1 Introduction

Cubital tunnel syndrome (CuTS) is the second most common entrapment neuropathy of the upper extremity after carpal tunnel syndrome, characterized by paresthesia in the 4th and 5th fingers, hand weakness, and pain in the medial elbow.¹ Etiological risk factors such as prolonged pressure on the elbow, severe burns, ulnar nerve luxation, hypertrophy of the medial head of the triceps muscle, distal humerus fracture, cubitus valgus, cubitus varus, osteoarthritic changes, rheumatoid arthritis, diabetes mellitus, aneurysmal bone cysts, Paget's disease, lipomas, and ganglion cysts have been defined with varying frequencies.² In the diagnosis, the patient's symptoms should be handled carefully; the onset and continuity of symptoms, positions that increase or decrease symptoms, and etiologic factors should be questioned. Tinel test, elbow flexion test and pressure provocation test to be applied directly to the cubital tunnel are among the clinical tests that may help the diagnosis.³ The diagnosis of compression of the ulnar nerve at the elbow and the localization of the compression are usually determined by electrodiagnostic studies.⁴ In recent years, ultrasound (US) and magnetic resonance imaging (MRI) have also been reported to be useful in the diagnosis.^5,6 When we look at the treatment of CuTS, lifestyle modification, positioning, splinting, stretching, and strengthening exercises, nonsteroidal anti-inflammatory drugs, and physical therapy modalities are among the conservative treatment options. Surgical techniques such as open or endoscopic cubital tunnel release in situ, subcutaneous transposition, submuscular transposition, and in situ release with medial epicondylectomy are applied in cases unresponsive to conservative treatment.⁷ Considering that it is a common neuropathy, CuTS continues to be popular due to improved diagnostic and therapeutic methods, surgical techniques, and the expanding etiologic factors in the literature.

Bibliometric studies are used to assess the research accumulation, focal points, and trends of a field. Important diseases related to the musculoskeletal system have recently been the subject of numerous bibliometric analyses. Suzan et al.⁸ presented an analysis by evaluating the 100 most cited publications (T100) related to osteoporosis in their study. Similarly, in another study on rheumatoid arthritis, the accumulation of research on rheumatoid arthritis in the literature was analyzed by evaluating the studies conducted in the last 30 years.⁹ Bibliometric analyses focused on charcot neuroarthropathy, carpal tunnel syndrome, and neuropathic pain have also gained a place in the literature.^10–12 Although bibliometric analyses are not a precise measure of the existing knowledge and publication quality of the subject of focus, they can identify trends in the subject of focus and guide future research. We present a bibliometric analysis of T100 publications on CuTS. To our knowledge, there has not been a bibliometric analysis study focusing on cubital tunnel syndrome until today.

2 Methods

3 Results

In this study, articles published between 1975 and 2024 were evaluated by searching the keyword "cubital tunnel syndrome". We identified T100 articles by searching for articles published between these dates. The publication range of T100 articles was found to be 1980–2020. As a result of the analysis of the data obtained through the Web of Science Core Collection, it can be considered that interest in CuTS has shown a general upward trend, although it varies between years (Fig. 1). When T100 articles published between 1980 and 2020 are analyzed, 2007 was the most productive year, with a total of 8 publications. In the evaluation made according to the number of citations, the total number of citations to the publications published in 2007 is 520, which is at the top. Although CuTS is still popular, it has been discussed in the scientific world remarkably between 2004 and 2011 (n = 40) (Fig. 1). When the citations to T100 articles were evaluated, the total number of citations was 5921 (minimum = 28, maximum = 183, Mean = 59.21 ± 33.86 Standard Deviation).

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Fig. 1 Number of articles published and number of citations by year.

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The evaluation based on the number of citations revealed that Andreisek et al.¹⁴ published the most cited article in 2006. It was an article titled "Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features", which discussed how MR imaging can help in the diagnosis of peripheral neuropathies of the radial, median, and ulnar nerves. The number of citations to this article to date is 183. The article titled "Detection of peripheral nerve pathology Comparison of ultrasound and MRI" by Zaidman et al.¹⁵ in 2013 was evaluated as the article with the highest citation index (number of citations per year = 11.58).

