Abstract
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Reverse total shoulder arthroplasty (rTSA) has been demonstrated to be an effective intervention for various shoulder disorders. The number of rTSA-related studies performed has increased annually over the past three decades.
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The Journal of Shoulder and Elbow Surgery had the highest number of publications and citations in the rTSA-related research domain and is therefore considered to be the most influential journal in this field.
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The USA published the most publications and established a high degree of cooperation with many countries worldwide. The University of Florida, the Hospital for Special Surgery, and Rush University, Mayo Clinic were representative and active institutions in this field.
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It is anticipated that advancements in prosthesis design, specifically with regards to lateralized design concepts, expanding indications for rTSA, a trend toward younger patient populations, and the management of postoperative complications will emerge as research hotspots in the following years.
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The most valuable publications, influential journals, major researchers, and leading countries were analyzed. The findings of our study will help researchers gain insights into current research hotspots and frontiers and shape their research focus in the field of rTSA.
Introduction
Reverse total shoulder arthroplasty (rTSA) was initially designed to address the unsatisfactory outcomes of anatomic total shoulder arthroplasty (aTSA) in treating degenerative shoulder diseases and complex fractures (1). The procedure involves the transformation of the glenoid into a sphere that articulates with a humeral socket, resulting in a more medial and distal shift of the center of rotation to enhance the mechanical advantage of the deltoid. While total shoulder arthroplasty (TSA) or hemiarthroplasty (HA) may yield favorable clinical outcomes for most shoulder diseases, such as primary osteoarthritis, inflammatory arthropathy, or posttraumatic osteoarthritis, the lack of soft tissue in cuff tear arthropathy poses a considerable challenge for shoulder replacement (2). rTSA can effectively overcome the limitations of TSA or HA, providing pain relief and improved function, thereby emerging as a widely accepted surgical intervention for patients with rotator cuff-deficient shoulders (3).
rTSA is typically indicated for conditions such as irreparable rotator cuff tears, aseptic necrosis of the humeral head, and revision surgery following failed anatomical or resurfacing arthroplasty (4, 5, 6). As the indications for rTSA have expanded, its development has undergone significant evolution in recent decades (7). In recent years, a growing body of research has reported on complications associated with rTSA, which can be broadly classified as nonspecific and specific to the procedure. In particular, rTSA-specific complications include intraoperative fracture of the glenoid and acromion, metaphyseal deterioration, muscular complications with fatty degeneration of the deltoid, and so on (8). Adequate postoperative rehabilitation is crucial for achieving optimal clinical outcomes and function after rTSA. Given the rapid growth of rTSA, postoperative rehabilitation has become an increasingly important concern, requiring rehabilitation protocols that differ from those used for traditional TSA or HA (9).
Over the past few decades, rTSA has undergone rapid growth and gained widespread use in orthopedic surgery, showing promising prospects for treating various conditions. However, the challenges associated with this procedure present a significant hurdle for orthopedic surgeons. As a result, a multitude of studies have explored various aspects of rTSA-related research. Bibliometric analysis is an established evidence-based method that can help gain insight into the current state and research trends in a particular field or topic. The purpose of our study is to use the methodology of bibliometric analysis to provide a quantitative description of the current status and development trends of rTSA-related research. The analysis aims to identify the most valuable publications, influential journals, major researchers, and core countries in the field. Ultimately, we hope to provide researchers with a reliable and up-to-date understanding of the current state of rTSA research, as well as future trends and potential fields for further exploration.
Methods
Database source
The raw data were extracted from the Web of Science Core Collection (WoSCC) database, a comprehensive indexing database that encompasses the Science Citation Index (SCI-E), Social Science Citation Index (SSCI), Arts and Humanities Citation Index (A&HCI), Conference Citation Index (CPCI), and other sources. WoSCC contains numerous high-impact research journals of significant international standing. It maintains a citation index that gathers data, such as the author, source, and publication year, about the references cited in published articles. These features of the WoSCC database make it an ideal resource for conducting bibliometric analyses of research related to rTSA. Our study did not involve human or animal subjects. Therefore, approval from an Institutional Review Board (IRB) or an Institutional Animal Care and Use Committee (IACUC) was not applicable for our research.
