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A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity

A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity Hindawi Surgery Research and Practice Volume 2019, Article ID 3068028, 12 pages https://doi.org/10.1155/2019/3068028 Review Article A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity 1 2 3 Zacharia Mbaidjol , Jens Rothenberger, and Rajesh Chetany Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, West Sussex RH19 3DZ, UK BG Unfallklink an der Universita¨t Tu¨bingen, Klinik fu¨r Hand, Plastische, Rekonstruktive und Verbrennungschirurgie, Tubingen, Germany FMI Spital Interlaken, Weissenaustrasse 27, 3800 Interlaken, Switzerland Correspondence should be addressed to Zacharia Mbaidjol; zahqaria@gmail.com Received 7 August 2018; Revised 13 December 2018; Accepted 27 December 2018; Published 28 January 2019 Academic Editor: Giuseppe Marulli Copyright © 2019 Zacharia Mbaidjol et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Lower extremity reconstruction has always been a challenge. Some of the published articles had a major impact on the field but are often not considered as classics because they have fewer citations. We therefore conducted a scientometric analysis of the most cited articles with a focus solely on the lower limb. Methods. A search was conducted on Medline, the Web of Science database, Google Scholar, and Scopus identifying articles relevant to reconstructive surgery of the lower limb. All journals were included with no time frames. Articles relating solely to orthopedics or vascular reconstruction were excluded. +e number of citations obtained were then plotted and compared between the different search engines. +e mean citation number was calculated by taking into consideration the total number of years since the article’s first year of publication. Articles were then ranked and classified according to their authors, their years of publications, and their countries. +ey were furthermore categorized and analyzed. Results. Highly cited articles were easily retrieved with Google Scholar, mostly published in Plastic and Reconstructive Surgery (n � 37) and were mainly authored by American Medical Centers (n � 22). Fifty-four percent (54%) of these classic articles discussed the design of new flaps or were anatomical studies. Conclusions. We were not able to find a correlation between the year of citation and the number of citations. +e citation pattern of a paper cannot be predicted, but a majority of highly cited article allowed the design of new reconstructive techniques. number of articles published by that journal in the same 1. Introduction two years [2]. Journals with the highest impact factors are +ere are over 24000 peer-reviewed journals [1] and more associated with quality and prestige [3], and the articles than 237 medical disciplines. To find articles that have high they publish tend to be more cited. +e impact factor relative importance to the research topic is a daunting task. therefore remains high in these journals because of the Garfield in response to this challenge devised the impact well-known 80/20 rule which results in 20% of the articles factor in 1960 [2]. It was intended to serve as a way to help accounting for 80% of the citations [2]. Breakthrough scientists browse with more ease and effectiveness through articles can have over 300.000 articles. +is lead to the term this magnitude of journals by identifying articles most often “Citations classic articles” introduced in 1977 by Eugene cited and by proxy more relevant. Garfield, selecting some of the most cited papers ever published in science. +e impact of an article is mostly observed the fol- lowing 2 years after its publication. +e impact factor of a In the field of reconstructive surgery, all previously journal is defined as the number of citations a journal has written citation articles limited their search criteria to main received in that current year to the number of published plastic surgery journals and either encompassed the whole articles within the two previous years, divided by the field of plastic surgery or a specific branch [4–7]. 2 Surgery Research and Practice Which are the 50 most cited articles in regard to re- the first author. Table 2 shows a list of 6 other authors with construction of the lower limb? +e aim of these articles is to multiple entries (Table 2). acknowledge the most cited articles referring to lower ex- Articles were most often written by American medical tremity reconstruction because of the challenging nature of centers (n � 22) (Table 3) and mostly published in PRS these procedures. +is article gives an overview of how most (n � 37); however, 17 countries were represented in 7 procedures and techniques now in place came into existence different peer-reviewed journals (Table 4). Of note, there and the different techniques that came to be before being was an article written by May et al. [25], and it is the only replaced by another in order to overcome the limitations of article published in a nonsurgical journal. All together, the previous technique. these “50 classics” have been cited 9599 times according to the WoS, 15536 times according to GS, and 9052 times in Scopus. +e articles fall broadly into 4 different categories: 2. Methods anatomical studies and new flaps description; the timing A search was conducted on Medline, the Web of Science for reconstruction and the prevention of osteomyelitis; the database (WoS), Google Scholar (GS), and Scopus identifying quality of life and functional results after reconstruction, articles relevant to reconstructive surgery of the lower limb. and finally clinical evidence studies (Figure 1). +e most All journals were included with no time frame. We used recent articles were published in 2006 [26, 35, 45] and the specific thesaurus (Mesh Terms) terms and keywords as oldest, 60 years earlier [52]. Within the 3 databases, the follows: “lower extremity,” “lower limb,” “legs,” “re- authors remain almost the same (Table 5). When using the construction,” “flaps,” “plastic surgery,” and “microsurgery.” mean citation number to sort the articles using the WoS On GS, an advanced search was performed with a combi- database, the article written by Masquelet et al. [9] in 1992 nation of our keywords as exact phrases. We excluded in a is the most cited article, while the 2 oldest articles are at the first step duplicate articles among the databases, using bottom of the list (Table 6). Highly cited articles tend to EndNote (Endnote X8.2, Clarivate analytics, Philadelphia, remain highly cited, but the number of citations did not PA, USA). In a second step, we went through all the titles and seem to be predictable (Figures 2(a) and 2(b)). abstracts. All articles that did not include our important terms and keywords on the abstract and titles were excluded. We 4. Discussion also did not consider those focusing on the lower extremity as a donor site for reconstruction of other parts of the body and +e reconstruction and the coverage of wounds of the lower those relating solely to orthopedics or vascular reconstruction. extremity is a tedious and challenging experience for +e search result of each database was also used to retrieve surgeons involved. +e bony support of the lower ex- articles in the other databases as a mean to evaluate con- tremity, often prone to infection and malunion following sistency of the results. trauma, has to be taken into consideration for its role in the In the final step, we noted the years with the most ci- gait biomechanics [12]. Furthermore, compared to the rest tations, the publishing journal, and the country of publication of the body, following loss of integument due to trauma, for each article and the mean citation number was calculated ulceration, or after skin resection, the lack of elasticity and by dividing the number of citations by the number of years poor vascularization of the surrounding skin associated since the article’s first year of publication. We furthermore with the lack of adipose tissue often prevents closure [19]. compared the