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The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine
Orthopedics and the sports medicine subspecialty are continually evolving fields that depend on research investigation and publication to further knowledge and advance practice. Research has produced new findings that have changed the way we practice sports medicine. In this review, we identify the most widely referenced sports medicine topics and articles, which we believe by their permeative presence in the literature have made lasting contributions to the field.
Many factors can be used to quantify the influence of an academic article on the practice of medicine. Citation analysis is one method that reflects the impact of a publication on the academic medical community.1-3 Total citations record the number of times a journal article has been credited by another study. Therefore, citation count indirectly highlights the articles that are widespread, relevant, and that form the foundation for other investigations on the topic. Related to the impact of the article is the impact of the journal that published the study. We examined journals by impact factor, a score based on the mean number of citations a published article received during the preceding 2 years.
Similar analyses have been performed of publication history in orthopedics and other medical fields. Investigators have examined which historical articles were the most influential in orthopedics as a whole,4 pediatric orthopedics,5,6 shoulder surgery,7 and arthroscopy.8 This influence has also been studied in general surgery,9 otolaryngology,10 plastic surgery,11 dermatology,12 critical care,13 and other disciplines. To our knowledge, the present study is the first bibliometric analysis of the highest-impact articles in orthopedic sports medicine.
Our goal was to identify the 100 articles that have had the highest impact on the clinical orthopedic sports medicine literature. We hypothesized that the most widely recognized articles would be from the highest-impact journals and may also have earlier publication dates. We describe the topics and objectives of these articles to highlight the sports medicine areas on which most research has focused during the past century.
Materials and Methods
Our bibliometric analysis used the Thomson Reuters Web of Knowledge, which consists of all publications from 1900 to the present. This research modality ranks journal articles by frequency of citation. Similar analyses have identified the most often cited articles in pediatric orthopedics,5 shoulder surgery,7 and arthroscopy.8 In our analysis, we included the top 25 journals by impact factor in the field of sports medicine, as rated by the Journal Citation Reports database. Within the highest-impact journals, we sorted all articles by those most often cited, and read them all to identify which ones discuss conditions commonly encountered in the clinical practice of sports medicine. We focused on clinical articles only and therefore excluded related basic science and cadaveric biomechanical studies. The 100 most cited articles were then further evaluated by primary author, journal of publication, institution, country of origin, year of publication, topic, and total number of citations. One-way analysis of variance (ANOVA) and linear regression analyses were used to determine if publication date correlated with mean number of citations.
Results
Eighty authors wrote the top 100 articles in sports medicine, and each publication garnered several hundred citations, ranging from 229 to 1629 with a mean of 408 (Table 114-113). Most of these articles were written in the past 3 decades, with equal distribution from the 1980s, 1990s, and 2000s (Figure 1A). We ran a linear regression to determine if publication date correlated with higher number of citations by virtue of longer time available for citation. The analysis poorly modeled the variability (R2 = 0.05), revealing no correlation between number of citations and publication date. Further, 1-way ANOVA found no significant difference between the number of citations per decade, F(5, 93) = 1.60, P = .17 (Figure 1B). Despite this finding, the oldest cited article, written by Fairbank39 in 1948, ranked high (position 7). Of these top 100 publications, the most recent, written by Knutsen and colleagues69 in 2007, ranked in the second half at position 66.
Seven journals published the top 100 articles, with the American volume of the Journal of Bone and Joint Surgery publishing nearly half (44%) (Table 2). In second place, with 28 articles, was the American Journal of Sports Medicine, followed by the British volume of the Journal of Bone and Joint Surgery, with 10 articles.
Thirty different topics were investigated in this collection of articles, encompassing nearly every major research area of sports medicine. There was a heavy emphasis on anterior cruciate ligament (ACL) injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation (Table 3).
In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes88-92 (5 articles), Neer81-84 (4 articles), and Rowe,102-104 Daniel,35-37 Peterson,97-99 and Hewett52-54 (3 articles each) (Table 417,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113). Articles from authors with multiple publications had a common topic.
Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.
Discussion
Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.114 The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.
The most cited sports medicine article was written by Insall and colleagues62 in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.32 This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.113 This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.
A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign82 and the Hawkins-Kennedy test51 are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score113 complements other functional scores (eg, Lysholm knee score74). For grading joint cartilage breakdown, the Outerbridge classification system96 is commonly used. The Fairbank test39 is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification47 is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,101 measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification84 of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.
As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,105 and Beck was listed as third author on 1 other article,42 raising their totals to 4 and 3, respectively.
A criticism of bibliometric analysis is its use of number of citations as an accurate measure of academic contribution. However, other methods for measuring the productivity and impact of researchers (eg, the recently developed Hirsch Index) have their own drawbacks,115,116 including being able to compare authors only at the same point in their careers and self-citation. It is important to note that our analyses focused strictly on publications related to clinical sports medicine, with the exclusion of basic science and cadaveric biomechanical studies.
Through bibliometric citation analysis, we have identified the authors who have made lasting contributions to the field of sports medicine, and we have highlighted the publications that have been cited by hundreds to thousands of authors. This list identifies trends within the articles that have become “classic,” by nature of their deep permeation into subsequent sports medicine literature, and offers guidance for trainees interested in studying the most high-yield sports medicine literature. Given that 69 institutions in 15 countries conducted these studies, we have also shown that orthopedic research can be readily disseminated internationally. Last, our study provides a thorough overview of the sports medicine literature over the past century and provides a strong framework for future research in our field.
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108. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders [see comments]. J Bone Joint Surg Am. 1995;77(1):10-15.
109. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85(2):278-286.
110. Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987;15(3):207-213.
111. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy. 2003;19(5):477-484.
112. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526.
113. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-49.
114. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660-667.
115. Bartneck C, Kokkelmans S. Detecting h-index manipulation through self-citation analysis. Scientometrics. 2011;87(1):85-98.