It was determined that T100 articles were published in a total of 36 different journals. When the distribution of articles among journals was analyzed, Journal of Hand Surgery—American Volume ranked first in terms of the number of articles in T100 articles, with a total of 28 articles. According to the number of articles, Journal of Hand Surgery—British and European Volume (n = 11) ranked second, while Neurosurgery (n = 6) ranked third. Considering the total number of citations, Journal of Hand Surgery-American Volume ranked first with 1561 citations, Journal of Hand Surgery-British and European Volume ranked second with 695 citations, and Journal of Bone and Joint Surgery-American Volume ranked third with 372 citations (Fig. 2). Table 1 shows the journals that published 3 or more articles within T100 articles.

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Fig. 2 Number of publications and citations published in the Top 8 Journals.

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55 articles represented the United States in the comparison between countries. Germany (n = 9), Japan (n = 9), and Canada (n = 6) were considered as potential research powers (Table 2).

The evaluation of the institutions that contributed to the T100 articles in the study revealed Washington University in St. Louis to be the pioneer (n = 11). Erasmus University Rotterdam (n = 3), Hacettepe University (n = 3), Harvard University (n = 3), Johannes Gutenberg University of Mainz and Pennsylvania State System of Higher Education (n = 3) were the other most productive institutions (Table 3).

Calfee RP (n = 4) and Mackinnon SE (n = 4) were considered the authors with the highest number of contributions to the T100 articles. However, neither author was the first author in any article. When the number of authors of T100 articles was evaluated, 70 % of the articles had 4 or fewer authors (minimum n = 1, maximum n = 13, Mean = 3.82 ± 2.027 Standard Deviation).

Most of the T100 articles (n = 63) were in the clinical study category. 27 articles were considered as review or meta-analysis. 9 articles were in the case-report category and 1 article was a clinical guideline.

The majority of the most cited T100 articles addressed treatment (n = 70), according to an evaluation of the main topics covered in the articles. These articles mostly mentioned surgical treatments (n = 64). The number of articles dealing with conservative treatment was less than surgical treatment (n = 17). Diagnosis (n = 31), etiology (n = 27), and symptoms (n = 14) were the other most common topics covered in the articles, respectively.

4 Discussion

This study used bibliometric analysis to discuss scientific trends related to CuTS and to provide insights into potential research directions for future research articles. Bibliometric analysis has been used in the world of medical science since 1990, with its popularity and functionality increasing over the years.¹⁶ Bibliometric analyses are used to reveal publishing trends and the relationship between published works; to discuss scientific trends on a topic; to investigate scientific collaboration between authors, publishers, institutions, and countries; and to indicate potential future research directions.¹⁷

In our study, Journal of Hand Surgery—American Volume was the most influential journal in terms of both the number of articles (n = 28) and citations (n = 1561). We can say that hand surgery journals are leading in the number of articles published on CuTS, compared to other highly influential journals (Table 1). This could be because discussions about surgical treatment options for CuTS have been ongoing over the years. In a bibliometric analysis published by Ram et al.¹¹ focusing on carpal tunnel syndrome, Journal of Hand Surgery—American Volume was the journal that published the majority of the publications (38.01 %). This may be an indication that the Journal of Hand Surgery—American Volume is in an important position for entrapment neuropathies of the upper limb. It also suggests that highly influential articles tend to be published in specialized journals that are fully focused on entrapment neuropathies and hand surgery rather than general medical journals with high IFs (e.g., Lancet or Nature).¹⁸

When the contents of T100 articles were analyzed, it was seen that surgical treatment was covered in a large proportion (n = 64). The superiority of different surgical techniques over each other has been evaluated in different articles with the help of the knowledge accumulated over the years.^19–22 In the article published by Brauer et al.²³ in 2007, 4 surgical methods; smple decompression of the cubital tunnel, medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition were compared, and simple decompression was presented as the method with the highest expected benefit. Additionally, a meta-analysis by Mowlavi et al.²⁴ suggests that submuscular transposition in moderate CuTS and medial epicondylectomy in mild CuTS may be more effective than other surgical techniques. In conclusion, the discussions on surgical treatment options, the development of new treatment protocols, and new surgical techniques may be the reason why surgical treatment was covered in the majority of the T100 article.

