1 Introduction

Research productivity and performance of a country are commonly measured based on the total number of publications.^1–3 Bibliometric research reflects the aspect of clinical excellence, highlights medical developments or knowledge gaps, and functions as a basis for future-oriented research.^4–7 With the implementation of evidence-based medicine in 1990, the number of published scientific papers has increased enormously.^8–10 This trend is based on the multitude of new medical and technological achievements.^11–14 Also in orthopaedics, the increased interest in publications has been observed resulting in the need for a structured selection of information.^15,16 Although the total number of publications a country contributed is not synonymous with output quality, it certainly indicates the influence of a country in a specific scientific field and is an important determinant of economic growth.^17,18 Previous bibliographic analyses of orthopaedic academic outputs that focused on the total number of publications per country over different periods predominantly referred to publications of the major orthopaedic journals or the most cited papers in general orthopaedics and orthopaedic sub-specialities.^19–23

Europe is the second-smallest continent and the European Union (EU) and the Council of Europe are two important organisations representing the European continent. The EU comprises 27 European states, but some important nations like the United Kingdom (UK), Norway and Switzerland are out of this group. Five European countries (Germany, Russia, UK, France, and Italy) are ranked in the top 10 of the world's largest national economies in Gross Domestic Product (GDP).²⁴ The European Commission's report for 2022 shows that the EU has remained one of the most valuable regions in terms of scientific production. While representing just 6 % of the world's population, it accounts for about 18 % of global Research and development (R&D) investments and 21 % of the worldwide top-cited scientific publications.²⁵

To the best of our knowledge, no one has analysed the European publications in orthopaedics and sports medicine over the last three decades. The present investigation evaluates the trend of publications and ranking in Orthopaedics and Sports Medicine of European countries during the last 26 years (1996–2022) and compares these with global country rankings. Furthermore, an analysis was carried out to compare the publication trends between Eastern and Western European countries.

2 Methods

3 Results

3.3

3.3 Trend of European publication in the period from 1996 to 2022

The total number of publications in the area of Orthopaedics and Sports Medicine in the period from 1996 to 2022 (26 years) at the European scale was led by the United Kingdom (N = 51510). Of these publications, a total of 47766 publications were cited 1386125 times. Thus The United Kingdom also achieved the highest H-index of 309. With a gap of 10883 publications (N = 40627) Germany followed and reached the second rank. The citable documents of Germany were similarly high in relative comparison, with 37686 publications cited. However, with a total of 726597 citations, they only achieved an H-index of 230. France (N = 25877), Italy (N = 19062), and Spain (N = 17131) published about half compared to the United Kingdom. This is also reflected in the influence of these countries, as measured by the number of publications cited. The detailed ranking and citation counts are given in Tables 1 and 2 The United Kingdom has remained and maintained its supremacy until recently in 2022 with 3399 publications, followed by Germany (N = 2564), France (N = 1669), Spain (N = 1564), and Italy (N = 1137) (Tables 1 and 2). All top five countries (United Kingdom, Germany, France, Italy, Spain) have shown an increasing trend of publications, year-wise since 1996, and the top three nations United Kingdom, Germany, and France have maintained their rankings. Spain has recently taken over the fourth rank from Italy in publication numbers (Tables 1 and 2). Fig. 1 shows an overview of the year-wise increase of the top five European countries.

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Fig. 1 The trend of orthopaedic publications of the top 5 European nations from 1996 to 2022.