116. Bornmann L, Daniel HD. The state of h index research. Is the h index the ideal way to measure research performance? EMBO Rep. 2009;10(1):2-6.
Orthopedics and the sports medicine subspecialty are continually evolving fields that depend on research investigation and publication to further knowledge and advance practice. Research has produced new findings that have changed the way we practice sports medicine. In this review, we identify the most widely referenced sports medicine topics and articles, which we believe by their permeative presence in the literature have made lasting contributions to the field.
Many factors can be used to quantify the influence of an academic article on the practice of medicine. Citation analysis is one method that reflects the impact of a publication on the academic medical community.1-3 Total citations record the number of times a journal article has been credited by another study. Therefore, citation count indirectly highlights the articles that are widespread, relevant, and that form the foundation for other investigations on the topic. Related to the impact of the article is the impact of the journal that published the study. We examined journals by impact factor, a score based on the mean number of citations a published article received during the preceding 2 years.
Similar analyses have been performed of publication history in orthopedics and other medical fields. Investigators have examined which historical articles were the most influential in orthopedics as a whole,4 pediatric orthopedics,5,6 shoulder surgery,7 and arthroscopy.8 This influence has also been studied in general surgery,9 otolaryngology,10 plastic surgery,11 dermatology,12 critical care,13 and other disciplines. To our knowledge, the present study is the first bibliometric analysis of the highest-impact articles in orthopedic sports medicine.
Our goal was to identify the 100 articles that have had the highest impact on the clinical orthopedic sports medicine literature. We hypothesized that the most widely recognized articles would be from the highest-impact journals and may also have earlier publication dates. We describe the topics and objectives of these articles to highlight the sports medicine areas on which most research has focused during the past century.
Materials and Methods
Our bibliometric analysis used the Thomson Reuters Web of Knowledge, which consists of all publications from 1900 to the present. This research modality ranks journal articles by frequency of citation. Similar analyses have identified the most often cited articles in pediatric orthopedics,5 shoulder surgery,7 and arthroscopy.8 In our analysis, we included the top 25 journals by impact factor in the field of sports medicine, as rated by the Journal Citation Reports database. Within the highest-impact journals, we sorted all articles by those most often cited, and read them all to identify which ones discuss conditions commonly encountered in the clinical practice of sports medicine. We focused on clinical articles only and therefore excluded related basic science and cadaveric biomechanical studies. The 100 most cited articles were then further evaluated by primary author, journal of publication, institution, country of origin, year of publication, topic, and total number of citations. One-way analysis of variance (ANOVA) and linear regression analyses were used to determine if publication date correlated with mean number of citations.
Results
Eighty authors wrote the top 100 articles in sports medicine, and each publication garnered several hundred citations, ranging from 229 to 1629 with a mean of 408 (Table 114-113). Most of these articles were written in the past 3 decades, with equal distribution from the 1980s, 1990s, and 2000s (Figure 1A). We ran a linear regression to determine if publication date correlated with higher number of citations by virtue of longer time available for citation. The analysis poorly modeled the variability (R2 = 0.05), revealing no correlation between number of citations and publication date. Further, 1-way ANOVA found no significant difference between the number of citations per decade, F(5, 93) = 1.60, P = .17 (Figure 1B). Despite this finding, the oldest cited article, written by Fairbank39 in 1948, ranked high (position 7). Of these top 100 publications, the most recent, written by Knutsen and colleagues69 in 2007, ranked in the second half at position 66.
Seven journals published the top 100 articles, with the American volume of the Journal of Bone and Joint Surgery publishing nearly half (44%) (Table 2). In second place, with 28 articles, was the American Journal of Sports Medicine, followed by the British volume of the Journal of Bone and Joint Surgery, with 10 articles.
Thirty different topics were investigated in this collection of articles, encompassing nearly every major research area of sports medicine. There was a heavy emphasis on anterior cruciate ligament (ACL) injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation (Table 3).
In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes88-92 (5 articles), Neer81-84 (4 articles), and Rowe,102-104 Daniel,35-37 Peterson,97-99 and Hewett52-54 (3 articles each) (Table 417,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113). Articles from authors with multiple publications had a common topic.
Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.
Discussion
Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.114 The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.
The most cited sports medicine article was written by Insall and colleagues62 in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.32 This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.113 This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.
A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign82 and the Hawkins-Kennedy test51 are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score113 complements other functional scores (eg, Lysholm knee score74). For grading joint cartilage breakdown, the Outerbridge classification system96 is commonly used. The Fairbank test39 is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification47 is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,101 measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification84 of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.
As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,105 and Beck was listed as third author on 1 other article,42 raising their totals to 4 and 3, respectively.
A criticism of bibliometric analysis is its use of number of citations as an accurate measure of academic contribution. However, other methods for measuring the productivity and impact of researchers (eg, the recently developed Hirsch Index) have their own drawbacks,115,116 including being able to compare authors only at the same point in their careers and self-citation. It is important to note that our analyses focused strictly on publications related to clinical sports medicine, with the exclusion of basic science and cadaveric biomechanical studies.
Through bibliometric citation analysis, we have identified the authors who have made lasting contributions to the field of sports medicine, and we have highlighted the publications that have been cited by hundreds to thousands of authors. This list identifies trends within the articles that have become “classic,” by nature of their deep permeation into subsequent sports medicine literature, and offers guidance for trainees interested in studying the most high-yield sports medicine literature. Given that 69 institutions in 15 countries conducted these studies, we have also shown that orthopedic research can be readily disseminated internationally. Last, our study provides a thorough overview of the sports medicine literature over the past century and provides a strong framework for future research in our field.
Orthopedics and the sports medicine subspecialty are continually evolving fields that depend on research investigation and publication to further knowledge and advance practice. Research has produced new findings that have changed the way we practice sports medicine. In this review, we identify the most widely referenced sports medicine topics and articles, which we believe by their permeative presence in the literature have made lasting contributions to the field.
