1 Introduction

Total knee arthroplasty, commonly referred to as knee replacement, is a complete reconstruction of the knee joint meant to relieve pain or improve function of the joint.¹ Commonly performed

for patients with knee osteoarthritis, the surgery is one of the most frequently conducted procedures worldwide.² Approximately 4.2 % of U.S. adults aged 50 and over, totaling around 4 million individuals, have undergone knee replacement surgery.³ Knee arthroplasty is known to be cost-effective and consistent to alleviate symptoms such as reduced joint mobility and stiffness.⁴ As populations age and obesity rates rise, both major risk factors for knee osteoarthritis, the utilization and necessity for total knee replacement has gone up. In the United States, the utilization of knee replacement surgery has doubled, and is continuing to increase.⁵

However, patients can experience pain and severe complications after the procedure. Despite being regarded as one of the most effective ways to treat knee pain due to osteoarthritis, arthroplasty has been shown to have postoperative complications including bleeding, thromboembolic disease, ligament injury, fracture, dislocation, and many more.⁶ Some patients require revision surgery, which serves to alleviate complications such as infection, mechanical loosening, instability, and periprosthetic fractures.⁷

Given the clinical importance of knee arthroplasty and its widespread use in the U.S., there is a growing need to systematically evaluate the research landscape surrounding it. A bibliometric analysis serves this purpose by quantitatively assessing to identify research trends, influential studies, prolific authors, key journals, and emerging topics.⁸ It could help in highlighting trends and advancing knowledge on the topic of knee arthroplasty, which is widely done, and based on published research in the field, a bibliometric analysis serves as something that can provide valuable insights into how the field has evolved, highlight gaps in the literature, and guide future research and funding priorities.⁹

2 Methods

This bibliometric analysis was conducted using data from the Web of Science (WoS) Core Collection. The following search query was used to find literature on the topic: query = knee arthroplasty (Topic) AND complications (Topic). The search yielded a total of 10,000 articles, which served as the main dataset for further analysis.

The data analysis was performed using VOSViewer, a software used to visualize and build bibliometric networks. The software tool was utilized to generate co-authorship networks, institutional collaborations, and country-based maps. Through network, overlay, and density maps, the software helps find relationships between institutions, countries, or authors, and finds clusters of research activity through lines and colors.

The following clustering approaches were used in the study.●Cluster Alpha: Co-authorship analysis based on different corresponding authors and their collaborative methods●Cluster Beta: Analysis with institutions, based organizational affiliations of contributors●Cluster Theta: Analysis with countries based on national contributions to the given topic VOSviewer was employed to conduct the bibliometric mapping and co-occurrence

network analysis. To visualize publication trends over time, bar graphs were generated from the extracted dataset, offering a clear representation of the annual research output and highlighting temporal shifts in scholarly activity within the field of knee arthroplasty. Thresholds for the amount of documents per author, country, or institution were also applied to ensure accuracy and relevance of analysis results.

3 Results

The topic of knee arthroplasty has seen fluctuations over the past 25 years, but has a net increase in articles published. The most dramatic increase is from 2020 to 2021, showing a relatively recent surge in research surrounding the topic of knee arthroplasty.(see Fig. 1)

The United States was the main contributor, producing 4464 documents, having 117,877 citations, and exhibiting a total link strength of 661. Other leading contributors were China (1104 documents, 14,559 citations, 127 link strength), Germany (556 documents, 8993 citations, 265 link strength), and England (530 documents, 13,843 citations, 295 link strength) (Fig. 2).

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Fig. 1 Visual Representation of the Number of Publications on complications of knee arthroplasty per year from 2001.

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Fig. 2 Visual representation from VOSViewer Co-Occurrence Strength: Number of countries with a minimum of 5 documents published on the topic of knee arthroplasty.

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The major contributing institution was The Hospital for Special Surgery, with 382 publications, 9665 citations, and a link strength of 452. Other institutions that stood out were Mayo Clinic (257 documents, 8945 citations, 247 link strength), Thomas Jefferson University (186 documents, 4791 citations, 213 link strength), and Cleveland Clinic (151 documents, 3968 citations, 223 link strength). There was a dense visual cluster consisting of U.S., Australian, and European institutions, as well as individual clusters for China and Korea (Fig. 3).

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Fig. 3 Visual representation from VOSViewer Co-Occurrence Strength: Number of organizations with a minimum of 5 documents published on the topic of knee arthroplasty.

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The most prolific author was Michael A. Mont, with 199 publications, 5254 citations, and a link strength of 862. Other major authors included Javad Parvizi (122 documents, 7446 citations, 272 link strength) and Ran Schwarzkopf (117 documents, 1744 citations, 273 link strength). These authors were affiliated with U.S. institutions that were found to have more publications, such as Thomas Jefferson University (Fig. 4).

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Fig. 4 Visual representation from VOSViewer Co-Occurrence Strength: Number of authors with a minimum of 5 documents published on the topic of knee arthroplasty.