Among the T100 articles, there were 17 articles that mainly dealt with conservative treatment. According to a review ranked 61st in the T100 (Total Citation = 40), activity modification to reduce repetitive elbow flexion, reduce activities that increase pressure in the cubital tunnel, and reduce direct pressure on the medial epicondyle are recommended in the conservative treatment of CuTS. Reports also suggest that splinting can effectively manage CuTS.²⁵ Upon detailed examination of the T100 articles, we found that while some articles addressed steroid injections, none directly discussed this topic within the T100 list. The reason for this may be that, unlike carpal tunnel syndrome, the efficacy of steroid injections in cubital tunnel syndrome is thought to be insufficient in light of existing studies.²⁶ On the other hand, an article reporting that a physical therapy program including nerve mobilization techniques, pulsed ultrasound, and strengthening exercises can be successful in mild and moderate CuTS was ranked 56th among T100 articles (Total Citation = 42).²⁷

It is unclear whether to choose conservative or surgical treatment for ulnar nerve entrapment at the elbow, according to a review by Caliandro et al.²⁸ that analyzed the results of nine randomized controlled trials. Nevertheless, the bibliometric analysis, the results of which we present here, showed that the T100 list, which is based on the number of citations, included more articles on surgical treatment (n = 64) than on conservative treatment (n = 17). We believe there is still a need for new studies and meta-analyses that analyze the long-term effects of conservative treatment options and compare conservative treatment with surgical treatment.

The second most common topic covered in T100 articles was the diagnosis of CuTS (n = 31). The diagnosis of peripheral nerve compression has traditionally utilized information from electrodiagnostic studies.³ However, with the development and continuous improvement of US technologies over time, US has gained a place as a non-invasive method in the diagnosis of peripheral nerve compression, including CuTS.³ In a recent study comparing electrophysiologic studies and US in the diagnosis of ulnar nerve compression at the elbow, it was reported that US may be an important method in the diagnosis and may be superior to electrophysiologic tests, especially in early-stage compression.²⁹ The prominent role of US in diagnosis was in line with the results obtained by bibliometric analysis. Ultrasonographic diagnosis was the main topic in a total of 8 articles out of T100 articles. Additionally, the T100 included publications suggesting that MRI and MR neurograpy may be useful in the diagnosis of CuTS.^14,15,30 The high number of articles on diagnosis in the T100 may be due to the rapid development of diagnostic methods over the years.

The USA was the country that contributed the most to T100 articles (n = 55). The USA was also the leading country in the bibliometric analysis on carpal tunnel syndrome.¹¹ The USA was also the leading country in bibliometric analyses on neuropathic pain, brachial plexus injury, and surgical treatment of carpal tunnel syndrome.^31–33 This may be an indicator of the power of the USA in the field of medical science. This power may stem from the huge financial support the US provides to medical science.³⁴

27 articles out of T100 covered etiologic factors. Among these articles, two different case reports in which CuTS developed after triceps tendon rupture were noteworthy.^35,36 This may be an indication of the scientific world's interest in rare phenomena. It is very important to determine the etiologic factors in the management of CuTS. According to a review included in the T100 article, traumatic CuTS was less responsive to conservative treatment than non-traumatic CuTS. In addition, revision surgeries were performed more frequently in the follow-up after traumatic CuTS surgery compared to non-traumatic CuTS.³⁷

Although CuTS is the second most common entrapment neuropathy of the upper extremity, the most cited article in the search for "cubital tunnel syndrome" was not only an article on CuTS. "Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features" on the role of MR imaging in the management of peripheral neuropathies of the median, radial, and ulnar nerves was the most cited article.¹⁴ Similarly, the article with the highest citation index was not directly related to CuTS.¹⁵ This may be an indication that articles directly addressing CuTS should be diversified and discussed more.

This study also had some limitations. Firstly, we conducted our analysis solely using data from the Web of Science database. The fact that databases such as Google Scholar etc. Were not included was one of the limitations of our study. The study also limited the language of the included articles to English. In addition, while collecting the data, only the articles obtained by searching the term "cubital tunnel syndrome" were included. Therefore, some quality articles published with different keywords may not have been included in our T100 list.

In this study, we evaluated T100 articles on CuTS. We found that most of the T100 articles were about surgical treatment. This study may help the scientific community show more interest in studies on the conservative treatment of CuTS. We also think that new studies are needed to include other databases and languages other than English.

CRediT authorship contribution statement

Burak Tayyip Dede: Conceptualization, Validation, Investigation, Writing – original draft, Visualization, Project administration. Muhammed Oğuz: Methodology, Investigation, Writing – original draft, Project administration. Fatih Bağcıer: Conceptualization, Validation, Writing – review & editing, Supervision. Ebru Aytekin: Methodology, Validation, Writing – review & editing, Supervision.

Guardian/patient's consent

Not applicable.

Ethics approval and consent to participate

As the data for our study were sourced from published articles, ethics committee approval was not necessary.

Consent for publication

Not applicable.

Availability of data and materials

The authors confirm that data supporting the findings of this paper are available upon appropriate request.

Funding

None.