Many factors can be used to quantify the influence of an academic article on the practice of medicine. Citation analysis is one method that reflects the impact of a publication on the academic medical community.1-3 Total citations record the number of times a journal article has been credited by another study. Therefore, citation count indirectly highlights the articles that are widespread, relevant, and that form the foundation for other investigations on the topic. Related to the impact of the article is the impact of the journal that published the study. We examined journals by impact factor, a score based on the mean number of citations a published article received during the preceding 2 years.
Similar analyses have been performed of publication history in orthopedics and other medical fields. Investigators have examined which historical articles were the most influential in orthopedics as a whole,4 pediatric orthopedics,5,6 shoulder surgery,7 and arthroscopy.8 This influence has also been studied in general surgery,9 otolaryngology,10 plastic surgery,11 dermatology,12 critical care,13 and other disciplines. To our knowledge, the present study is the first bibliometric analysis of the highest-impact articles in orthopedic sports medicine.
Our goal was to identify the 100 articles that have had the highest impact on the clinical orthopedic sports medicine literature. We hypothesized that the most widely recognized articles would be from the highest-impact journals and may also have earlier publication dates. We describe the topics and objectives of these articles to highlight the sports medicine areas on which most research has focused during the past century.
Materials and Methods
Our bibliometric analysis used the Thomson Reuters Web of Knowledge, which consists of all publications from 1900 to the present. This research modality ranks journal articles by frequency of citation. Similar analyses have identified the most often cited articles in pediatric orthopedics,5 shoulder surgery,7 and arthroscopy.8 In our analysis, we included the top 25 journals by impact factor in the field of sports medicine, as rated by the Journal Citation Reports database. Within the highest-impact journals, we sorted all articles by those most often cited, and read them all to identify which ones discuss conditions commonly encountered in the clinical practice of sports medicine. We focused on clinical articles only and therefore excluded related basic science and cadaveric biomechanical studies. The 100 most cited articles were then further evaluated by primary author, journal of publication, institution, country of origin, year of publication, topic, and total number of citations. One-way analysis of variance (ANOVA) and linear regression analyses were used to determine if publication date correlated with mean number of citations.
Results
Eighty authors wrote the top 100 articles in sports medicine, and each publication garnered several hundred citations, ranging from 229 to 1629 with a mean of 408 (Table 114-113). Most of these articles were written in the past 3 decades, with equal distribution from the 1980s, 1990s, and 2000s (Figure 1A). We ran a linear regression to determine if publication date correlated with higher number of citations by virtue of longer time available for citation. The analysis poorly modeled the variability (R2 = 0.05), revealing no correlation between number of citations and publication date. Further, 1-way ANOVA found no significant difference between the number of citations per decade, F(5, 93) = 1.60, P = .17 (Figure 1B). Despite this finding, the oldest cited article, written by Fairbank39 in 1948, ranked high (position 7). Of these top 100 publications, the most recent, written by Knutsen and colleagues69 in 2007, ranked in the second half at position 66.
Seven journals published the top 100 articles, with the American volume of the Journal of Bone and Joint Surgery publishing nearly half (44%) (Table 2). In second place, with 28 articles, was the American Journal of Sports Medicine, followed by the British volume of the Journal of Bone and Joint Surgery, with 10 articles.
Thirty different topics were investigated in this collection of articles, encompassing nearly every major research area of sports medicine. There was a heavy emphasis on anterior cruciate ligament (ACL) injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation (Table 3).
In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes88-92 (5 articles), Neer81-84 (4 articles), and Rowe,102-104 Daniel,35-37 Peterson,97-99 and Hewett52-54 (3 articles each) (Table 417,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113). Articles from authors with multiple publications had a common topic.
Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.
Discussion
Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.114 The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.
The most cited sports medicine article was written by Insall and colleagues62 in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.32 This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.113 This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.
A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign82 and the Hawkins-Kennedy test51 are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score113 complements other functional scores (eg, Lysholm knee score74). For grading joint cartilage breakdown, the Outerbridge classification system96 is commonly used. The Fairbank test39 is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification47 is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,101 measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification84 of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.
As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,105 and Beck was listed as third author on 1 other article,42 raising their totals to 4 and 3, respectively.
A criticism of bibliometric analysis is its use of number of citations as an accurate measure of academic contribution. However, other methods for measuring the productivity and impact of researchers (eg, the recently developed Hirsch Index) have their own drawbacks,115,116 including being able to compare authors only at the same point in their careers and self-citation. It is important to note that our analyses focused strictly on publications related to clinical sports medicine, with the exclusion of basic science and cadaveric biomechanical studies.
Through bibliometric citation analysis, we have identified the authors who have made lasting contributions to the field of sports medicine, and we have highlighted the publications that have been cited by hundreds to thousands of authors. This list identifies trends within the articles that have become “classic,” by nature of their deep permeation into subsequent sports medicine literature, and offers guidance for trainees interested in studying the most high-yield sports medicine literature. Given that 69 institutions in 15 countries conducted these studies, we have also shown that orthopedic research can be readily disseminated internationally. Last, our study provides a thorough overview of the sports medicine literature over the past century and provides a strong framework for future research in our field.
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50. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.
51. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-157.
52. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27(6):699-706.
53. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.
54. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996;24(6):765-773.
55. Homminga GN, Bulstra SK, Bouwmeester PSM, van der Linden AJ. Perichondral grafting for cartilage lesions of the knee. J Bone Joint Surg Br. 1990;72(6):1003-1007.
56. Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85(2):185-192.
57. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-1684.
58. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159-172.
59. Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996;24(4):427-436.
60. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am. 1991;73(1):17-29.
61. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. A prospective study. J Bone Joint Surg Am. 1976;58(1):1-8.
62. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-14.
63. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29(5):600-613.
64. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80(8):1132-1145.
65. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
66. Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(3):719-729.