differences in citation ranking for the 10 most +e reconstructive surgeon has to find a way to insure cited articles according to the three abovementioned main prompt coverage while replacing “like for like.” Multiple search engines. +ese top 10 articles were then further techniques have since been put into place to remedy this evaluated by plotting the number of citations per year everlasting challenge. according to each year since their initial publication to see if a In order to find the 50 most cited papers, we cross- citation pattern existed. +ree authors extracted the data from referenced three search databases: the WoS, GS, and Scopus. the full-articles examined. Discrepancies between two re- +ese search tools were evaluated in an article written by viewers were resolved by discussion. A third author per- Bakkalasi et al. in 2006 [60] by comparing databases, and formed an independent search, and results were compared to findings indicated that they all returned unique materials verify accuracy. and no search engine was superior over another. By cross- referencing, the articles were found in the different data- bases, and we were able to obtain a 100% concordance for 3. Results the first 10 articles. +e most cited article entitled “+e free vascularized bone +e articles found that, within the “most cited articles” graft: a clinical extension of microvascular techniques [8]” was list, all had a major impact in the evolution of reconstructive published in plastic and reconstructive surgery (PRS) in 1975 surgery of the extremity: and has been cited 829 times according to the WoS database. th +e 50 most cited article “+e instep of the foot as a fas- ciocutaneous island and as a free flap for heel defects” was 4.1. Muscle Flaps in the Treatment and Prevention of Osteo- referenced 106 times also according to the WoS (Table 1). myelitis and the Timing of Surgery. +e oldest article in this +ese 2 articles were both published in PRS 6 years apart. classic citation analysis dates back from 1946 and was Taylor is the most cited author with three (3) articles listing as written by Starks [52]. +is is the first description of the use Surgery Research and Practice 3 Table 1: Ranking according to WoS, GS, Scopus, and years with the most citations. Rank Author and title Year Top year CN WoS CN GS CN Scopus MC WoS Taylor et al. +e free vascularized bone graft: a clinical 1 1975 2013 829 1263 760 20.72 extension of microvascular techniques [8]. Masquelet et al. Skin island flaps supplied by the 2 vascular axis of the sensitive superficial nerves: 1992 2011 530 1448 411 23.04 anatomic study and clinical experience in the leg [9]. Godina. Early microsurgical reconstruction of 3 1986 2007 553 1016 575 19.06 complex trauma of the extremities [10]. Daniel and Taylor. Distant transfer of an island flap by 4 1973 1979 438 652 352 8.42 microvascular anastomoses: a clinical technique [11]. Ponten. +e fasciocutaneous flap: its use in soft tissue 5 1981 1990 433 729 447 12.73 defects of the lower leg [12]. Mathes. Use of the muscle flap in chronic osteomyelitis: 6 1982 1996 348 451 314 10.54 experimental and clinical correlation [13]. Wei et al. Fibular osteoseptocutaneous flap: anatomic 7 1986 2010 256 345 276 8.83 study and clinical application [14]. DeFranzo et al. +e use of vacuum-assisted closure 8 therapy for the treatment of lower-extremity wounds 2001 2006 249 506 272 17.78 with exposed bone [15]. 9 Byrd et al. Management of open tibial fractures [16]. 1985 1999, 2008 239 390 225 7.97 Khouri and Shaw. Reconstruction of the lower 10 extremity with microvascular free flaps: a 10-year 1989 1995 229 289 223 8.81 experience with 304 consecutive cases [17]. Gopal et al. Fix and flap: the radical orthopaedic and 11 plastic treatment of severe open fractures of the tibia 2000 2014 199 380 227 13.27 [18]. Hasegawa et al. +e distally based superficial sural 12 1994 2008 196 378 229 9.33 artery flap [19]. O’Brien et al. Successful transfer of a large island flap 13 from the groin to the foot by microvascular 1973 1976 180 222 141 4.28 anastomoses [20]. Byrd et al. +e management of open tibial fractures 14 with associated soft-tissue loss: external pin fixation 1981 1997 172 256 166 5.06 with early flap coverage [21]. Yaremchuk et al. Acute and definitive management of 15 traumatic osteocutaneous defects of the lower 1987 2010 166 256 169 5.93 extremity [22]. Taylor and Pan. Angiosomes of the leg: anatomic 16 1998 2013 163 298 122 9.59 study and clinical implications [23]. Taylor and Watson. One-stage repair of compound 17 leg defects with free, revascularized flaps of groin skin 1982 1989 161 175 119 4.88 and iliac bone [24]. May et al. Microvascular transfer of free tissue for closure 18 1982 1989 161 175 119 4.88 of bone wounds of the distal lower extremity [25]. Yazar et al. Outcome comparison between free muscle and free fasciocutaneous flaps for 19 2006 2009, 2011 156 95 99 17.33 reconstruction of distal third and ankle traumatic open tibial fractures [26]. May et al. Free microvascular muscle flaps with skin 20 graft reconstruction of extensive defects of the 1985 1986 152 227 151 5.07 foot—a clinical and gait analysis study [27]. Amarante et al. A new distally based fasciocutaneous 21 1986 1990 151 200 157 5.20 flap of the leg [28]. Carriquiry et al. An anatomic study of the 22 1985 1990 150 218 144 5 septocutaneous vessels of the leg [29]. Yazar et al. One-stage reconstruction of composite 23 bone and soft-tissue defects in traumatic lower 2004 2010 149 216 140 13.54 extremities [30]. Donski and Fogdestam. Distally based 24 fasciocutaneous flap from the sural region: a 1983 1990 148 242 168 4.62 preliminary report [31]. McCraw et al. +e dorsalis pedis arterialized flap: a 25 1975 1979 146 258 140 3.65 clinical study [32]. 4 Surgery Research and Practice Table 1: Continued. Rank Author and title Year Top year CN WoS CN GS CN Scopus MC WoS Yoshimura et al. Peroneal flap for reconstruction in 26 1984 1990 140 176 142 4.52 the extremity [33]. Georgiadis et al. Open tibial fractures with severe 27 soft-tissue loss-limb salvage compared with below- 1993 1997 140 228 140 6.36 the-knee amputation [34] Parrett et al. Lower extremity trauma: trends in the 28 management of soft-tissue reconstruction of open 2006 2011, 2015 139 240 139 15.44 tibia-fibula fractures [35] Ger. Muscle transposition for treatment and 29 prevention of chronic posttraumatic osteomyelitis of 1977 1983 134 172 93 3.53 the tibia [36]. 30 Masquelet et al. +e lateral supramalleolar flap [37]. 1988 2001 134 246 145 4.96 Francel et al. Microvascular soft-tissue transplantation for reconstruction of acute open tibial 31 1992 2014 134 204 143 5.83 fractures: timing of coverage and long-term functional results [38]. Orticochea. +e musculo-cutaneous flap method: an 32 immediate and heroic substitute for the method of 1972 1983 133 178 97 3.09 delay [39]. Fischer et al. +e timing of flap coverage, bone- grafting, and intramedullary nailing in patients who 33 1991 2012 132 271 152 5.5 have a fracture of the tibial shaft with extensive soft- tissue injury [40]. Baumeister et al. A realistic complication analysis of 70 34 2003 2008 128 251 153 10.67 sural artery flaps in a multimorbid patient group [41]. Serafin et al. Comparison of free flaps with pedicled 35 1977 1979 126 174 114 3.31 flaps for coverage of defects of the leg or foot [42]. Haertsch. +e blood supply to the skin of the leg: a 36 1981 1986 125 216 109 3.68 post-mortem investigation [43]. Wee. Reconstruction of the lower leg and foot with 37 the reverse-pedicled anterior tibial flap: preliminary 1986 1990 123 163 116 4.24 report of a new fasciocutaneous flap [44]. Attinger et al. Angiosomes of the foot and ankle and 38 clinical implications for limb salvage: reconstruction, 2006 2013 123 272 162 13.67 incisions and revascularization [45] Anthony et al. +e muscle flap in the treatment of 39 chronic lower extremity osteomyelitis: results in 1991 2004 122 173 125 5.08 patients over 5 years after treatment [46] Serafin et al. Reconstruction of the lower extremity 40 with vascularized composite tissue: improved tissue 1980 1989 121 146 100 3.46 survival and specific indications [47]. Buncke et al. Free osteocutaneous flap from a rib to 41 1977 1982 121 166 70 3.18 the tibia [48]. Nakajima et al. Accompanying arteries of the lesser 42 saphenous vein and sural nerve: anatomic study and 1999 2011 119 230 129 7.0 its clinical applications [49]. McCraw et al. Versatile gastrocnemius myocutaneous 43 1978 1984 115 168 91 3.11 flap [50] Cavadas et al. +e medial sural artery perforator free 44 2001 2007 108 173 57 7.2 flap [51] Starks +e use of pedicled muscle flaps in the surgical 45 treatment of chronic osteomyelitis resulting from 1946 1993 108 126 75 1.54 compound fractures [52]. Jeng and Wei. Distally based sural island flap for foot 46 1997 2008 107 185 131 5.94 and ankle reconstruction [53]. Morrison et al. +e instep of the foot as a 47 Fascicutaneous island and as a free flap for heel 1983 1986 106 157 104 4.72 defects [54]. 