Search strategy
The search term [Topic = (‘Reverse Total Shoulder Replacement’ OR ‘RTSR’ OR ‘Reverse Total Shoulder Arthroplasty’ OR ‘rTSA’)] was used to search all the rTSA-related publications in the WoSCC database. The document types included Article and Review; other document types, such as Meeting Abstracts, Proceedings Papers, Editorial Materials, and Letters, were excluded. The search period was set from 1991 to 2022. Raw data in plain text format were saved from the WoSCC database for further analysis.
Inclusion and exclusion criteria
Inclusion criteria were as follows: (i) peer-reviewed published articles on rTSA-related research, including basic and clinical research; (ii) reviews on rTSA-related research; (iii) publications in English; (iv) publications published from 1991 to 2022; and (v) publications retrieved from the WoSCC database. Exclusion criteria were: (i) articles not officially published, including proceeding paper and early access; (ii) meeting abstract, letter, editorial material, and correction; (iii) repeated publications; and (iv) unrelated publications.
Statistical analysis
The comprehensive bibliometric analysis was analyzed by the ‘bibliometrix’ package (version 4.0.0) installed in R software (version 4.1.0) (10). The changes in burst keywords with the year of publication were analyzed by CiteSpace (version 6.1. R6) software (11). VOSviewer (version 1.6.18) software was mainly used to conduct co-occurrence, co-citation, and co-authorship analyses (12). Bar charts and line graphs were drawn by GraphPad Prism (version 9.0.0) (Fig. 1).
Flowchart for the ‘Search Strategy’: in total, 1176 unique publication records were identified for the bibliometric analysis.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
Results
General information and annual publication production
In total, 1311 publication records from the period of 1991 to 2022 were identified in the WoSCC database through the search term [Topic = (‘Reverse Total Shoulder Replacement’ OR ‘RTSR’ OR ‘Reverse Total Shoulder Arthroplasty’ OR ‘rTSA’)]. After discarding 135 nonofficially published and irrelevant records, 1176 publication records were obtained, comprising 1019 articles (87%) and 157 reviews (13%) published from 1991 to 2022. These publications originated from 202 sources, such as journals and books, and were authored by 3264 contributors. Early works in the rTSA field were relatively scarce, with no rTSA-related publications appearing in 1992, 1994, 1997, and 1999. However, the number of publications has been steadily increasing since 2007 (Fig. 2A).
General information and annual publication productions. (A) The document types and number of rTSA-related publications. (B) The yearly publication production of the rTSA-related publications. (C) The top ten most productive countries in the rTSA-related field (MCP, multiple corresponding author publication; SCP, single corresponding author publication). (D) The top ten most productive afflictions in the rTSA-related field.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
The publication trends revealed that the highest number of articles was published in 2021 (n = 204) (Fig. 2B). Furthermore, Fig. 2C illustrates that the majority of publications originated from the USA. Of the top contributing institutions, the University of Florida ranked first, with a significant contribution to the rTSA-related field (Fig. 2D).
Sources and journals
The publications on rTSA-related studies are spread across a broad range of over 200 sources and journals, which can serve as valuable references for new researchers. The top ten journals with the highest number of published rTSA-related articles are presented in Table 1. Leading the list was the Journal of Shoulder and Elbow Surgery with the largest number of publications (405, 34.3%), which is a specialized journal focused on medical, surgical, and physical techniques for the treatment of injuries or illnesses of the upper extremities such as the shoulder girdle, arm, and elbow. International Orthopaedics (41, 3.5%) and Clinical Orthopaedics and Related Research (40, 3.4%) were ranked second and third, respectively, followed by Journal of Bone and Joint Surgery – American Volume (36, 3.1%), Orthopedics (35, 3.0%), and Journal of the American Academy of Orthopaedic Surgeons (34, 2.9%).