67. Jones HH, Priest JD, Hayes WC, Tichenor CC, Nagel DA. Humeral hypertrophy in response to exercise. J Bone Joint Surg Am. 1977;59(2):204-208.
68. Jones KG. Reconstruction of the anterior cruciate ligament: a technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
69. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Joint Surg Am. 2007;89(10):2105-2112.
70. Knutsen G, Engebretsen L, Ludvigsen TC, et al. Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am. 2004;86(3):455-464.
71. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-163.
72. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
73. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291.
74. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154.
75. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-1010.
76. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med. 1991;19(5):478-484.
77. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58.
78. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption. Arthroscopy. 1993;9(3):318-321.
79. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am. 1980;62(5):696-705.
80. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14(6):553-565.
81. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50.
82. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77.
83. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65(9):1232-1244.
84. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980;62(6):897-908.
85. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839.
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53. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.
54. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996;24(6):765-773.
55. Homminga GN, Bulstra SK, Bouwmeester PSM, van der Linden AJ. Perichondral grafting for cartilage lesions of the knee. J Bone Joint Surg Br. 1990;72(6):1003-1007.
56. Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85(2):185-192.
57. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-1684.
58. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159-172.
59. Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996;24(4):427-436.
60. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am. 1991;73(1):17-29.
61. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. A prospective study. J Bone Joint Surg Am. 1976;58(1):1-8.
62. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-14.
63. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29(5):600-613.
64. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80(8):1132-1145.
65. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
66. Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(3):719-729.
67. Jones HH, Priest JD, Hayes WC, Tichenor CC, Nagel DA. Humeral hypertrophy in response to exercise. J Bone Joint Surg Am. 1977;59(2):204-208.
68. Jones KG. Reconstruction of the anterior cruciate ligament: a technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
69. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Joint Surg Am. 2007;89(10):2105-2112.
70. Knutsen G, Engebretsen L, Ludvigsen TC, et al. Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am. 2004;86(3):455-464.
71. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-163.
72. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
73. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291.
74. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154.
75. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-1010.
76. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med. 1991;19(5):478-484.
77. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58.
78. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption. Arthroscopy. 1993;9(3):318-321.
79. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am. 1980;62(5):696-705.
80. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14(6):553-565.
81. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50.
82. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77.
83. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65(9):1232-1244.
84. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980;62(6):897-908.
85. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839.
86. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg Am. 1981;63(3):394-399.
87. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
88. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513-518.
89. Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62(5):687-695, 757.
90. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate–deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983;65(2):163-174.
91. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate–deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am. 1983;65(2):154-162.
92. Noyes FR, Stabler CL. A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med. 1989;17(4):505-513.
93. O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL. Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Joint Surg Am. 1991;73(2):278-286.
94. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440-446.
95. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med. 2004;32(4):1002-1012.
96. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43(4):752-757.
97. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12.
98. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am. 2003;85(suppl 2):17-24.
99. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000;(374):212-234.
100. Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998;80(9):1276-1284.
101. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28(2):88-96.
102. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38(5):957-977.
103. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60(1):1-16.
104. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am. 1981;63(6):863-872.
105. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med. 1989;17(6):760-765.
106. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65(4):456-460.
107. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18(3):292-299.
108. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders [see comments]. J Bone Joint Surg Am. 1995;77(1):10-15.
109. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85(2):278-286.
110. Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987;15(3):207-213.
111. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy. 2003;19(5):477-484.
112. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526.
113. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-49.
114. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660-667.
115. Bartneck C, Kokkelmans S. Detecting h-index manipulation through self-citation analysis. Scientometrics. 2011;87(1):85-98.
116. Bornmann L, Daniel HD. The state of h index research. Is the h index the ideal way to measure research performance? EMBO Rep. 2009;10(1):2-6.
Cutaneous Burn Caused by Radiofrequency Ablation Probe During Shoulder Arthroscopy
Cautery and radiofrequency ablation (RFA) devices are commonly used in shoulder arthroscopic surgery for hemostasis and ablation of soft tissue. Although these devices are easily used and applied, complications (eg, extensive release of deltoid muscle,1 nerve damage,2 tendon damage,3 cartilage damage from heat transfer4) can occur during arthroscopic surgery. Radiofrequency devices can elevate fluid temperatures to unsafe levels and directly or indirectly injure surrounding tissue.5,6 Skin complications from using these devices include direct burns to the subcutaneous tissues from the joint to the skin surface7 and skin burns related to overheated arthroscopic fluid.8
In our English-language literature review, however, we found no report of a skin burn secondary to contact between a RFA device and a spinal needle used in identifying structures during an arthroscopic acromioplasty. We report such a case here. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 51-year-old woman injured her left, nondominant shoulder when a descending garage door hit her directly on the superior aspect of the shoulder. She had immediate onset of pain on the top and lateral side of the shoulder and was evaluated by a primary care physician. Radiographs and magnetic resonance imaging (MRI) were normal. The patient was referred to an orthopedic surgeon for further evaluation.
The orthopedic surgeon found her to be in good health, with no history of diabetes, vascular conditions, or skin disorders. The initial diagnosis after history taking and physical examination was impingement syndrome with subacromial bursitis. The surgeon recommended nonoperative treatment: ice, nonsteroidal anti-inflammatory drugs, and physical therapy. After 3 months, the patient’s examination was unchanged, and there was no improvement in pain. Cortisone injected into the subacromial space helped for a few weeks, but the pain returned. After 2 more cortisone injections over 9 months failed, repeat MRI showed no tears of the rotator cuff or any other salient abnormalities. The treatment options were discussed with the patient, and, because the physical examination findings were consistent with impingement syndrome and nonoperative measures had failed, she consented to arthroscopic evaluation of the shoulder and arthroscopic partial anterior-lateral acromioplasty.