48 Almeida et al. Reverse-flow island sural flap [55]. 2002 2007, 2008 104 186 114 8 Heller and Levin. Lower extremity microsurgical 49 2001 2009 102 169 65 7.28 reconstruction [56]. Yilmaz et al. +e distally based superficial sural artery 50 1998 2006 101 181 140 5.94 island flap: clinical experiences and modifications [57]. Web of Science (Wos); Google Scholar (GS); citation number (CN); mean citation (MC); top year: year with the most citations. Surgery Research and Practice 5 Table 2: Authors with multiple articles as the first author. Authors Number of articles Taylor 3 McCraw 2 18% Masquelet 2 Mathes 2 May 2 6% Serafin 2 54% Yazar 2 Total 15 22% Table 3: List of countries of publication. Countries Number of articles USA 22 Flaps and anatomy Quality of life and Australia 6 function Japan 3 Osteomyelitis and Clinical studies China 1 timing Taiwan 4 Figure 1: Categories of articles. France 2 England 2 Switzerland 1 tissue and bone defect separately or not. Seven (7) studies Germany 1 investigating this issue appear in the 50 most cited articles Colombia 1 Sweden 1 for lower limb reconstructions. +e use of muscle flap and Turkey 1 free flap transfer not only gave reconstructive surgeons Portugal 1 the possibility to carry these procedures in one step but Yugoslavia 1 also the possibility to close wounds that previously would Spain 1 have required an amputation. Taking into consideration Canada 1 Gustilo’s classification [61] for open fractures, a new Brazil 1 approach was then adopted. Byrd et al. [16, 21] were the Total 50 pioneers to advocate the use of external osseous fixation and definitive early wound coverage (within the first 5 days of injury) for tibial shaft fractures. Yaremchuk et al. Table 4: List of journals. [22] corroborated these results in a long-term study. But the article written by Godina [10] had the most impact in Journal name Number this area. +ough its findings have been disputed because Plastic and Reconstructive Surgery 37 of the comparison groups used and the associated injuries Journal of Plastic Reconstructive and Aesthetic Surgery that could delay the intervention and therefore the sta- American Journal of Bone and Joint Surgery 4 tistical analysis, he is most often considered as the father of British Journal of Bone and Joint surgery 1 early wound coverage and the initiator of the collaboration Scandinavian Journal of Plastic Surgery 1 between plastic surgeons and orthopaedic surgeons for the Journal of Trauma Injury Infection and Critical care 1 treatment of open fractures. Fischer et al. [40] in their +e New England Journal of Medicine 1 article advocated that bone grafting should take place after Total 50 complete soft tissue healing, but immediate intramedullary nailing had a lower risk of infection compared to delayed. of a muscle flap for the treatment of chronic osteomyelitis. It Gopal et al. [18] went further by showing that immediate is also a clear example of how authors do not always receive soft tissue reconstruction with internal bone fixation the recognition they deserve. +e article by Mathes re- (<72 hours) was not only feasible but also caused less garding the use of muscle flap in the treatment of infection complications even for fractures with extensive tissue loss [13], published 26 years later, is most often cited, and the use (grades IIIb and IIIc). More recently, reconstructions of this technique is often attributed to Ger [36] who also techniques have been modified by the arrival of new tech- described the role of muscle flaps in the treatment and nologies such as the vacuum-assisted closure device (VAC) prevention of chronic osteomyelitis. and skin substitutes such as Integra which has allowed closure An important factor in the prevention of infection in of wounds without the need for the complex reconstructive lower extremity wounds is to find the appropriate timing. procedure. DeFranzo et al. [15]. were the first to report a An important question is whether reconstruction should considerable cohort of patients treated with VAC therapy for be early versus delayed and whether to reconstruct soft closure of lower extremity wounds. 6 Surgery Research and Practice Table 5: Comparison of the 10 most cited articles ranked with different search engines (WoS, GS, and Scopus). Rank WoS GS Scopus Masquelet et al. Skin island flaps supplied Taylor et al. +e free vascularized bone Taylor et al. +e free vascularized bone by the vascular axis of the sensitive 1 graft: a clinical extension of microvascular graft: a clinical extension of microvascular superficial nerves: anatomic study and techniques [8]. techniques [8]. clinical experience in the leg [9]. Masquelet et al. Skin island flaps supplied Godina. Early microsurgical by the vascular axis of the sensitive Taylor et al. +e free vascularized bone 2 reconstruction of complex trauma of the superficial nerves: anatomic study and graft: a clinical extension of microvascular. extremities [10]. clinical experience in the leg [9]. Masquelet et al. Skin island flaps supplied Godina Early microsurgical Godina. Early microsurgical by the vascular axis of the sensitive 3 reconstruction of complex trauma of the reconstruction of complex trauma of the superficial nerves: anatomic study and extremities [10]. extremities [10]. clinical experience in the leg. Daniel and Taylor. Distant transfer of an Ponten. ´ +e fasciocutaneous flap: its use in Ponten. ´ +e fasciocutaneous flap: its use in 4 island flap by microvascular anastomoses: soft tissue defects of the lower leg [12]. soft tissue defects of the lower leg [12]. a clinical technique [11]. Daniel and Taylor. Distant transfer of an Daniel and Taylor. Distant transfer of an Ponten. +e fasciocutaneous flap: its use in 5 island flap by microvascular anastomoses: island flap by microvascular anastomoses: soft tissue defects of the lower leg [12]. a clinical technique [11]. a clinical technique [11]. Mathes. Use of the muscle flap in chronic DeFranzo et al. +e use of vacuum-assisted Mathes. Use of the muscle flap in chronic 6 osteomyelitis: experimental and clinical closure therapy for the treatment of lower- osteomyelitis: experimental and clinical correlation [13]. extremity wounds with exposed bone [15]. correlation [13]. Wei et al. Fibular osteoseptocutaneous Mathes. Use of the muscle flap in chronic Wei et al. Fibular osteoseptocutaneous 7 flap: anatomic study and clinical osteomyelitis: experimental and clinical flap: anatomic study and clinical application [14]. correlation [13]. application [14]. DeFranzo et al. +e use of vacuum-assisted Wei et al.. Fibular osteoseptocutaneous DeFranzo et al. +e use of vacuum-assisted 8 closure therapy for the treatment of lower- flap: anatomic study and clinical closure therapy for the treatment of lower- extremity wounds with exposed bone [15]. application [14]. extremity wounds with exposed bone [15]. Byrd et al. Management of open tibial Byrd et al. Management of open tibial Byrd et al. Management of open tibial fractures [16]. fractures [16]. fractures [16]. Khouri and Shaw. Reconstruction of the Khouri and Shaw. Reconstruction of the Khouri and Shaw. Reconstruction of the lower extremity with microvascular free lower extremity