Journals with the highest frequency of publications on rTSA.
| Journal | Publications, n |
|---|---|
| Journal of Shoulder and Elbow Surgery | 405 |
| International Orthopaedics | 41 |
| Clinical Orthopaedics and Related Research | 40 |
| Journal of Bone and Joint Surgery – American Volume | 36 |
| Orthopedics | 35 |
| Journal of the American Academy of Orthopaedic Surgeons | 34 |
| Archives of Orthopaedic and Trauma Surgery | 28 |
| Journal of Clinical Medicine | 22 |
| BMC Musculoskeletal Disorders | 15 |
| Bone & Joint Journal | 14 |
The H-index or H-factor is a useful tool to assess the academic productivity and impact of authors or journals. Figure 3 demonstrates that the Journal of Shoulder and Elbow Surgery is the top-ranking journal in terms of total citations and H-index, suggesting that it has the highest impact and is considered the most influential publication in the rTSA-related research domain. Moreover, the H-index values of Journal of Bone and Joint Surgery – American Volume, Clinical Orthopaedics and Related Research, Journal of the American Academy of Orthopaedic Surgeons, and International Orthopaedics signify their influence in the field of rTSA-related studies. Therefore, these journals can serve as an important source to identify the latest research frontiers and hotspots in rTSA-related fields.
The number of total citations and H-index of the top ten journals in the rTSA-related fields. (A) The number of total citations of the top ten journals in the rTSA-related fields. (B) The H-index of the top ten journals in the rTSA-related fields.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
Collaboration relationship analysis
Co-author
Co-authorship analysis is a powerful method of bibliometric analysis to investigate collaboration relationships among authors, and it can provide valuable insights into research networks. In this study, a co-authorship analysis was conducted on rTSA-related studies published from 1991 to 2022 using a yearly time slice. The resulting co-authorship network, depicted in Fig. 4A, visualizes the collaborations among authors. The circle size indicates the number of publications by the authors, while the color of the circles reflects the year of publication. Purple circles denote earlier publications, while yellow circles represent more recent ones. The links between the circles represent the collaborations between authors. The co-authorship network reveals that several major author clusters have been formed, with many authors establishing long-term collaborative relationships. Notably, Thomas W Wright, Anthony A Romeo, Lawrence V Gulotta, Christian Gerber, Joseph D Zuckerman, and George S Athwal emerged as key authors in the rTSA-related field, having established numerous collaborative relationships with researchers worldwide.
Collaboration relationship analysis of the rTSA-related publications. (A) The co-author analysis of the rTSA-related studies published from 1991 to 2022. (B) The co-institute analysis of the rTSA-related studies published from 1991 to 2022. (C) The co-country analysis of the rTSA-related studies published from 1991 to 2022.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
Co-institute
CiteSpace software was used to gain insight into the collaborative relationships among institutions by co-occurrence frequency analysis of the relevant publication records. Co-institutes were identified based on the appearance of two authors' institutes in the same publications, which was considered a collaboration. The analysis was conducted on the rTSA-related studies published between 1991 and 2022 using a time slice of 1 year. The results of the analysis are presented in Fig. 4B, which illustrates the co-institutes in the rTSA-related field. Each node in the figure represents an institution, with node size indicating the frequency of co-occurrence and circle size representing the number of publications produced by the institution. The link between the two circles represents the cooperation relationship between the institutes. Gray nodes indicate earlier publications, while red nodes denote more recent publications. The University of Florida, Mayo Clinic, Hospital for Special Surgery, the University of Zurich, and Rush University emerged as the leading institutions in the field of rTSA-related research. These institutions have produced a significant amount of scientific output and have established extensive collaborative relationships with other institutions worldwide.
Co-country
In our study, the collaborative relationships among countries in conducting rTSA-related research were analyzed by CiteSpace software. A time slice of 1 year was used to extract the relevant studies published between 1991 and 2022 for the analysis. Figure 4C presents the collaboration network of countries involved in rTSA-related research during this period. Each node on the network represents a country, and the link between two nodes indicates a collaborative relationship between those countries. It was found that the USA had the highest number of relevant publications and had established numerous collaborative relationships with various countries worldwide, thereby emerging as the leading country in rTSA-related research. Furthermore, Germany, Switzerland, South Korea, and Australia were also identified as representative countries in the field of rTSA-related research.