The procedure was performed 8 months after initial injury. With the patient under general anesthesia and in a lateral decubitus position, her arm was placed in an arm holder. Before the partial acromioplasty, two 18-gauge spinal needles were inserted from the skin surface into the subacromial space to help localize the anterolateral acromion and the acromioclavicular joint. The procedure was performed with a pump using saline bags kept at room temperature. A bipolar radiofrequency device (Stryker Energy Radiofrequency Ablation System; Stryker, Mahwah, New Jersey) was used to débride the subacromial bursa and the periosteum of the undersurface of the acromion. While the bursa was being débrided, the radiofrequency device inadvertently touched the anterior lateral needle probe, and a small skin burn formed around the needle on the surface of the shoulder (Figure). The radiofrequency device did not directly contact the skin, and the deltoid fascia was intact. The spinal needle was removed, and the skin around the burn was excised; the muscle beneath the skin was intact and showed no signs of thermal damage. The skin was mobilized and closed with interrupted simple sutures using a 4-0 nylon suture. The procedure was then completed with no other complications.
After surgery, the patient recovered without complications, and the skin lesion healed with no signs of infection and no skin or muscle defects. Some stiffness was treated with medication and physical therapy. Nine months after surgery, the patient reported mild shoulder stiffness and remained dissatisfied with the appearance of the skin in the area of the burn.
Discussion
Our patient’s case is a reminder that contact between a radiofrequency device and metal needles can transfer heat to tissues and cause skin burns. When using a radiofrequency device around metal needles or cannulas, surgeons should be sure to avoid prolonged contact with the metal. Our patient’s case is the first reported case of a thermal skin injury occurring when a spinal needle was heated by an arthroscopic ablater.
Other authors have reported indirect thermal skin injuries caused by radiofrequency devices during arthroscopic surgery, but the causes were postulated to be direct contact between device and skin7 and overheating of the arthroscopy fluid.5,6,8 Huang and colleagues8 reported that full-thickness skin burns occurred when normal saline used during routine knee arthroscopy overheated from use of a radiofrequency device. Burn lesions, noted on their patient’s leg within 1 day after surgery, required subsequent débridement, a muscle flap, and split-skin grafting. Skin burns caused by overheated fluid have occurred irrespective of type of fluid used (eg, 1.5% glycine or lactated Ringer solution).6 There was no evidence that our patient’s burn resulted from extravasated overheated fluid, as the lesion was localized to the area immediately around the needle and was not geographic, as was described by Huang and colleagues.8
Other possible causes of skin burns during arthroscopic surgery have been described, but none applies in our patient’s case. Segami and colleagues7 described a burn resulting from direct transfer of heat from the radiofrequency device to the skin because of their proximity. This mechanism was not the cause in our patient’s case; there was no evidence of a defect or burned deltoid muscle at time of surgery. Lau and Dao9 reported 2 small full-thickness skin burns caused by a fiberoptic-light cable tip placed on a patient’s leg; in addition, the hot (>170°C) cables caused the paper drapes to combust.9 Skin burns secondary to use of skin antiseptics have been reported,10 but such lesions typically are located beneath tourniquets or in areas of friction from surgical drapes. In some cases, lesions described as skin burns may actually have been pressure lesions secondary to moist skin and friction.11
Whether type of radiofrequency device contributes to the occurrence of heat-related lesions during arthroscopic surgery is unknown. Some investigators have suggested there is more potential for harm with bipolar RFA devices than with monopolar devices.12,13 Monopolar devices pass energy between a probe and a grounding plate, whereas bipolar devices pass energy through 2 points on the probe.14 Because the heat for the monopolar probe derives from the frictional resistance of tissues to each other rather than from the probe itself, the bipolar probe theoretically allows for better temperature control. In addition, bipolar probes require less current to achieve the same heating effect. However, recent studies have suggested that, compared with monopolar radiofrequency devices, bipolar radiofrequency devices are associated with larger increases in temperature at equal depths after an equal number of applications.12,13
To our knowledge, no one has specifically investigated the type of bipolar device used in the present case. This case report, the first to describe a thermal skin injury caused by direct contact between a radiofrequency device and a metal needle inserted in the skin, is a reminder that contact between radiofrequency devices and spinal needles or other metal cannulas used in arthroscopic surgery should be avoided.
1. Bonsell S. Detached deltoid during arthroscopic subacromial decompression. Arthroscopy. 2000;16(7):745-748.
2. Mohammed KD, Hayes MG, Saies AD. Unusual complications of shoulder arthroscopy. J Shoulder Elbow Surg. 2000;9(4):350-353.
3. Pell RF 4th, Uhl RL. Complications of thermal ablation in wrist arthroscopy. Arthroscopy. 2004;20(suppl 2):84-86.
4. Lu Y, Hayashi K, Hecht P, et al. The effect of monopolar radiofrequency energy on partial-thickness defects of articular cartilage. Arthroscopy. 2000;16(5):527-536.
5. Kouk SN, Zoric B, Stetson WB. Complication of the use of a radiofrequency device in arthroscopic shoulder surgery: second-degree burn of the shoulder girdle. Arthroscopy. 2011;27(1):136-141.
6. Lord MJ, Maltry JA, Shall LM. Thermal injury resulting from arthroscopic lateral retinacular release by electrocautery: report of three cases and a review of the literature. Arthroscopy. 1991;7(1):33-37.
7. Segami N, Yamada T, Nishimura M. Thermal injury during temporomandibular joint arthroscopy: a case report. J Oral Maxillofac Surg. 2004;62(4):508-510.
8. Huang S, Gateley D, Moss ALH. Accidental burn injury during knee arthroscopy. Arthroscopy. 2007;23(12):1363.e1-e3.
9. Lau YJ, Dao Q. Cutaneous burns from a fiberoptic cable tip during arthroscopy of the knee. Knee. 2008;15(4):333-335.
10. Sanders TH, Hawken SM. Chlorhexidine burns after shoulder arthroscopy. Am J Orthop. 2012;41(4):172-174.
11. Keyurapan E, Hu SJ, Redett R, McCarthy EF, McFarland EG. Pressure ulcers of the thorax after shoulder surgery. Knee Surg Sports Traumatol Arthrosc. 2007;15(12):1489-1493.
