Editorial Feature

Bibliometric Analysis of Robotic Orthopedic Surgery

Robotic technology has become integrated into a range of different fields, including orthopedic surgery. An article published in the journal BMC Musculoskeletal Disorders has analyzed the trends of robotic orthopedic surgeries in a clinical setting employing bibliometrics.

​​​​​​​Image Credit: Gorodenkoff/Shutterstock.com

Orthopedic techniques continue to evolve at a rapid pace, even more so following the technological explosion of robotic surgery, deep learning approaches, 3D printing, and virtual reality.

Robotic technology use in the medical sector continues to rise, and many surgical robots have obtained approval for clinical practice in the USA from the Food and Drug Administration. There are also reports that robotic surgery is highly precise in orthopedic implant placement. However, orthopedic robotics remains a challenging and complex technique.

Bibliometrics is a research technique commonly utilized to investigate the characteristics and development of a subject area. Until now, there is no comprehensive analysis of the clinical study of orthopedic robots by bibliometric analysis.

Here, the researchers aim to use bibliometric analysis to identify the features in robotic orthopedic surgery, including study design, kind of surgery, robot information and country of use. 

The team also set out to complete data visualization to explore the relationship between various institutions, journals, countries and investigate research hotspots and trends.

Methodology

The electronic database, Web of Science, was explored between 2000 and 2019 (no language restrictions) using the search for various keywords. The search results and the cited literature were reviewed.

Inclusion criteria depended on the article elaborating clinical research on the application of robotic surgery in orthopedics and review article, clinical trial, meta-analysis, and guideline. Book chapters, animal studies, conference proceedings, and cadaveric investigations were included under exclusion criteria.

The information was exported from the WoS, summarized, and examined with the WPS office. The widely employed approach of coupling, co-citation, co-occurrence analysis was carried out.

Results

A total of 1013 primary research results, 186 publications, and 1124 cited papers were reviewed and 224 clinically-related publications were selected for bibliometric analysis.

The selected publications comprised 164 articles, 47 reviews, and 13 meta-analyses. Figure 1 shows the complete global contribution of publications from 2000 to 2019.

Graphs indicating the total annual number of global contributions.

Figure 1. Graphs indicating the total annual number of global contributions. Image Credit: Li, et al., 2021

The articles were from 23 countries (see Figure 2).

Global distribution according to country.

Figure 2. Global distribution according to country. Image Credit: Li, et al., 2021

During 2018 and 2019, major contributions were from the United States, China, and the United Kingdom (see Figure 3).

Annual contributions according to country.

Figure 3. Annual contributions according to country. Image Credit: Li, et al., 2021

The minimum number of publications from a country was set to two publications with 17 countries meeting the criteria (see Figure 4).

Coupling analysis of countries on global robotic orthopedic surgery research.

Figure 4. Coupling analysis of countries on global robotic orthopedic surgery research. Image Credit: Li, et al., 2021

Table 1 lists the institutions with at least eight publications.

Table 1. Global institutions with at least eight publications on orthopedic robotic surgery. Source: Li, et al., 2021

Institutions Number of
articles
Country H-index Sum of
Times
Cited
Average
citations
per item
Beijing Jishuitan Hospital 15 China 5 97 6.47
Cleveland Clinic 13 USA 7 145 11.15
University of London 13 UK 7 140 10.77
Hospital for Special Surgery 10 USA 7 178 17.8
Northwell Health 8 USA 4 33 4.13
University of Göttingen 8 Germany 7 404 50.5

 

Coupling analysis indicated the top three institutions with the highest total link strengths (see Figure 5).

Coupling analysis of institutions on robotic orthopedic surgery.

Figure 5. Coupling analysis of institutions on robotic orthopedic surgery. Image Credit: Li, et al., 2021

Table 2 enlists the top nine authors who according to the number of publications.