with microvascular free lower extremity with microvascular free flaps: a 10-year experience with 304 flaps: a 10-year experience with 304 flaps: a 10-year experience with 304 consecutive cases [17]. consecutive cases [17]. consecutive cases [17]. Web of Science (Wos); Google Scholar (GS). Table 6: Ranking according to the mean citation number. Rank Author and title Mean citation Masquelet et al. Skin island flaps supplied by the 1 vascular axis of the sensitive superficial nerves: 23.04 anatomic study and clinical experience in the leg [9]. Taylor et al. +e free vascularized bone graft: a clinical 2 20.72 extension of microvascular [8]. Godina. Early microsurgical reconstruction of 3 19.06 complex trauma of the extremities [10]. DeFranzo et al. +e use of vacuum-assisted closure 4 therapy for the treatment of lower-extremity wounds 17.78 with exposed bone [15]. Yazar et al. Outcome comparison between free muscle and free fasciocutaneous flaps for 5 17.33 reconstruction of distal third and ankle traumatic open tibial fractures [26]. Parrett et al. Lower extremity trauma: trends in the 6 management of soft-tissue reconstruction of open 15.44 tibia-fibula fractures [35]. Attinger et al. Angiosomes of the foot and ankle and 7 13.67 clinical implications [45]. Yazar et al. One-stage reconstruction of composite 8 bone and soft-tissue defects in traumatic lower 13.54 extremities [30]. Surgery Research and Practice 7 Table 6: Continued. Rank Author and title Mean citation Gopal et al. Fix and flap: the radical orthopaedic and 9 plastic treatment of severe open fractures of the tibia 13.27 [18]. Ponten. ´ +e fasciocutaneous flap: its use in soft tissue 10 12.73 defects of the lower leg [12]. Baumeister et al. A realistic complication analysis of 11 70 sural artery flaps in a multimorbid patient group 10.67 [41]. Mathes et al. Use of the muscle flap in chronic 12 osteomyelitis: experimental and clinical correlation 10.54 [58]. Taylor et al. Angiosomes of the leg: anatomic study 13 9.59 and clinical implications [23]. Hasegawa et al. +e distally based superficial sural 14 9.33 artery flap [19]. Wei et al. Fibula osteoseptocutaneous flap for 15 8.83 reconstruction of composite mandibular defects [14]. Khouri and Shaw. Reconstruction of the lower 16 extremity with microvascular free flaps: a 10-year 8.81 experience with 304 consecutive cases [17]. Daniel and Taylor. Distant transfer of an island flap 17 by microvascular anastomoses: a clinical technique 8.42 [11]. 18 Almeida et al. Reverse-flow island sural flap [55]. 8.0 19 Byrd et al. Management of open tibial fractures [16]. 7.97 Heller and Levin Lower extremity microsurgical 20 7.28 reconstruction [56]. Cavadas et al. +e medial sural artery perforator free 21 7.2 flap [51]. Nakajima et al. Accompanying arteries of the lesser 22 saphenous vein and sural nerve: anatomic study and 7.0 its clinical applications [49]. Georgiadis et al. Open tibial fractures with severe 23 soft-tissue loss-limb salvage compared with below- 6.36 the-knee amputation [34]. Jeng and Wei. Distally based sural island flap for foot 24 5.94 and ankle reconstruction [53]. Yilmaz et al. +e distally based superficial sural artery 25 island flap: clinical experiences and modifications 5.94 [57]. Yaremchuk et al. Acute and definitive management of 26 traumatic osteocutaneous defects of the lower 5.93 extremity [22]. Francel et al. Microvascular soft-tissue transplantation for reconstruction of acute open tibial 27 5.83 fractures: timing of coverage and long-term functional results [38]. Fischer et al. +e timing of flap coverage, bone- grafting, and intramedullary nailing in patients who 28 5.5 have a fracture of the tibial shaft with extensive soft- tissue injury [40]. Amarante et al. A new distally based fasciocutaneous 29 5.20 flap of the leg [28]. Anthony et al. +e muscle flap in the treatment of 30 chronic lower extremity osteomyelitis: results in 5.08 patients over 5 years after treatment [46]. May et al. Free microvascular muscle flaps with skin 31 graft reconstruction of extensive defects of the 5.07 foot—a clinical and gait analysis study [27]. 8 Surgery Research and Practice Table 6: Continued. Rank Author and title Mean citation Byrd et al. +e management of open tibial fractures 32 with associated soft-tissue loss: external pin fixation 5.06 with early flap coverage [21]. Carriquiry et al. An anatomic study of the 33 5.0 septocutaneous vessels [29]. 34 Masquelet et al. +e lateral supramalleolar flap [37]. 4.96 May et al. Microvascular transfer of free tissue for 35 closure of bone wounds of the distal lower extremity 4.88 [25]. Taylor and Pan. Angiosomes of the leg: anatomic 36 4.88 study and clinical implications [23]. Morrison et al. +e instep of the foot as a 37 fasciocutaneous island and as a free flap for heel 4.72 defects [59]. Donski and Fogdestam. Distally based 38 fasciocutaneous flap from the sural region: a 4.62 preliminary report [31]. Yoshimura et al. Peroneal flap for reconstruction in 39 4.52 the extremity [33]. O’Brien et al. Successful transfer of a large island flap 40 from the groin to the foot by microvascular 4.28 anastomoses [20]. Wee. Reconstruction of the lower leg and foot with 41 the reverse-pedicled anterior tibial flap: preliminary 4.24 report of a new fasciocutaneous flap [44]. Haertsch. +e blood supply to the skin of the leg: a 42 3.68 post-mortem [43]. McCraw et al. +e dorsalis pedis arterialized flap: a 43 3.65 clinical study [32]. Ger. Muscle transposition for treatment and 44 prevention of chronic posttraumatic osteomyelitis of 3.53 the tibia [36]. Serafin et al. Reconstruction of the lower extremity 45 with vascularized composite tissue: improved tissue 3.46 survival and specific indications [47]. Serafin et al. Comparison of free flaps with pedicled 46 3.31 flaps for coverage of defects of the leg or foot [42]. Buncke et al. Free osteocutaneous flap from a rib to 47 3.18 the tibia [48]. McCraw et al. Versatile gastrocnemius myocutaneous 48 3.11 flap [50]. Orticochea. +e musculo-cutaneous flap method: an 49 immediate and heroic substitute for the method of 3.09 delay [39]. Starks. +e use of pedicled muscle flaps in the surgical 50 treatment of chronic osteomyelitis resulting from 1.54 compound fractures [52]. 4.2. Anatomical Studies and New Flaps. As more flaps are 4.2.1. Musculocutaneous Flaps. +e article written in 1972 being designed, the anatomical description behind these new by Orticochea [39] describing a musculocutaneous flap surgical techniques is more and more precise. +e oldest allowed a way to have immediate wound coverage without anatomical study for the lower extremity in this review was the useful delay technique. It assured a good blood supply performed by Haertsch in 1981 [43] describing the cuta- and a viable flap without the need for microvascular neous vessels of the legs. It was followed shortly after by the anastomoses. It also paved the way for the description of description of septocutaneous vessels by Carriquiry et al. in further musculocutaneous flap to be used for reconstruction. 1985 [29] and the introduction of the notion of angiosomes +is was achieved with the gastrocnemius myocutaneous by Taylor and Pan [23, 62] that opened the doors to a flap described by McCraw et al. [50] in 1976 and the medial multitude of new flap possibilities. gastrocnemius flap in 1978 by Feldman et al. [63]. +ese flaps Surgery Research and Practice 9 –5 1980 1990 2000 2010 1995 2000 2005 2010 2015 Years Years (a) (b) Figure 2: Example of citation patterns. were described as an attempt to find a local alternative for superficial nerves [9],” written in 1992, has the most citations coverage of wounds of the lower thigh and below this level. It per year. +ey introduced the concept of neuroskin flaps, provided another option to the then over used cross leg flap and their findings allowed the description of many new flaps and the growing field of microsurgery for free flap transfer. based on arteries accompanying the sural, saphenous, and peroneal nerves. It allowed sparing of the main underlying With its long arc of rotation, the medial gastrocnemius flap is still widely used for reconstruction of the knee area. arteries while providing coverage for distal wounds such as with the distally based superficial sural artery flap [19]. Based on this study and previous anatomical description, Nakajima 4.2.2. Free Flap Transfer. 