12. Edwards RB 3rd, Lu Y, Rodriguez E, Markel MD. Thermometric determination of cartilage matrix temperatures during thermal chondroplasty: comparison of bipolar and monopolar radiofrequency devices. Arthroscopy. 2002;18(4):339-346.
13. Figueroa D, Calvo R, Vaisman A, et al. Bipolar radiofrequency in the human meniscus. Comparative study between patients younger and older than 40 years of age. Knee. 2007;14(5):357-360.
14. Sahasrabudhe A, McMahon PJ. Thermal probes: what’s available in 2004. Oper Tech Sports Med. 2004;12:206-209.
Cautery and radiofrequency ablation (RFA) devices are commonly used in shoulder arthroscopic surgery for hemostasis and ablation of soft tissue. Although these devices are easily used and applied, complications (eg, extensive release of deltoid muscle,1 nerve damage,2 tendon damage,3 cartilage damage from heat transfer4) can occur during arthroscopic surgery. Radiofrequency devices can elevate fluid temperatures to unsafe levels and directly or indirectly injure surrounding tissue.5,6 Skin complications from using these devices include direct burns to the subcutaneous tissues from the joint to the skin surface7 and skin burns related to overheated arthroscopic fluid.8
In our English-language literature review, however, we found no report of a skin burn secondary to contact between a RFA device and a spinal needle used in identifying structures during an arthroscopic acromioplasty. We report such a case here. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 51-year-old woman injured her left, nondominant shoulder when a descending garage door hit her directly on the superior aspect of the shoulder. She had immediate onset of pain on the top and lateral side of the shoulder and was evaluated by a primary care physician. Radiographs and magnetic resonance imaging (MRI) were normal. The patient was referred to an orthopedic surgeon for further evaluation.
The orthopedic surgeon found her to be in good health, with no history of diabetes, vascular conditions, or skin disorders. The initial diagnosis after history taking and physical examination was impingement syndrome with subacromial bursitis. The surgeon recommended nonoperative treatment: ice, nonsteroidal anti-inflammatory drugs, and physical therapy. After 3 months, the patient’s examination was unchanged, and there was no improvement in pain. Cortisone injected into the subacromial space helped for a few weeks, but the pain returned. After 2 more cortisone injections over 9 months failed, repeat MRI showed no tears of the rotator cuff or any other salient abnormalities. The treatment options were discussed with the patient, and, because the physical examination findings were consistent with impingement syndrome and nonoperative measures had failed, she consented to arthroscopic evaluation of the shoulder and arthroscopic partial anterior-lateral acromioplasty.
The procedure was performed 8 months after initial injury. With the patient under general anesthesia and in a lateral decubitus position, her arm was placed in an arm holder. Before the partial acromioplasty, two 18-gauge spinal needles were inserted from the skin surface into the subacromial space to help localize the anterolateral acromion and the acromioclavicular joint. The procedure was performed with a pump using saline bags kept at room temperature. A bipolar radiofrequency device (Stryker Energy Radiofrequency Ablation System; Stryker, Mahwah, New Jersey) was used to débride the subacromial bursa and the periosteum of the undersurface of the acromion. While the bursa was being débrided, the radiofrequency device inadvertently touched the anterior lateral needle probe, and a small skin burn formed around the needle on the surface of the shoulder (Figure). The radiofrequency device did not directly contact the skin, and the deltoid fascia was intact. The spinal needle was removed, and the skin around the burn was excised; the muscle beneath the skin was intact and showed no signs of thermal damage. The skin was mobilized and closed with interrupted simple sutures using a 4-0 nylon suture. The procedure was then completed with no other complications.
After surgery, the patient recovered without complications, and the skin lesion healed with no signs of infection and no skin or muscle defects. Some stiffness was treated with medication and physical therapy. Nine months after surgery, the patient reported mild shoulder stiffness and remained dissatisfied with the appearance of the skin in the area of the burn.
Discussion
Our patient’s case is a reminder that contact between a radiofrequency device and metal needles can transfer heat to tissues and cause skin burns. When using a radiofrequency device around metal needles or cannulas, surgeons should be sure to avoid prolonged contact with the metal. Our patient’s case is the first reported case of a thermal skin injury occurring when a spinal needle was heated by an arthroscopic ablater.
Other authors have reported indirect thermal skin injuries caused by radiofrequency devices during arthroscopic surgery, but the causes were postulated to be direct contact between device and skin7 and overheating of the arthroscopy fluid.5,6,8 Huang and colleagues8 reported that full-thickness skin burns occurred when normal saline used during routine knee arthroscopy overheated from use of a radiofrequency device. Burn lesions, noted on their patient’s leg within 1 day after surgery, required subsequent débridement, a muscle flap, and split-skin grafting. Skin burns caused by overheated fluid have occurred irrespective of type of fluid used (eg, 1.5% glycine or lactated Ringer solution).6 There was no evidence that our patient’s burn resulted from extravasated overheated fluid, as the lesion was localized to the area immediately around the needle and was not geographic, as was described by Huang and colleagues.8
Other possible causes of skin burns during arthroscopic surgery have been described, but none applies in our patient’s case. Segami and colleagues7 described a burn resulting from direct transfer of heat from the radiofrequency device to the skin because of their proximity. This mechanism was not the cause in our patient’s case; there was no evidence of a defect or burned deltoid muscle at time of surgery. Lau and Dao9 reported 2 small full-thickness skin burns caused by a fiberoptic-light cable tip placed on a patient’s leg; in addition, the hot (>170°C) cables caused the paper drapes to combust.9 Skin burns secondary to use of skin antiseptics have been reported,10 but such lesions typically are located beneath tourniquets or in areas of friction from surgical drapes. In some cases, lesions described as skin burns may actually have been pressure lesions secondary to moist skin and friction.11
Whether type of radiofrequency device contributes to the occurrence of heat-related lesions during arthroscopic surgery is unknown. Some investigators have suggested there is more potential for harm with bipolar RFA devices than with monopolar devices.12,13 Monopolar devices pass energy between a probe and a grounding plate, whereas bipolar devices pass energy through 2 points on the probe.14 Because the heat for the monopolar probe derives from the frictional resistance of tissues to each other rather than from the probe itself, the bipolar probe theoretically allows for better temperature control. In addition, bipolar probes require less current to achieve the same heating effect. However, recent studies have suggested that, compared with monopolar radiofrequency devices, bipolar radiofrequency devices are associated with larger increases in temperature at equal depths after an equal number of applications.12,13
To our knowledge, no one has specifically investigated the type of bipolar device used in the present case. This case report, the first to describe a thermal skin injury caused by direct contact between a radiofrequency device and a metal needle inserted in the skin, is a reminder that contact between radiofrequency devices and spinal needles or other metal cannulas used in arthroscopic surgery should be avoided.