Keyword analysis
Keywords serve as the cornerstone of scholarly publications, as they can provide crucial information on the central themes and research trends. The use of high-frequency keywords during a given period can offer insights into the focus and hotspots of research on rTSA. Figure 5A displays the most commonly used keywords in rTSA-related literature, with ‘prosthesis’ leading at a total usage frequency of 343, followed by ‘outcome’ (186), ‘hemiarthroplasty’ (156), ‘complications’ (152), and ‘replacement’ (148). Co-occurring analysis of keywords may reflect research hotspots in the field, whereby the frequency of a group of keywords within the same publications forms a co-occurring network that highlights the associations between them. VOSviewer was used to conduct this analysis on publications from 1991 to 2022. From the change in frequency of keywords over time in Fig. 5B, it can be seen that after 2010, the frequency of related keywords has grown rapidly, with ‘prosthesis’ being the hottest keyword in this field all the time. Figure 5C and D illustrates the co-occurring network of keywords. Each node in Fig. 5C represents a keyword, with the size of the node corresponding to the frequency of co-occurrence. Keywords of the same color belong to the same cluster. All the keywords were divided into five clusters in Fig. 5C, with the largest cluster containing 31 keywords, including ‘reverse total shoulder arthroplasty’, ‘total shoulder arthroplasty’, ‘complications’, ‘outcomes’, and others.
Keyword analysis of the rTSA-related publications. (A) TreeMap of the top 50 high-frequency keywords used. (B) Keyword frequency over time. (C) Co-occurring network of keywords. (D) Co-occurring network of keywords in overlay visualization.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
The top 100 most-cited publications analysis
To gain insight into the most influential studies in the rTSA-related research field, we conducted a citation analysis of the top 100 most-cited publications. Figure 6 provides an overview of the general information regarding these publications. We found that Journal of Shoulder and Elbow Surgery was the primary source of highly cited articles, accounting for 37% of the top 100 most-cited publications, followed by Journal of Bone and Joint Surgery – American Volume, Clinical Orthopaedics and Related Research, Journal of the American Academy of Orthopaedic Surgeons, and International Orthopaedics, and others. The highest production period of these articles was from 2009 to 2017, with a significant number of highly cited publications produced during this time frame. In particular, 2011 had the largest number of most-cited publications. Table 2 and Fig. 6C provide an analysis of the top ten most-cited publications, including the publication ‘Reverse total shoulder arthroplasty: a review of results according to etiology’ by Bryan Wall et al., which ranked first with a total of 608 citations (13). This study is regarded as a representative work in the field and demonstrates that rTSA prostheses can produce positive results in the treatment of complex shoulder problems, while patients with posttraumatic arthritis and those undergoing revision arthroplasty had lower improvement rates and higher complication rates.
General information about the top 100 most-cited publications. (A) The sources and journals of highly cited articles. (B) The publication time of highly cited articles. (C) Citation analysis of the top ten most-cited publications.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
The top ten most-cited publications regarding RTSA-related research.
| Publication | Article Type | Journal | Total citations |
|---|---|---|---|
| Wall et al. (13) | Article | Journal of Bone & Joint Surgery – American volume | 602 |
| Guery et al. (38) | Article | Journal of Bone & Joint Surgery – American volume | 437 |
| Zumstein et al. (36) | Review | Journal of Shoulder and Elbow Surgery | 383 |
| Simovitch et al. (39) | Article | Journal of Bone & Joint Surgery – American volume | 291 |
| Rittmeister & Kerschbaumer (40) | Clinical Trial | Journal of Shoulder and Elbow Surgery | 232 |
| Ellermeier & Slauch (41) | Review | Current Opinion in Microbiology | 207 |
| Gerber et al. (17) | Review | Journal of the American Academy of Orthopaedic Surgeons | 195 |
| Ek et al. (42) | Article | Journal of Shoulder and Elbow Surgery | 193 |
| Mizuno et al. (44) | Article | Journal of Bone and Joint Surgery – American volume | 183 |
| Farshad & Gerber (43) | Review | International Orthopaedics | 178 |
Thematic evolution
Thematic evolution analysis is a valuable tool for identifying specific themes or phenomena and gaining deeper insights into large data sets. We used the ‘bibliometrix’ package in R software to analyze publications related to rTSA research from 1991 to 2022. The results of our analysis, as illustrated in Fig. 7, reveal that ‘Expansion of surgical indications of rTSA’, ‘Younger patient population’ and ‘Implant design-related scientific research’ are prominent themes in this field in recent years.