2 articles had a major impact in et al. then described flaps based on arteries accompanying this area for the reconstruction of lower extremity. Both the lesser saphenous vein [65]. Daniel and Taylor [11] and O’Brien et al. [20] described in 1973 the feasibility of the transfer of an island flap from a 4.2.5. Soft Tissue Reconstruction of the Foot Area. +e lack of distant location for coverage of wounds in the lower ex- soft tissue associated with the anatomy of the foot makes tremity. Two years later in 1975, Taylor et al. described the reconstruction of the foot even more challenging. Re- first free vascularized bone graft for osseous reconstruction construction can be obtained with a wide variety of free flaps using a harvested fibula [8]. Buncke et al. went on in 1977 to or locoregional flaps, such as with the distally based su- transfer an island of skin with the underlying bone to re- perficial sural artery flap or the lateral supramalleolar flap construct a tibia [48]. +ese 4 pioneer studies paved the way which are in the list of most cited articles. +e dorsalis for further work concerning free bone transfer and osteo- arterialized flap described by McCraw in 1975 [32] is the septocutaneous flap (Wei et al. [64], Yoshimura et al. [33].) only local flap for dorsal foot resurfacing that has been highly cited. +e reason might be for its role in the reconstruction 4.2.3. Fasciocutaneous Flap. +e fasciocutaneous flap was of heel defects, and the fact that it also allowed the de- introduced by Ponten ´ in 1981 [12]. It gave reconstructive scription of the dorsalis pedis free flap which is a valuable surgeons yet another mean for wound coverage in the lower neurovascular free flap in areas where thin skin is needed extremity. It also gave the alternative to spare the muscle and (i.e., hand reconstruction). Nevertheless, one limitation with have more versatility for wound coverage. Ponten showed this flap is the potential donor site complications. that flaps could be vascularized through the fascia, allowing coverage from the knee down to the foot with the possibility 4.3. Evidence-Based Medicine. A large proportion of highly to harvest larger flaps with no need for ratio consideration. cited articles are not actually new flaps description, but they Amarante et al. [28], Donski and Fogdestam [31], and Wee bring the clinical evidence of these previously described [44] are amongst the most cited authors for their contri- flaps. It is critical for reconstructive surgeons to know the bution to the coverage of the distal lower limb wounds with outcome of different techniques on a large scale of patients their fasciocutaneous flap techniques. or to have comparison data of various techniques. +ese articles will most likely remain highly cited until larger series or more accurate ones are produced 4.2.4. Neuroskin Island Flaps. Masquelet et al.’s article “Skin island flaps supplied by the vascular axis of the sensitive [17, 26, 33, 35, 41, 42, 47, 56]. Citations Citations 10 Surgery Research and Practice to predict citation patterns [73, 74], but predicting citation 4.4. Quality of Life and Functional Results after Reconstruction. Lower extremity reconstruction is not only complex because numbers still remain challenging. Most highly cited articles were published in PRS which is the osseous structure has to be properly aligned and covered with soft tissue. +e goal of the reconstruction is also to currently the plastic surgery journal with the highest impact restore the functionality. A few studies have looked spe- factor. Even though authors aim for a high impact factor cifically at the quality of life, the patient’s satisfaction, and journal when submitting an article, they have to keep in the functional results post-reconstruction. In their study, mind that it is a biased number. A more reliable way to May et al. [27] were able to address the role of cutaneous identify the impact of an article is by observing how it is cited sensibility in successful long-term reconstruction of weight over time by other authors. With effective search engines such as Medline and Google Scholar and the possibility of bearing surfaces of the foot with a gait analysis, an issue that had not been previously solved. Francel et al. [38] in their open access publications, if an article brings an important contribution to its field, it will become highly cited over time. classical article also looked at the functional outcome post- reconstruction but in relation to the quality of life of pa- Authors should not focus on being published in prestigious journals but rather evaluate their contribution by their tients. +is study helped reconstructive surgeons realize that a traumatic limb should not always be salvaged. More re- number of citations, which is now mentioned in platforms cently, studies from the LEAP group (lower extremity as- such as ResearchGate. sessment project) have also produced data that are redefining reconstructive surgery by establishing evidence- 5. Conclusion based criteria on when to salvage a traumatic extremity. Flap designs and reconstructive techniques of the lower limb Although these studies bring insights into the field, they do have been influenced by a wide variety of articles. Most not specifically address the subject set up in this article and highly cited articles have been anatomical studies allowing were therefore not included. the design of new flaps. Only a small portion of articles are +ese are not the only interesting studies that we were focusing on the effect of these procedures on the quality of not able to include is this classical citation paper. Another life of patients. Furthermore, the timing of these procedures highly referred article is the one written by Gustilo and has also been taken into consideration. Clinical studies have Anderson [61], for the classification of open fractures. then been put in place to validate these results. Clinician and Although it is cited in a vast majority of papers dealing with researchers alike need also to focus on this neglected area of reconstructive surgery of the lower limb, its topic is too research and follow the trend started by our predecessors diverse. Other articles simply did not have sufficient ci- towards a minimally invasive and safe surgery with the best tations to be listed in this article but will probably be in a functional results for our patients without focusing on the near future. Such is the case with propeller perforator flaps. journal of publication. +ey have gained approval in their use for lower limb reconstruction because of their low donor site morbidity [66]. Conflicts of Interest Citation do not always give an author deserved recog- +e authors declare that they have no conflicts of interest. nition as many factors can cause an original article and an author to be incorrectly cited such as the language of Acknowledgments publication and the access to the article [67–69]. Likewise, breakthrough techniques that become common knowledge +e authors would like to thank Dr. Lystra B. Wilson stops being cited [70]. Also, some authors can be overcited Celestine for her input and thorough review. for these same reasons or because of self-citations. We did not evaluate all these multiple limitations in- References herent to such study. To counteract the possible time bias, we calculated the mean citation per year by including all years [1] P. O. Larsen and M. Von Ins, “+e rate of growth in scientific since the articles’ first publication. Loonen et al. 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A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity

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Copyright © 2019 Zacharia Mbaidjol et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Surgery Research and Practice Volume 2019, Article ID 3068028, 12 pages https://doi.org/10.1155/2019/3068028 Review Article A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity 1 2 3 Zacharia Mbaidjol , Jens Rothenberger, and Rajesh Chetany Plastic and Reconstructive Surgery, Queen Victoria Hospital, East Grinstead, West Sussex RH19 3DZ, UK BG Unfallklink an der Universita¨t Tu¨bingen, Klinik fu¨r Hand, Plastische, Rekonstruktive und Verbrennungschirurgie, Tubingen, Germany FMI Spital Interlaken, Weissenaustrasse 27, 3800 Interlaken, Switzerland Correspondence should be addressed to Zacharia Mbaidjol; zahqaria@gmail.com Received 7 August 2018; Revised 13 December 2018; Accepted 27 December 2018; Published 28 January 2019 Academic Editor: Giuseppe Marulli Copyright © 2019 Zacharia Mbaidjol et al. +is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Lower extremity reconstruction has always been a challenge. Some of the published articles had a major impact on the field but are often not considered as classics because they have fewer citations. We therefore conducted a scientometric analysis of the most cited articles with a focus solely on the lower limb. Methods. A search was conducted on Medline, the Web of Science database, Google Scholar, and Scopus identifying articles relevant to reconstructive surgery of the lower limb. All journals were included with no time frames. Articles relating solely to orthopedics or vascular reconstruction were excluded. +e number of citations obtained were then plotted and compared between the different search engines. +e mean citation number was calculated by taking into consideration the total number of years since the article’s first year of publication. Articles were then ranked and classified according to their authors, their years of publications, and their countries. +ey were furthermore categorized and analyzed. Results. Highly cited articles were easily retrieved with Google Scholar, mostly published in Plastic and Reconstructive Surgery (n � 37) and were mainly authored by American Medical Centers (n � 22). Fifty-four percent (54%) of these classic articles discussed the design of new flaps or were anatomical studies. Conclusions. We were not able to find a correlation between the year of citation and the number of citations. +e citation pattern of a paper cannot be predicted, but a majority of highly cited article allowed the design of new reconstructive techniques. number of articles published by that journal in the same 1. Introduction two years [2]. Journals with the highest impact factors are +ere are over 24000 peer-reviewed journals [1] and more associated with quality and prestige [3], and the articles than 237 medical disciplines. To find articles that have high they publish tend to be more cited. +e impact factor relative importance to the research topic is a daunting task. therefore remains high in these journals because of the Garfield in response to this challenge devised the impact well-known 80/20 rule which results in 20% of the articles factor in 1960 [2]. It was intended to serve as a way to help accounting for 80% of the citations [2]. Breakthrough scientists browse with more ease and effectiveness through articles can have over 300.000 articles. +is lead to the term this magnitude of journals by identifying articles most often “Citations classic articles” introduced in 1977 by Eugene cited and by proxy more relevant. Garfield, selecting some of the most cited papers ever published in science. +e impact of an article is mostly observed the fol- lowing 2 years after its publication. +e impact factor of a In the field of reconstructive surgery, all previously journal is defined as the number of citations a journal has written citation articles limited their search criteria to main received in that current year to the number of published plastic surgery journals and either encompassed the whole articles within the two previous years, divided by the field of plastic surgery or a specific branch [4–7]. 2 Surgery Research and Practice Which are the 50 most cited articles in regard to re- the first author. Table 2 shows a list of 6 other authors with construction of the lower limb? +e aim of these articles is to multiple entries (Table 2). acknowledge the most cited articles referring to lower ex- Articles were most often written by American medical tremity reconstruction because of the challenging nature of centers (n � 22) (Table 3) and mostly published in PRS these procedures. +is article gives an overview of how most (n � 37); however, 17 countries were represented in 7 procedures and techniques now in place came into existence different peer-reviewed journals (Table 4). Of note, there and the different techniques that came to be before being was an article written by May et al. [25], and it is the only replaced by another in order to overcome the limitations of article published in a nonsurgical journal. All together, the previous technique. these “50 classics” have been cited 9599 times according to the WoS, 15536 times according to GS, and 9052 times in Scopus. +e articles fall broadly into 4 different categories: 2. Methods anatomical studies and new flaps description; the timing A search was conducted on Medline, the Web of Science for reconstruction and the prevention of osteomyelitis; the database (WoS), Google Scholar (GS), and Scopus identifying quality of life and functional results after reconstruction, articles relevant to reconstructive surgery of the lower limb. and finally clinical evidence studies (Figure 1). +e most All journals were included with no time frame. We used recent articles were published in 2006 [26, 35, 45] and the specific thesaurus (Mesh Terms) terms and keywords as oldest, 60 years earlier [52]. Within the 3 databases, the follows: “lower extremity,” “lower limb,” “legs,” “re- authors remain almost the same (Table 5). When using the construction,” “flaps,” “plastic surgery,” and “microsurgery.” mean citation number to sort the articles using the WoS On GS, an advanced search was performed with a combi- database, the article written by Masquelet et al. [9] in 1992 nation of our keywords as exact phrases. We excluded in a is the most cited article, while the 2 oldest articles are at the first step duplicate articles among the databases, using bottom of the list (Table 6). Highly cited articles tend to EndNote (Endnote X8.2, Clarivate analytics, Philadelphia, remain highly cited, but the number of citations did not PA, USA). In a second step, we went through all the titles and seem to be predictable (Figures 2(a) and 2(b)). abstracts. All articles that did not include our important terms and keywords on the abstract and titles were excluded. We 4. Discussion also did not consider those focusing on the lower extremity as a donor site for reconstruction of other parts of the body and +e reconstruction and the coverage of wounds of the lower those relating solely to orthopedics or vascular reconstruction. extremity is a tedious and challenging experience for +e search result of each database was also used to retrieve surgeons involved. +e bony support of the lower ex- articles in the other databases as a mean to evaluate con- tremity, often prone to infection and malunion following sistency of the results. trauma, has to be taken into consideration for its role in the In the final step, we noted the years with the most ci- gait biomechanics [12]. Furthermore, compared to the rest tations, the publishing journal, and the country of publication of the body, following loss of integument due to trauma, for each article and the mean citation number was calculated ulceration, or after skin resection, the lack of elasticity and by dividing the number of citations by the number of years poor vascularization of the surrounding skin associated since the article’s first year of publication. We furthermore with the lack of adipose tissue often prevents closure [19]. compared the differences in citation ranking for the 10 most +e reconstructive surgeon has to find a way to insure cited articles according to the three abovementioned main prompt coverage while replacing “like for like.” Multiple search