Cautery and radiofrequency ablation (RFA) devices are commonly used in shoulder arthroscopic surgery for hemostasis and ablation of soft tissue. Although these devices are easily used and applied, complications (eg, extensive release of deltoid muscle,1 nerve damage,2 tendon damage,3 cartilage damage from heat transfer4) can occur during arthroscopic surgery. Radiofrequency devices can elevate fluid temperatures to unsafe levels and directly or indirectly injure surrounding tissue.5,6 Skin complications from using these devices include direct burns to the subcutaneous tissues from the joint to the skin surface7 and skin burns related to overheated arthroscopic fluid.8
In our English-language literature review, however, we found no report of a skin burn secondary to contact between a RFA device and a spinal needle used in identifying structures during an arthroscopic acromioplasty. We report such a case here. The patient provided written informed consent for print and electronic publication of this case report.
Case Report
A 51-year-old woman injured her left, nondominant shoulder when a descending garage door hit her directly on the superior aspect of the shoulder. She had immediate onset of pain on the top and lateral side of the shoulder and was evaluated by a primary care physician. Radiographs and magnetic resonance imaging (MRI) were normal. The patient was referred to an orthopedic surgeon for further evaluation.
The orthopedic surgeon found her to be in good health, with no history of diabetes, vascular conditions, or skin disorders. The initial diagnosis after history taking and physical examination was impingement syndrome with subacromial bursitis. The surgeon recommended nonoperative treatment: ice, nonsteroidal anti-inflammatory drugs, and physical therapy. After 3 months, the patient’s examination was unchanged, and there was no improvement in pain. Cortisone injected into the subacromial space helped for a few weeks, but the pain returned. After 2 more cortisone injections over 9 months failed, repeat MRI showed no tears of the rotator cuff or any other salient abnormalities. The treatment options were discussed with the patient, and, because the physical examination findings were consistent with impingement syndrome and nonoperative measures had failed, she consented to arthroscopic evaluation of the shoulder and arthroscopic partial anterior-lateral acromioplasty.
The procedure was performed 8 months after initial injury. With the patient under general anesthesia and in a lateral decubitus position, her arm was placed in an arm holder. Before the partial acromioplasty, two 18-gauge spinal needles were inserted from the skin surface into the subacromial space to help localize the anterolateral acromion and the acromioclavicular joint. The procedure was performed with a pump using saline bags kept at room temperature. A bipolar radiofrequency device (Stryker Energy Radiofrequency Ablation System; Stryker, Mahwah, New Jersey) was used to débride the subacromial bursa and the periosteum of the undersurface of the acromion. While the bursa was being débrided, the radiofrequency device inadvertently touched the anterior lateral needle probe, and a small skin burn formed around the needle on the surface of the shoulder (Figure). The radiofrequency device did not directly contact the skin, and the deltoid fascia was intact. The spinal needle was removed, and the skin around the burn was excised; the muscle beneath the skin was intact and showed no signs of thermal damage. The skin was mobilized and closed with interrupted simple sutures using a 4-0 nylon suture. The procedure was then completed with no other complications.
After surgery, the patient recovered without complications, and the skin lesion healed with no signs of infection and no skin or muscle defects. Some stiffness was treated with medication and physical therapy. Nine months after surgery, the patient reported mild shoulder stiffness and remained dissatisfied with the appearance of the skin in the area of the burn.
Discussion
Our patient’s case is a reminder that contact between a radiofrequency device and metal needles can transfer heat to tissues and cause skin burns. When using a radiofrequency device around metal needles or cannulas, surgeons should be sure to avoid prolonged contact with the metal. Our patient’s case is the first reported case of a thermal skin injury occurring when a spinal needle was heated by an arthroscopic ablater.