Thematic evolution analysis of rTSA-related research from 1991 to 2022.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
Discussion
Status of current scientific research
Our study conducted a comprehensive bibliometric analysis to provide a comprehensive and quantitative assessment of rTSA-related publications. As delineated in the Results section, rTSA-related publications have experienced notable growth over the last three decades, and we anticipate that research pertaining to this field will continue to garner attention in the coming years. Notably, the Journal of Shoulder and Elbow Surgery had the highest number of publications and citations in the rTSA-related research domain and is therefore considered to be the most influential journal in this field. It is likely that this journal will continue to publish high-quality publications in the field of rTSA in the future. The USA emerged as the leading country in terms of academic influence, with the highest number of publications and citations, while the University of Florida was identified as the most active institution, fostering collaborative relationships with other research institutions worldwide. Of the researchers, Anthony A Romeo from Midwest Orthopaedics at Rush University Medical Center emerged as an active contributor, with extensive partnerships and numerous noteworthy publications. Charles Neer played a significant role in the design and development of shoulder arthroplasty. Neer's contributions to the field of shoulder arthroplasty have had a lasting impact, influencing subsequent generations of researchers, surgeons, and medical professionals. The iterative improvements on his original designs have contributed to the evolution of prostheses, ultimately benefiting patients with shoulder joint conditions (14). Paul Grammont's design of the first commercially available and clinically successful rTSA represents a significant milestone in the field of rTSA-related research. Grammont's design revolutionized the conventional approach to shoulder joint replacement surgery (15). The evolution of traditional rTSA by Grammont has witnessed several significant iterations, each aimed at refining and optimizing the surgical technique and implant design. These iterations include innovations such as glenoid lateralization, a reduced neck-shaft angle, modular components, stemless designs, and the incorporation of onlay systems (1). rTSA has now emerged as a mature surgical procedure and can be considered the ultimate intervention for treating shoulder joint disorders. The invention of any surgical procedure undergoes extended contemplation, improvement, or evolution to gradually progress from initial imperfections to better outcomes. This process is lengthy, requiring the dedication of generation after generation of researchers. Researchers such as L Marmor, Gilles Walch, Christian Gerber, and others have made significant contributions in this field (16, 17). Of note, the publication ‘Reverse total shoulder arthroplasty: a review of results according to etiology’ by Wall, Bryan et al. was identified as the most representative publication and can serve as a valuable resource for those seeking insights into rTSA-related research.