Table 2. The top nine authors in the orthopedic robotic surgery field ranked according to the number of publications. Source: Li, et al., 2021

Author
name
Number of
article
Country Institution H-index Sum of
times
cited
Average
citations
per item
Mont,
Michael A
14 USA Cleveland
Clinic
7 115 8.21
Tian,
Wei
14 China Beijing Jishuitan
Hospital
5 84 6
Domb,
Benjamin G
10 USA Hinsdale
Orthopaedics
6 153 15.3
Liu,
Ya-Jun
10 China Beijing Jishuitan
Hospital
5 59 5.9
Haddad,
Fares S
9 UK University of
London
5 91 10.11
Khlopas,
Anton
9 USA Cleveland
Clinic
6 83 9.22
Konan,
Sujith
9 UK University of
London
5 88 9.78
Sodhi,
Nipun
9 USA Cleveland
Clinic
6 81 9
Kayani,
Babar
9 UK University of
London
5 91 10.11

 

Analyzing the top 30 most cited papers Spine had the highest number of publications with five papers. It was noted that 69 journals published the use of robotics in orthopedic surgery (see Table 3).

Table 3. Journals with at least six publications in orthopedic robotic surgery. Source: Li, et al., 2021

Journals Total
publications
Total
cites
Average citations
per item
Journal of Arthroplasty 27 238 8.81
Spine 13 212 16.31
International Journal of Medical Robotics
and Computer Assisted Surgery
13 78 6
Orthopaedic Surgery 13 15 1.15
World Neurosurgery 10 26 2.6
Knee Surgery, Sports Traumatology, Arthroscopy 9 62 6.89
Journal of Knee Surgery 9 30 3.33
Neurosurgical Focus 7 48 6.86
Bone & Joint Journal 7 18 2.57
Clinical Orthopaedics and Related Research 6 104 17.33
European Spine Journal 6 108 18
Expert Review of Medical Devices 6 20 3.33
Knee 6 54 9

 

Table 4 shows the top 10 journals on orthopedic robotic surgery based on the impact factor.

Table 4. Top 10 journals on orthopedic robotic surgery ranked according to impact factor. Source: Li, et al., 2021

Journals Impact factor (2018) Total publications
Sports Medicine 7.583 1
Journal of Bone and Joint Surgery-American Volume 4.716 4
Neurosurgery 4.605 4
Bone & Joint Journal 4.301 7
Clinical Orthopaedics and Related Research 4.154 6
Scientific Reports 4.011 1
Plastic and Reconstructive Surgery 3.946 1
Annals of Translational Medicine 3.689 3
Bone & Joint Research 3.652 1
Haemophilia 3.59 1

 

The minimum number of publications of a journal was then set to two papers and coupling analysis of 32 journals was carried out (Figure 6).

Coupling analysis of journals on robotic orthopedic surgery.

Figure 6. Coupling analysis of journals on robotic orthopedic surgery. Image Credit: Li, et al., 2021

Then the minimum number of publications of a journal was set to at least 30 citations and co-citation analysis of the 30 journals was carried out (see Figure 7).

Co-citation analysis of journals on robotic orthopedic surgery.

Figure 7. Co-citation analysis of journals on robotic orthopedic surgery. Image Credit: Li, et al., 2021

Around 152 studies detailed the kind of robot and surgical information and the most common surgical sites were the knee, spine, and hip. It was also noted that pedicle screw implantation was performed mostly (see Table 5).

Table 5. Type of robotic orthopedic surgery and the surgical site. Source: Li, et al., 2021

Surgical site Type of procedure n (%)
Spine Pedicle screw implantation 56 (89%)
Vertebral augmentation 3 (5%)
Laparoscopic anterior lumbar interbody fusion 1 (1%)
Spine tumor resection surgery 1 (1%)
Intraoperative localization 1 (1%)
Anterior lumbar interbody fusion 1 (1%)
Knee Total knee arthroplasty 24 (50%)
Unicompartmental Knee Arthroplasty 23 (48%)
Anterior cruciate ligament reconstruction 1 (2%)
Hip Total hip arthroplasty 30 (100%)
Femur Femoral neck cannulated screw placement 3 (60%)
Intramedullary nail fixation 1 (20%)
Core decompression of the femoral head 1 (20%)
Pelvis Internal fixation of pelvic acetabular injuries 1 (25%)
Percutaneous cannulated screw fixation, INFIX fixation,
open reduction and internal plate fixation
1 (25%)
Percutaneous screw placement combined with INFIX 1 (25%)
Neurolysis 1 (25%)
Hand Percutaneous internal fixation 1 (100%)
Elbow Oberlin procedure 1 (100%)

 

It was noted that 14 types of orthopedic robots were employed and the most diverse were utilized in the knee and spine. The widely used one was TiRobot, succeeded by DA Vinci (see Figure 8).