Other authors have reported indirect thermal skin injuries caused by radiofrequency devices during arthroscopic surgery, but the causes were postulated to be direct contact between device and skin7 and overheating of the arthroscopy fluid.5,6,8 Huang and colleagues8 reported that full-thickness skin burns occurred when normal saline used during routine knee arthroscopy overheated from use of a radiofrequency device. Burn lesions, noted on their patient’s leg within 1 day after surgery, required subsequent débridement, a muscle flap, and split-skin grafting. Skin burns caused by overheated fluid have occurred irrespective of type of fluid used (eg, 1.5% glycine or lactated Ringer solution).6 There was no evidence that our patient’s burn resulted from extravasated overheated fluid, as the lesion was localized to the area immediately around the needle and was not geographic, as was described by Huang and colleagues.8
Other possible causes of skin burns during arthroscopic surgery have been described, but none applies in our patient’s case. Segami and colleagues7 described a burn resulting from direct transfer of heat from the radiofrequency device to the skin because of their proximity. This mechanism was not the cause in our patient’s case; there was no evidence of a defect or burned deltoid muscle at time of surgery. Lau and Dao9 reported 2 small full-thickness skin burns caused by a fiberoptic-light cable tip placed on a patient’s leg; in addition, the hot (>170°C) cables caused the paper drapes to combust.9 Skin burns secondary to use of skin antiseptics have been reported,10 but such lesions typically are located beneath tourniquets or in areas of friction from surgical drapes. In some cases, lesions described as skin burns may actually have been pressure lesions secondary to moist skin and friction.11
Whether type of radiofrequency device contributes to the occurrence of heat-related lesions during arthroscopic surgery is unknown. Some investigators have suggested there is more potential for harm with bipolar RFA devices than with monopolar devices.12,13 Monopolar devices pass energy between a probe and a grounding plate, whereas bipolar devices pass energy through 2 points on the probe.14 Because the heat for the monopolar probe derives from the frictional resistance of tissues to each other rather than from the probe itself, the bipolar probe theoretically allows for better temperature control. In addition, bipolar probes require less current to achieve the same heating effect. However, recent studies have suggested that, compared with monopolar radiofrequency devices, bipolar radiofrequency devices are associated with larger increases in temperature at equal depths after an equal number of applications.12,13
To our knowledge, no one has specifically investigated the type of bipolar device used in the present case. This case report, the first to describe a thermal skin injury caused by direct contact between a radiofrequency device and a metal needle inserted in the skin, is a reminder that contact between radiofrequency devices and spinal needles or other metal cannulas used in arthroscopic surgery should be avoided.
1. Bonsell S. Detached deltoid during arthroscopic subacromial decompression. Arthroscopy. 2000;16(7):745-748.
2. Mohammed KD, Hayes MG, Saies AD. Unusual complications of shoulder arthroscopy. J Shoulder Elbow Surg. 2000;9(4):350-353.
3. Pell RF 4th, Uhl RL. Complications of thermal ablation in wrist arthroscopy. Arthroscopy. 2004;20(suppl 2):84-86.
4. Lu Y, Hayashi K, Hecht P, et al. The effect of monopolar radiofrequency energy on partial-thickness defects of articular cartilage. Arthroscopy. 2000;16(5):527-536.
5. Kouk SN, Zoric B, Stetson WB. Complication of the use of a radiofrequency device in arthroscopic shoulder surgery: second-degree burn of the shoulder girdle. Arthroscopy. 2011;27(1):136-141.
6. Lord MJ, Maltry JA, Shall LM. Thermal injury resulting from arthroscopic lateral retinacular release by electrocautery: report of three cases and a review of the literature. Arthroscopy. 1991;7(1):33-37.
7. Segami N, Yamada T, Nishimura M. Thermal injury during temporomandibular joint arthroscopy: a case report. J Oral Maxillofac Surg. 2004;62(4):508-510.
8. Huang S, Gateley D, Moss ALH. Accidental burn injury during knee arthroscopy. Arthroscopy. 2007;23(12):1363.e1-e3.
9. Lau YJ, Dao Q. Cutaneous burns from a fiberoptic cable tip during arthroscopy of the knee. Knee. 2008;15(4):333-335.
10. Sanders TH, Hawken SM. Chlorhexidine burns after shoulder arthroscopy. Am J Orthop. 2012;41(4):172-174.
11. Keyurapan E, Hu SJ, Redett R, McCarthy EF, McFarland EG. Pressure ulcers of the thorax after shoulder surgery. Knee Surg Sports Traumatol Arthrosc. 2007;15(12):1489-1493.
12. Edwards RB 3rd, Lu Y, Rodriguez E, Markel MD. Thermometric determination of cartilage matrix temperatures during thermal chondroplasty: comparison of bipolar and monopolar radiofrequency devices. Arthroscopy. 2002;18(4):339-346.
13. Figueroa D, Calvo R, Vaisman A, et al. Bipolar radiofrequency in the human meniscus. Comparative study between patients younger and older than 40 years of age. Knee. 2007;14(5):357-360.
14. Sahasrabudhe A, McMahon PJ. Thermal probes: what’s available in 2004. Oper Tech Sports Med. 2004;12:206-209.
1. Bonsell S. Detached deltoid during arthroscopic subacromial decompression. Arthroscopy. 2000;16(7):745-748.
2. Mohammed KD, Hayes MG, Saies AD. Unusual complications of shoulder arthroscopy. J Shoulder Elbow Surg. 2000;9(4):350-353.
3. Pell RF 4th, Uhl RL. Complications of thermal ablation in wrist arthroscopy. Arthroscopy. 2004;20(suppl 2):84-86.
4. Lu Y, Hayashi K, Hecht P, et al. The effect of monopolar radiofrequency energy on partial-thickness defects of articular cartilage. Arthroscopy. 2000;16(5):527-536.
5. Kouk SN, Zoric B, Stetson WB. Complication of the use of a radiofrequency device in arthroscopic shoulder surgery: second-degree burn of the shoulder girdle. Arthroscopy. 2011;27(1):136-141.
6. Lord MJ, Maltry JA, Shall LM. Thermal injury resulting from arthroscopic lateral retinacular release by electrocautery: report of three cases and a review of the literature. Arthroscopy. 1991;7(1):33-37.
7. Segami N, Yamada T, Nishimura M. Thermal injury during temporomandibular joint arthroscopy: a case report. J Oral Maxillofac Surg. 2004;62(4):508-510.
8. Huang S, Gateley D, Moss ALH. Accidental burn injury during knee arthroscopy. Arthroscopy. 2007;23(12):1363.e1-e3.
9. Lau YJ, Dao Q. Cutaneous burns from a fiberoptic cable tip during arthroscopy of the knee. Knee. 2008;15(4):333-335.
10. Sanders TH, Hawken SM. Chlorhexidine burns after shoulder arthroscopy. Am J Orthop. 2012;41(4):172-174.
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