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4 Discussion

Bibliometric analysis is a sensitive indicator used to quantitatively analyze scientific publications, showing the impact of a certain publication in a certain field. In orthopaedics and sports medicine, bibliometric analysis has been used to identify the most influential papers, authors, topics, countries, and universities from the 1950s–2020s. These studies provide valuable insights into the trends and impact of research in orthopaedics and sports medicine and can guide future research in these fields. In the present study, the European continent is the major contributor of publications related to orthopaedics and sports medicine worldwide and has contributed to around 1/3rd of the total publications in this field. The top European countries United Kingdom, Germany, France, and Spain have maintained their rank in the top ten nations over the cumulative period from 1996 to 2022. All top five countries (United Kingdom, Germany, France, Italy, and Spain) have shown an increasing trend of publications, year-wise since 1996, and the top three nations United Kingdom, Germany, and France have maintained their rankings on the European rank score. Italy counted in the global rank two places down from 9th to 11th in 2022 and Spain has recently taken over the 4th rank from Italy in publication numbers in European comparison. COVID-19 pandemic led to a decline in the annual publication rate for the first time in 20 years (2020–2021: 5.69 %).²⁶ Differences in publication rate could be significantly associated with the respective Covid-19 case number (r = −0.77, p < 0.01).²⁶ A decrease in the publication rate in the pandemic year 2021 was observed in almost all countries with some exceptions. Among the exceptions was Spain, which recorded an increase of +6.49 %.²⁶

As with the other continents, Europe has a large wealth gap among its countries. The richer states tend to be in the Western, followed by Central, and Eastern Europe, with higher GDP (World Bank Data 2022, worldbank.org). The richer European nations have higher research outputs perhaps due to more funding and research facilities available to them. More international collaboration between European countries and globally is needed to enhance research outputs from Eastern European countries. The research output is less from economically weaker countries such as of Southeast Asia, where a large proportion (21 %) of the global population lives, with a meagre 1.45 % of the global.²⁷ The research related to the health problems of Low-Middle-Income-Countries (LMIC) must address their local problems and find cost-effective treatments rather than relying on the results and recommendations derived from the research done in High-Income-countries (HIC), which may not be feasible and applicable to lesser affluent countries, such as Eastern Europe etc. COVID-19 has been a booster for the researcher as the number of publications rose significantly not only during the pandemic but have remained higher after the pandemic, as compared to the pre-pandemic period.²⁸

Compared to previous analyses of orthopaedic academic outputs that focused on the total number of publications per country and used the Web of Science database, the present analysis is based on publications in Orthopaedics and Sports Medicine from the SCImago Journal & Country Rank database.¹⁴ Both Web of Science and Scopus databases use the same model of classification. However, the online database SCImago Journal & Country Rank, founded by Felix de Moya in 2007 accesses the significantly larger Scopus database thus it takes into account more journals.^29,30 Furthermore, many journals are only indexed in Scopus.³¹ Another great advantage of this database is that it is free of charge.^31,32

The five top publishing European countries when compared with the top five Asian countries in 2022 revealed that China was ahead of all of them with 4607 publications, followed by the UK (n = 3399), Germany (n = 2564), Japan (n = 2128), France (n = 1669), Spain (n = 1656), Italy (n = 1564), India (n = 999), South Korea (n = 993), and Taiwan (n = 292)¹⁴ (Supplementary Table 3).

This study has limitations to be considered. Published articles were presented as the number of articles published, and the quality of articles was not considered, although this should probably be assessed using bibliometric indicators such as Impact Factor (IF), Eigenfactor score (ES) Article Influence Score (AIS) or SCImago Journal Rank Indicator (SJR). Current bibliographic analysis continues to neglect influencing factors such as population size, economic discrepancies such as median household income, and the number of orthopaedic surgeons in a given regional area. Adjustment for these factors should result in more meaningful data.

5 Conclusion

The present bibliometric analysis examined European orthopaedic research trends published between 1996 and 2022. The findings highlight Europe's prominent role in orthopaedic research, accounting for nearly a third of global publications in this field. Notably, European nations claimed half of the top 10 publishing countries worldwide, with Western Europe leading the way compared to Eastern Europe. The United Kingdom stands out as the top contributor within Europe, both historically and in the most recent year analysed (2022).

Ethical statement

Not applicable.

Funding

No funding was received for this research.

Guardian/patient's consent

Not applicable.

CRediT authorship contribution statement

Raju Vaishya: data extraction and writing. Abhishek Vaish: data extraction and writing. Luise Schäfer: writing. Filippo Migliorini: writing, All authors have agreed to the final version to be published and agree to be accountable for all aspects of the work.