engines. +ese top 10 articles were then further techniques have since been put into place to remedy this evaluated by plotting the number of citations per year everlasting challenge. according to each year since their initial publication to see if a In order to find the 50 most cited papers, we cross- citation pattern existed. +ree authors extracted the data from referenced three search databases: the WoS, GS, and Scopus. the full-articles examined. Discrepancies between two re- +ese search tools were evaluated in an article written by viewers were resolved by discussion. A third author per- Bakkalasi et al. in 2006 [60] by comparing databases, and formed an independent search, and results were compared to findings indicated that they all returned unique materials verify accuracy. and no search engine was superior over another. By cross- referencing, the articles were found in the different data- bases, and we were able to obtain a 100% concordance for 3. Results the first 10 articles. +e most cited article entitled “+e free vascularized bone +e articles found that, within the “most cited articles” graft: a clinical extension of microvascular techniques [8]” was list, all had a major impact in the evolution of reconstructive published in plastic and reconstructive surgery (PRS) in 1975 surgery of the extremity: and has been cited 829 times according to the WoS database. th +e 50 most cited article “+e instep of the foot as a fas- ciocutaneous island and as a free flap for heel defects” was 4.1. Muscle Flaps in the Treatment and Prevention of Osteo- referenced 106 times also according to the WoS (Table 1). myelitis and the Timing of Surgery. +e oldest article in this +ese 2 articles were both published in PRS 6 years apart. classic citation analysis dates back from 1946 and was Taylor is the most cited author with three (3) articles listing as written by Starks [52]. +is is the first description of the use Surgery Research and Practice 3 Table 1: Ranking according to WoS, GS, Scopus, and years with the most citations. Rank Author and title Year Top year CN WoS CN GS CN Scopus MC WoS Taylor et al. +e free vascularized bone graft: a clinical 1 1975 2013 829 1263 760 20.72 extension of microvascular techniques [8]. Masquelet et al. Skin island flaps supplied by the 2 vascular axis of the sensitive superficial nerves: 1992 2011 530 1448 411 23.04 anatomic study and clinical experience in the leg [9]. Godina. Early microsurgical reconstruction of 3 1986 2007 553 1016 575 19.06 complex trauma of the extremities [10]. Daniel and Taylor. Distant transfer of an island flap by 4 1973 1979 438 652 352 8.42 microvascular anastomoses: a clinical technique [11]. Ponten. +e fasciocutaneous flap: its use in soft tissue 5 1981 1990 433 729 447 12.73 defects of the lower leg [12]. Mathes. Use of the muscle flap in chronic osteomyelitis: 6 1982 1996 348 451 314 10.54 experimental and clinical correlation [13]. Wei et al. Fibular osteoseptocutaneous flap: anatomic 7 1986 2010 256 345 276 8.83 study and clinical application [14]. DeFranzo et al. +e use of vacuum-assisted closure 8 therapy for the treatment of lower-extremity wounds 2001 2006 249 506 272 17.78 with exposed bone [15]. 9 Byrd et al. Management of open tibial fractures [16]. 1985 1999, 2008 239 390 225 7.97 Khouri and Shaw. Reconstruction of the lower 10 extremity with microvascular free flaps: a 10-year 1989 1995 229 289 223 8.81 experience with 304 consecutive cases [17]. Gopal et al. Fix and flap: the radical orthopaedic and 11 plastic treatment of severe open fractures of the tibia 2000 2014 199 380 227 13.27 [18]. Hasegawa et al. +e distally based superficial sural 12 1994 2008 196 378 229 9.33 artery flap [19]. O’Brien et al. Successful transfer of a large island flap 13 from the groin to the foot by microvascular 1973 1976 180 222 141 4.28 anastomoses [20]. Byrd et al. +e management of open tibial fractures 14 with associated soft-tissue loss: external pin fixation 1981 1997 172 256 166 5.06 with early flap coverage [21]. Yaremchuk et al. Acute and definitive management of 15 traumatic osteocutaneous defects of the lower 1987 2010 166 256 169 5.93 extremity [22]. Taylor and Pan. Angiosomes of the leg: anatomic 16 1998 2013 163 298 122 9.59 study and clinical implications [23]. Taylor and Watson. One-stage repair of compound 17 leg defects with free, revascularized flaps of groin skin 1982 1989 161 175 119 4.88 and iliac bone [24]. May et al. Microvascular transfer of free tissue for closure 18 1982 1989 161 175 119 4.88 of bone wounds of the distal lower extremity [25]. Yazar et al. Outcome comparison between free muscle and free fasciocutaneous flaps for 19 2006 2009, 2011 156 95 99 17.33 reconstruction of distal third and ankle traumatic open tibial fractures [26]. May et al. Free microvascular muscle flaps with skin 20 graft reconstruction of extensive defects of the 1985 1986 152 227 151 5.07 foot—a clinical and gait analysis study [27]. Amarante et al. A new distally based fasciocutaneous 21 1986 1990 151 200 157 5.20 flap of the leg [28]. Carriquiry et al. An anatomic study of the 22 1985 1990 150 218 144 5 septocutaneous vessels of the leg [29]. Yazar et al. One-stage reconstruction of composite 23 bone and soft-tissue defects in traumatic lower 2004 2010 149 216 140 13.54 extremities [30]. Donski and Fogdestam. Distally based 24 fasciocutaneous flap from the sural region: a 1983 1990 148 242 168 4.62 preliminary report [31]. McCraw et al. +e dorsalis pedis arterialized flap: a 25 1975 1979 146 258 140 3.65 clinical study [32]. 4 Surgery Research and Practice Table 1: Continued. Rank Author and title Year Top year CN WoS CN GS CN Scopus MC WoS Yoshimura et al. Peroneal flap for reconstruction in 26 1984 1990 140 176 142 4.52 the extremity [33]. Georgiadis et al. Open tibial fractures with severe 27 soft-tissue loss-limb salvage compared with below- 1993 1997 140 228 140 6.36 the-knee amputation [34] Parrett et al. Lower extremity trauma: trends in the 28 management of soft-tissue reconstruction of open 2006 2011, 2015 139 240 139 15.44 tibia-fibula fractures [35] Ger. Muscle transposition for treatment and 29 prevention of chronic posttraumatic osteomyelitis of 1977 1983 134 172 93 3.53 the tibia [36]. 30 Masquelet et al. +e lateral supramalleolar flap [37]. 1988 2001 134 246 145 4.96 Francel et al. Microvascular soft-tissue transplantation for reconstruction of acute open tibial 31 1992 2014 134 204 143 5.83 fractures: timing of coverage and long-term functional results [38]. Orticochea. +e musculo-cutaneous flap method: an 32 immediate and heroic substitute for the method of 1972 1983 133 178 97 3.09 delay [39]. Fischer et al. +e timing of flap coverage, bone- grafting, and intramedullary nailing in patients who 33 1991 2012 132 271 152 5.5 have a fracture of the tibial shaft with extensive soft- tissue injury [40]. Baumeister et al. A realistic complication analysis of 70 34 2003 2008 128 251 153 10.67 sural artery flaps in a multimorbid patient group [41]. Serafin et al. Comparison of free flaps with pedicled 35 1977 1979 126 174 114 3.31 flaps for coverage of defects of the leg or foot [42]. Haertsch. +e blood supply to the skin of the leg: a 36 1981 1986 125 216 109 3.68 post-mortem investigation [43]. Wee. Reconstruction of the lower leg and foot with 37 the reverse-pedicled anterior tibial flap: preliminary 1986 1990 123 163 116 4.24 report of a new fasciocutaneous flap [44]. Attinger et al. Angiosomes of the foot and ankle and 38 clinical implications for limb salvage: reconstruction, 2006 2013 123 272 162 13.67 incisions and revascularization [45] Anthony et al. +e muscle flap in the treatment of 39 chronic lower extremity osteomyelitis: results in 1991 2004 122 173 125 5.08 patients over 5 years after treatment [46] Serafin et al. Reconstruction of the lower extremity 40 with vascularized composite tissue: improved tissue 1980 1989 121 146 100 3.46 survival and specific indications [47]. Buncke et al. Free osteocutaneous flap from a rib to 41 1977 1982 121 166 70 3.18 the tibia [48]. Nakajima et al. Accompanying arteries of the lesser 42 saphenous vein and sural nerve: anatomic study and 1999 2011 119 230 129 7.0 its clinical applications [49]. McCraw et al. Versatile gastrocnemius myocutaneous 43 1978 1984 115 168 91 3.11 flap [50] Cavadas et al. +e medial sural artery perforator free 44 2001 2007 108 173 57 7.2 flap [51] Starks +e use of pedicled muscle flaps in the surgical 45 treatment of chronic osteomyelitis resulting from 1946 1993 108 126 75 1.54 compound fractures [52]. Jeng and Wei. Distally based sural island flap for foot 46 1997 2008 107 185 131 5.94 and ankle reconstruction [53]. Morrison et al. +e instep of the foot as a 47 Fascicutaneous island and as a free flap for heel 1983 1986 106 157 104 4.72 defects [54]. 