Page 86 - Journal of Special Operations Medicine - Spring 2017

from the 1950s, and one article came from the 1970s. from orthopedic injuries. The proportion of articles by
Thus, our original search missed some of these older ar- topic was roughly reflective of their importance to or-
ticles. These missing articles also did not seem to feature thopedics in war.
prominently any of the search terms used in the current
study. However, two important topics, debridement and in-
jury prevention, were missing. In our original search,
Further, these missed articles were often written by abstracts often mentioned debridement. However, de-
nonorthopedists, and the content of the articles was bridement was not identified in any of the articles as
more acute, primarily focused on life-and-death situ- a focus of empiric study, and “debride” is not featured
ations rather than the treatment of extremity injuries. in any form in any top-cited article title. This is likely
Nevertheless, it was thought that these articles carry because debridement is a difficult topic to study. It re-
significant weight in the literature on combat-related mains, however, an important topic for future research,
extremity injury. This mirrors the emphatic case that Sir because it is poorly delineated in operational terms for
Robert Jones, knighted for his combat casualty care dur- new surgeons deploying to war.
ing World War I, made earlier for military surgeons to
expand their scope of surgical practice: “the War [World Second, prevention of injury also seems to be an impor-
War I] has taught the orthopaedic surgeon that he has to tant topic that remains missing and underresearched.
be more of a general surgeon; it has taught the general Body armor was mentioned often in abstracts, but it
surgeon that he should be more of an orthopaedist.” 27 was often without accompanying empiric data. This
might be because the design of body armament and re-
lated sciences may be classified as sensitive for opera-
Number of Top-Cited Publications by Decade
tional security and tactical reasons.
The largest increase in the number of top-cited publica-
tions occurred from the 1990s (n = 16) to 2000s (n = Omissions From the Scope of the
57). This tripling of top-cited articles in one decade sug- Present Citation Analysis
gests a period when sustained armed conflicts spawned
high interest and scientific productivity in the research We also chose to narrow our focus on extremity injury.
of orthopedic trauma and extremity injury. The number We purposefully omitted “spine” and its related terms,
of publications from the 2010s, although still substan- such as “fusion.” We also purposefully omitted “junc-
tial, is lower than the number of publications from the tional” (i.e., those wounds at the junction of the torso
2000s. This likely reflects the fact that articles published and its appendages). Although beyond the focus of this
in this most recent decade have had less time to be cited analysis, these terms are very relevant to orthopedics.
than have articles published earlier.
Topics Addressed Well in the Scope
Topics of Top-Cited Publications of This Citation Analysis
Vascular trauma was the leading topic of the top 115 Our top-cited articles also demonstrate how the field of
most-cited articles. These injuries are associated with combat orthopedic trauma evolved and has improved
major hemorrhage, and recent advances in hemorrhage to address some topics well, such as muscle injury and
control have been lifesaving. survival. Muscle topics were often addressed scientifi-
cally and featured prominently as a title word. The com-
Even with the evolution and improvement of battle- bat orthopedic surgeon often finds muscle problems to
field armor, the Soldier’s extremities remain vulnerable be common, complex, and disabling, because they have
to injury and trauma in modern warfare. This is more little in their muscle-repair skill set, whereas they have
so because current conflicts tend to be associated more much in their skill sets for injured or missing bone, fas-
with counterinsurgency, and operations are conducted cia, tendon, nerve, and skin.
often as dismounted (foot) patrols. Extremity injuries
that often are the result of improvised explosive muni- Survival was addressed well in terms of survival, death,
tions are frequently complex and include damage to the and mortality. This was mixed among titles and ab-
blood vessels supplying the extremities. stracts; it was also often reported on with empirical
evidence. This demonstrates a dramatic departure and
historical improvement for orthopedics, which has tra-
Missing Topics Among Top-Cited Publications
ditionally taken a stance oriented more toward recon-
Our top 115 articles covered a wide range of topics (n struction and rehabilitation in survivors, as opposed
=11) relating to the care of combat wounded suffering to attempting to improve survival. This reflects how

64 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017