Types of robots in orthopedic surgery and corresponding surgical sites.

Figure 8. Types of robots in orthopedic surgery and corresponding surgical sites. Image Credit: Li, et al., 2021

Six countries developed 14 kinds of surgical robots, with more than half originating from the United States (see Figure 9).

Six countries produce robots for orthopedic use.

Figure 9. Six countries produce robots for orthopedic use. Image Credit: Li, et al., 2021

The study exported 950 author keywords from the included studies. Table 6 lists the most frequently used 20 keywords.

Table 6. Top 20 most frequently used keywords in robotic orthopedic surgery publications. Source: Li, et al., 2021

Keywords Number of occurrences
Robotics 43
Pedicle screw 33
Total knee arthroplasty 30
Unicompartmental knee arthroplasty 27
Navigation 25
Outcome 24
Spinal fusion 24
Robotic surgery 21
Minimally invasive 20
Total hip arthroplasty 17
Computer-assisted surgery 17
Accuracy 16
Arthroplasty 14
ROBODOC 9
MAKO 9
Learning curve 8
Complication 7
Freehand technique 7
TKA 7
Mazor 6

All keywords were examined by VOSviewer software. The red-colored group in Figure 10 was associated with robotic surgery in joint replacement and the green-colored group was linked to spinal surgery.

Co-occurrence network of robotic orthopedic surgery.

Figure 10. Co-occurrence network of robotic orthopedic surgery. Image Credit: Li, et al., 2021

Figure 11 shows the overlay visualization between 2000 and 2019 in robotic orthopedic surgery.

Overlay visualization from 2000–2019 in robotic orthopedic surgery.

Figure 11. Overlay visualization from 2000–2019 in robotic orthopedic surgery. Image Credit: Li, et al., 2021

Discussion

This research identified 224 related papers in the 2000 to 2019 timespan. Bibliometric analysis analyzed the characteristics of the robotic technique in orthopedics.

The bibliometric analysis showed an increasing trend in the global contributions from 2000 to 2019. Most numbers of relevant publications were from the United States, and currently, only 23 countries are involved in orthopedic robot research. 

It is likely that the lack of competition may create market monopolies.

It was noted that the authors Tian Wei and Mont Michael A made the majority of the contributions in the orthopedic robot field. Bibliographic coupling networks of institutions revealed that most institutions were from the United States.

Research from the Cleveland Clinic was found to be the most relevant, followed by Beijing Jishuitan Hospital and the University of London.

Bibliographic coupling and co-citation network of the journal showed that the Journal of Arthroplasty was the most influential and relevant in the orthopedic robot field. MAKO and Mazor were the most widely used orthopedic robot in spine and lower limb joint surgery.

Limitations

The bibliometric analysis missed numerous publications from databases like PubMed and Scopus. 

Citation time may also have been affected by the time sequence of publications, self-citation, and controversial articles. The study also did not consider publications involving cadaveric or animal studies.

Conclusion

Robotic technology in clinical orthopedics is an emerging field, and many researchers and institutions will play a vital role in broadening its use. 

Fracture fixation, in particular, is a hopeful application for further development in robotic trauma surgery. 

Robotic Microswimmers: The Next Biomedical Breakthrough.

Journal Reference:

Li, C., Wang, L., Perka, C., Trampuz, A. (2021) Clinical application of robotic orthopedic surgery: a bibliometric study. BMC Musculoskeletal Disorders, 22, p. 968. Available online: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-021-04714-7#citeas.

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Megan Craig

Written by

Megan Craig

Megan graduated from The University of Manchester with a B.Sc. in Genetics, and decided to pursue an M.Sc. in Science and Health Communication due to her passion for combining science with content creation. As part of her studies, Megan partnered with Jodrell Bank Discovery Centre as a Digital Marketing Assistant, producing content and updating sections of their website. In her spare time, she loves to travel, exploring each location's culture and history - including the local cuisine. Her other interests include embroidery, reading fiction, and practicing her Japanese language skills.

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