Emerging trends
Considerations for rTSA prosthesis design
The development of rTSA prosthesis design has evolved from its early simplistic designs to the current more complex, individualized, and advanced stages. Currently, the implant design for rSTA is founded on the Grammont principle. This principle encompasses four key features: (1) the medially displaced center of rotation, which reduces humeral tension and increases recruitment of the anterior and posterior deltoid muscles to compensate for rotator cuff deficiency; (2) a convex weight-bearing component and concave supportive component; (3) the fixed center of rotation, which is distalized and medialized to the glenoid joint line to establish inherent implant stability; and (4) a large glenosphere to enhance the ROM via a semi-constrained implant attribute (18, 19). However, the implementation of rTSA implant design differs in some implant details to overcome potential postoperative issues reported extensively in the current studies. In recent years, novel implant design concepts have been proposed, yet they remain subject to controversy. Certain researchers maintain that the lateral displacement of the center of rotation may carry greater significance for shoulder joint mobility, rotator cuff strength, and glenohumeral joint stability. Nonetheless, there is still uncertainty about the optimal degree of lateralization for the glenoid and humerus, as well as the maximum tolerable joint reaction force after reduction (20). Addressing these issues necessitates more high-quality research. As research advances in rTSA and biomechanics-related research, future implant designs should prioritize maximizing shoulder joint efficiency, ameliorating nonimpingement range of motion, reducing scapular notching risk, preserving bone stock, and minimizing instability risk (21). This progression has led to significant advancements in the treatment of shoulder joint diseases and injuries (22). The current research on rTSA prosthesis is a highly active and prominent area of investigation. As the demand for shoulder joint replacement surgeries continues to rise, researchers are dedicated to further optimizing and enhancing rTSA prosthesis to improve surgical outcomes and enhance patients' quality of life (QoL) (Fig. 8). Researchers are exploring the use of advanced and novel materials to enhance the durability and biocompatibility of rTSA prosthesis (23, 24). Individualized design has become a focal point. This contributes to improved surgical precision, reduced risk of complications, and better accommodation of individual patient variations. With ongoing advancements in surgical techniques, researchers are innovating to improve long-term outcomes and patient satisfaction, ensuring that patients attain a better QoL. In the future, innovative designs for reverse shoulder arthroplasty implants are expected to provide better treatment options for patients. It is anticipated that novel designs of implants for rSTA will offer improved therapeutic possibilities for patients with severe shoulder disorders.
Current designs of rTSA prostheses. (A) The Grammont reverse prosthesis, also known as the Delta III prosthesis. (B) The center of rotation (COR) lateralization design for rTSA. (C) The Bony Increased Offset (BIO) design for rTSA. (D) The onlay curved stem design for rTSA. (E) The stem-less design for rTSA.
Citation: EFORT Open Reviews 9, 4; 10.1530/EOR-23-0106
Expanding indications for rTSA
There has been a notable rise in the annual utilization of rTSA procedures over the past three decades. In addition, the range of indications for which rTSA is considered a viable treatment option has expanded substantially, making it a popular area of research in the rTSA-related field. Notably, rotator cuff tear arthropathy has emerged as the primary indication for rTSA as per the approval of the U.S. Food and Drug Administration (FDA) (25). rTSA is widely acknowledged as an optimal treatment option for massive irreparable cuff tears, especially when arthritis is not present. A considerable body of research has shown that rTSA can significantly improve patients' clinical function and enhance their overall quality of life (QoL) (26). rTSA presents several advantages over HA and internal fixation, leading to a significant enhancement in functional outcomes. Therefore, the application of rTSA for proximal humerus fractures (PHFs) has witnessed an exponential rise over the past three decades (27). Rotator cuff instability and anterosuperior escape are potential complications following the failure of aTSA or HA. To address these issues, rTSA has emerged as a viable option for revision shoulder arthroplasty because it does not rely on the stability of the rotator cuff (28). Inflammatory arthropathy can result in significant osseous deformity, glenoid bone loss, and rotator cuff dysfunction, which makes rTSA an appealing option for treating such patients (29). Additionally, for patients with proximal humeral tumors requiring resection, the rTSA may be the sole implant capable of maintaining joint stability and preserving shoulder function (30). The use of rTSA for the management of glenohumeral instability is considered uncommon. However, it is a promising therapeutic alternative for elderly patients with significant bone loss or those who have undergone failed surgical glenohumeral stabilization procedures (31). As the number of rTSA surgeries has increased and more data have become available, it has become clear that rTSA is effective in treating various shoulder pathologies (32). It is predicted that this procedure will be performed in the clinic with a broader range of indications.
