [PubMed]
16. Shulman B, Catalano L. Wrist Arthroscopy Scope for the Best and Plan for the Worst. Bull Hosp Jt Dis (2013) 2020;78:81-7. [PubMed]
17. Jamil M, Dandachli W, Noordin S, et al. Hip arthroscopy: Indications, outcomes and complications. Int J Surg 2018;54:341-4. [Crossref] [PubMed]
18. Degen RM, Lebedeva Y, Birmingham TB, et al. Trends in knee arthroscopy utilization: a gap in knowledge translation. Knee Surg Sports Traumatol Arthrosc 2020;28:439-47. [Crossref] [PubMed]
19. Shimozono Y, Seow D, Kennedy JG, et al. Ankle Arthroscopic Surgery. Sports Med Arthrosc Rev 2018;26:190-5. [Crossref] [PubMed]
20. Sircana G, Passiatore M, Capasso L, et al. Infections in arthroscopy. Eur Rev Med Pharmacol Sci 2019;23:279-87. [PubMed]
21. Cancienne JM, Brockmeier SF, Carson EW, et al. Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population. Am J Sports Med 2018;46:809-14. [Crossref] [PubMed]
22. Winter AR, Collins JE, Katz JN. The likelihood of total knee arthroplasty following arthroscopic surgery for osteoarthritis: a systematic review. BMC Musculoskelet Disord 2017;18:408. [Crossref] [PubMed]
23. Nakano N, Lisenda L, Jones TL, et al. Complications following arthroscopic surgery of the hip: a systematic review of 36 761 cases. Bone Joint J 2017;99-B:1577-83. [Crossref] [PubMed]
24. Howard DH. Trends in the Use of Knee Arthroscopy in Adults. JAMA Intern Med 2018;178:1557-8. [Crossref] [PubMed]
25. Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res 2003;84-8. [Crossref] [PubMed]
26. Stärke F, Awiszus F, Lohmann CH, et al. The effect of irrigation time and type of irrigation fluid on cartilage surface friction. J Mech Behav Biomed Mater 2018;77:187-91. [Crossref] [PubMed]
27. Rosseland LA, Helgesen KG, Breivik H, et al. Moderate-to-severe pain after knee arthroscopy is relieved by intraarticular saline: a randomized controlled trial. Anesth Analg 2004;98:1546-51. [Crossref] [PubMed]
28. Wang JJ, Ho ST, Lee SC, et al. Intraarticular triamcinolone acetonide for pain control after arthroscopic knee surgery. Anesth Analg 1998;87:1113-6. [Crossref] [PubMed]
29. Koraman E, Turkmen I, Uygur E, et al. A Multisite Injection Is More Effective Than a Single Glenohumeral Injection of Corticosteroid in the Treatment of Primary Frozen Shoulder: A Randomized Controlled Trial. Arthroscopy 2021;37:2031-40. [Crossref] [PubMed]
30. Shen D, Chen M, Chen K, et al. Efficacy of hyaluronic acid after knee arthroscopy: A systematic review and meta-analysis. J Rehabil Med 2018;50:860-5. [Crossref] [PubMed]