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Together, these findings illustrate that knee arthroplasty is a mature and globally significant and relevant field of study characterized by concentrated institutional leadership, influential authors, and international collaboration. This analysis not only maps the current landscape but also identifies key players, emerging regions, and evolving research directions, helping in guiding future inquiry and resource allocation.

4 Discussion

This bibliometric analysis examined 10,000 publications related to complications of knee arthroplasty over the past two decades. The results show that the United States has been the primary driver of research output, both in volume and citation impact. With 4464 documents and over 117,000 citations, the U.S. led by a wide margin, followed by China, Germany, and England. The dominance of the U.S. was further reflected in institutional contributions, with The Hospital for Special Surgery, Mayo Clinic, and Thomas Jefferson University among the most prolific.¹⁰ This concentration of research indicates a geographic and institutional clustering of expertise, particularly in North America and Europe, as well as China.¹¹ Interestingly, emerging contributions from Latin-American countries like Ecuador and Colombia highlight a broadening of global participation in the field, especially since Latin-American countries are proven to not use knee replacement as a primary method, reflecting the global growth in the area of knee arthroplasty.^12,13

Citation networks revealed strong intra-country and intra-institutional collaboration, particularly among U.S.-based researchers, suggesting a well-integrated domestic research network driving innovation and clinical best practices.¹⁴ The co-authorship analysis identified Michael A. Mont, Javad Parvizi, and Ran Schwarzkopf as the most prolific and influential authors. All three are affiliated with major U.S. orthopedic centers and have contributed significantly to the literature on arthroplasty complications, including periprosthetic joint infection, implant performance, and revision surgery.^15–17 Their high link strengths point to their central roles in collaborative networks, making them key opinion leaders in the field.

The observed spike in publication output from 2020 to 2021 could be attributed to increased surgical delays and complication tracking during the COVID-19 pandemic, as well as growing interest in surgical outcomes, patient satisfaction, and cost-effectiveness, causing subsequent advances in the field. This uptick signals a renewed global attention to improving both short- and long-term outcomes of knee arthroplasty procedures. However, during the pandemic, studies have shown that knee replacement surgery rates were low.^18–20

As the global demand for knee replacement increases, driven by aging populations and rising obesity rates, research on TKA complications has expanded both in volume and scope.

Bibliometric studies have shown a growing focus on identifying risk factors, refining surgical techniques, improving perioperative protocols, and developing biomaterials and technologies to reduce complication rates.^21,22 For instance, the integration of computer-assisted navigation and robotic-assisted surgery is being studied for its potential to reduce alignment errors and postoperative instability.²³ The evolving research landscape reflects a multidisciplinary approach that combines orthopedic innovation, biomedical engineering, and patient-specific care to mitigate complications and improve long-term/outcomes.

5 Strengths and limitations

One of the main strengths of this study is the use of a large and reputable dataset from the Web of Science, ensuring coverage of high-impact research across several decades. Additionally, the use of VOSviewer allowed for a detailed visualization of collaboration patterns, keyword co-occurrences, and institutional influence.

However, this analysis is limited by its reliance on a single database, excluding relevant publications from other platforms such as PubMed. Furthermore, language restrictions and variations in indexing practices may have led to an underrepresentation of non-English or regional research. Despite these limitations, the data provide a comprehensive overview of scholarly activity in the field of knee arthroplasty.

6 Conclusion

This study presents the first comprehensive bibliometric analysis of research surrounding complications of knee arthroplasty. The findings underscore the leadership of U.S. institutions and authors in shaping the field, with emerging contributions from countries such as China and Germany. Key complications such as infection, mechanical failure, and revision surgery dominate the literature, reflecting ongoing clinical concerns. The analysis offers valuable insights into research trends, influential contributors, and international collaboration networks. As knee arthroplasty continues to grow in clinical relevance, especially with aging populations, these findings can inform future research priorities, funding strategies, and collaborative efforts to improve patient outcomes and surgical innovations worldwide.

Patient consent

Guardian/patient consent is not applicable to this manuscript as it is a bibliometric review and not a case report. There is no identifiable data in this review.

Authors contributions

The study was designed by LG. LG, KE and NI managed data capture. KE and NI performed the analysis, and LG supervised the conduct of the research. KE and NI drafted the initial manuscript, LG reviewed and edited the initial manuscript, and all authors approved the final version of the manuscript.

Ethics in publishing statement

This research presents an accurate account of the work performed, all data presented are accurate and methodologies detailed enough to permit others to replicate the work.

This manuscript represents entirely original works and or if work and/or words of others have been used, that this has been appropriately cited or quoted and permission has been obtained where necessary.

This material has not been published in whole or in part elsewhere.

The manuscript is not currently being considered for publication in another journal.

That generative AI and AI-assisted technologies have not been utilized in the writing process or if used, disclosed in the manuscript the use of AI and AI-assisted technologies and a statement will appear in the published work.

That generative AI and AI-assisted technologies have not been used to create or alter images unless specifically used as part of the research design where such use must be described in a reproducible manner in the methods section.

All authors have been personally and actively involved in substantive work leading to the manuscript and will hold themselves jointly and individually responsible for its content.

Funding

None.

Financial support and sponsorship

None.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.