Complications after rTSA
Postoperative complications after rTSA can be classified into nonspecific complications and complications specific to rTSA. rTSA is associated with complications that are similar to those seen in conventional TSA, such as nerve injury, infections, intraoperative fracture, dislocation, and others (33). Nerve injury, especially the brachial plexus or the axillary nerve, should be considered before and after surgery. Electromyography (EMG) is a valuable diagnostic tool for assessing nerve injury in this population (8). Postoperative infection generally includes superficial infections and deep periprosthetic infections. Treating postoperative infections with rTSA is similar to other joint arthroplasty procedures (34). Intraoperative fracture and dislocation are also worthy concerns for surgeons. Commonly used techniques, such as avoiding excessive torsion and manual expansion of the pulp cavity reaming the canal by hand, may help to lower the risks of intraoperative fractures (35). Dislocation is a relatively common complication in rTSA. Sufficient soft-tissue tension is essential for the stability of the inverted shoulder joint. Various factors that cause the decreased stability of the shoulder joint may lead to dislocation (36). Recreating the vertical offset of the acromion-greater tuberosity distance and the lateral offset of the tuberosity-glenoid distance may help achieve anatomic soft tissue tension and increase the shoulder’s stability (35). rTSA-related complications include scapular notching, glenoid loosening, metaphyseal deterioration, humeral loosening, fatty degeneration of the deltoid, component disassociation, and scapular stress fractures (33, 37). Complications after rTSA pose a huge challenge for healthcare providers and bring great pain and psychological burden to patients. Therefore, recognizing risk factors, improving surgical skills, and understanding the component design of rTSA are essential to minimize patient morbidity and improve clinical outcomes (33).
Limitations
Bibliometric analysis can visualize the structures of publication data in a specific field of science. However, there are some limitations to our study that need to be clarified. First, we only chose the WoSCC database and did not include other relevant databases, such as PubMed and Scopus. Secondly, we only examined English language publications, potentially overlooking other non-English language studies that may have been relevant. Furthermore, it is essential to note that there is no direct correlation between the frequency of citations and the quality of publications. Some excellent studies may have been excluded from our analysis due to a low citation count. Finally, our analysis was restricted to publications that had sufficient data, and recently published studies may not have been included. It is crucial to acknowledge that research findings can evolve over time. All our results are derived from publication records in databases, which may not fully reflect the actual situation. This limitation is inherent to all bibliometric analysis studies. There are still many hotspots and frontiers in the field of rTSA that are worth exploring by researchers, such as ‘Limitations in Robotic Surgery and PSI Research’, ‘Prevalence of Augmented Reality in Surgical Theater’, ‘Percentage of Research on Patient-Reported Outcome Scores’, and so on. In the future, we hope to see more outstanding bibliometric analyses or research studies to delve deeper into this field.
Conclusion
In summary, rTSA-related research has presented high-speed growth over the past three decades. The USA possesses the highest academic status due to its largest contribution to this field. In particular, the University of Florida in the USA was the most active institution in rTSA-related research. The journal Journal of Shoulder and Elbow Surgery was the most influential journal in its own area of expertise. It is anticipated that advancements in prosthesis design, specifically with regards to lateralized design concepts, expanding indications for rTSA, and a trend towards younger patient populations, as well as the management of postoperative complications, will emerge as research hotspots in the following years.
ICMJE Conflict of Interest Statement
The authors declare that the research was conducted without any commercial or financial relationships that could be construed as potential competing interests.
Funding Statement
This work was supported by the National Key R&D Program of China (No. 2019YFA0111900), the National Natural Science Foundation of China (No. 92268115, 82272611, 82072506), Outstanding Youth Fund Project of Hunan Province (2024JJ2089), Hunan Young Talents of Science and Technology (No. 2021RC3025), National Clinical Research Center for Geriatric Disorders (Xiangya Hospital, No. 2021KF02), National Clinical Research Center for Orthopedics Sports Medicine and Rehabilitation (2021-NCRC-CXJJ-PY-40) and Exploration and Innovation Project for Undergraduate Students of Hunan (CX20230303) and Centra South University Fundamental Research Funds for the Central Universities of Central South University (2023ZZTS0229).
Author contributions statement
HFJ wrote the manuscript. SDJ and VP prepared the figures. DT AV revised the manuscript. JHF and DT AV contributed to the analysis and interpretation of data. WFX and YSL conceptualized this research and decided on the content. All authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work.
Data availability statement
The datasets used and/or analyzed during the research are available from the corresponding author upon reasonable request.
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