48 Almeida et al. Reverse-flow island sural flap [55]. 2002 2007, 2008 104 186 114 8 Heller and Levin. Lower extremity microsurgical 49 2001 2009 102 169 65 7.28 reconstruction [56]. Yilmaz et al. +e distally based superficial sural artery 50 1998 2006 101 181 140 5.94 island flap: clinical experiences and modifications [57]. Web of Science (Wos); Google Scholar (GS); citation number (CN); mean citation (MC); top year: year with the most citations. Surgery Research and Practice 5 Table 2: Authors with multiple articles as the first author. Authors Number of articles Taylor 3 McCraw 2 18% Masquelet 2 Mathes 2 May 2 6% Serafin 2 54% Yazar 2 Total 15 22% Table 3: List of countries of publication. Countries Number of articles USA 22 Flaps and anatomy Quality of life and Australia 6 function Japan 3 Osteomyelitis and Clinical studies China 1 timing Taiwan 4 Figure 1: Categories of articles. France 2 England 2 Switzerland 1 tissue and bone defect separately or not. Seven (7) studies Germany 1 investigating this issue appear in the 50 most cited articles Colombia 1 Sweden 1 for lower limb reconstructions. +e use of muscle flap and Turkey 1 free flap transfer not only gave reconstructive surgeons Portugal 1 the possibility to carry these procedures in one step but Yugoslavia 1 also the possibility to close wounds that previously would Spain 1 have required an amputation. Taking into consideration Canada 1 Gustilo’s classification [61] for open fractures, a new Brazil 1 approach was then adopted. Byrd et al. [16, 21] were the Total 50 pioneers to advocate the use of external osseous fixation and definitive early wound coverage (within the first 5 days of injury) for tibial shaft fractures. Yaremchuk et al. Table 4: List of journals. [22] corroborated these results in a long-term study. But the article written by Godina [10] had the most impact in Journal name Number this area. +ough its findings have been disputed because Plastic and Reconstructive Surgery 37 of the comparison groups used and the associated injuries Journal of Plastic Reconstructive and Aesthetic Surgery that could delay the intervention and therefore the sta- American Journal of Bone and Joint Surgery 4 tistical analysis, he is most often considered as the father of British Journal of Bone and Joint surgery 1 early wound coverage and the initiator of the collaboration Scandinavian Journal of Plastic Surgery 1 between plastic surgeons and orthopaedic surgeons for the Journal of Trauma Injury Infection and Critical care 1 treatment of open fractures. Fischer et al. [40] in their +e New England Journal of Medicine 1 article advocated that bone grafting should take place after Total 50 complete soft tissue healing, but immediate intramedullary nailing had a lower risk of infection compared to delayed. of a muscle flap for the treatment of chronic osteomyelitis. It Gopal et al. [18] went further by showing that immediate is also a clear example of how authors do not always receive soft tissue reconstruction with internal bone fixation the recognition they deserve. +e article by Mathes re- (<72 hours) was not only feasible but also caused less garding the use of muscle flap in the treatment of infection complications even for fractures with extensive tissue loss [13], published 26 years later, is most often cited, and the use (grades IIIb and IIIc). More recently, reconstructions of this technique is often attributed to Ger [36] who also techniques have been modified by the arrival of new tech- described the role of muscle flaps in the treatment and nologies such as the vacuum-assisted closure device (VAC) prevention of chronic osteomyelitis. and skin substitutes such as Integra which has allowed closure An important factor in the prevention of infection in of wounds without the need for the complex reconstructive lower extremity wounds is to find the appropriate timing. procedure. DeFranzo et al. [15]. were the first to report a An important question is whether reconstruction should considerable cohort of patients treated with VAC therapy for be early versus delayed and whether to reconstruct soft closure of lower extremity wounds. 6 Surgery Research and Practice Table 5: Comparison of the 10 most cited articles ranked with different search engines (WoS, GS, and Scopus). Rank WoS GS Scopus Masquelet et al. Skin island flaps supplied Taylor et al. +e free vascularized bone Taylor et al. +e free vascularized bone by the vascular axis of the sensitive 1 graft: a clinical extension of microvascular graft: a clinical extension of microvascular superficial nerves: anatomic study and techniques [8]. techniques [8]. clinical experience in the leg [9]. Masquelet et al. Skin island flaps supplied Godina. Early microsurgical by the vascular axis of the sensitive Taylor et al. +e free vascularized bone 2 reconstruction of complex trauma of the superficial nerves: anatomic study and graft: a clinical extension of microvascular. extremities [10]. clinical experience in the leg [9]. Masquelet et al. Skin island flaps supplied Godina Early microsurgical Godina. Early microsurgical by the vascular axis of the sensitive 3 reconstruction of complex trauma of the reconstruction of complex trauma of the superficial nerves: anatomic study and extremities [10]. extremities [10]. clinical experience in the leg. Daniel and Taylor. Distant transfer of an Ponten. ´ +e fasciocutaneous flap: its use in Ponten. ´ +e fasciocutaneous flap: its use in 4 island flap by microvascular anastomoses: soft tissue defects of the lower leg [12]. soft tissue defects of the lower leg [12]. a clinical technique [11]. Daniel and Taylor. Distant transfer of an Daniel and Taylor. Distant transfer of an Ponten. +e fasciocutaneous flap: its use in 5 island flap by microvascular anastomoses: island flap by microvascular anastomoses: soft tissue defects of the lower leg [12]. a clinical technique [11]. a clinical technique [11]. Mathes. Use of the muscle flap in chronic DeFranzo et al. +e use of vacuum-assisted Mathes. Use of the muscle flap in chronic 6 osteomyelitis: experimental and clinical closure therapy for the treatment of lower- osteomyelitis: experimental and clinical correlation [13]. extremity wounds with exposed bone [15]. correlation [13]. Wei et al. Fibular osteoseptocutaneous Mathes. Use of the muscle flap in chronic Wei et al. Fibular osteoseptocutaneous 7 flap: anatomic study and clinical osteomyelitis: experimental and clinical flap: anatomic study and clinical application [14]. correlation [13]. application [14]. DeFranzo et al. +e use of vacuum-assisted Wei et al.. Fibular osteoseptocutaneous DeFranzo et al. +e use of vacuum-assisted 8 closure therapy for the treatment of lower- flap: anatomic study and clinical closure therapy for the treatment of lower- extremity wounds with exposed bone [15]. application [14]. extremity wounds with exposed bone [15]. Byrd et al. Management of open tibial Byrd et al. Management of open tibial Byrd et al. Management of open tibial fractures [16]. fractures [16]. fractures [16]. Khouri and Shaw. Reconstruction of the Khouri and Shaw. Reconstruction of the Khouri and Shaw. Reconstruction of the lower extremity with microvascular free lower extremity with microvascular free lower extremity with microvascular free flaps: a 10-year experience with 304 flaps: a 10-year experience with 304 flaps: a 10-year experience with 304 consecutive cases [17]. consecutive cases [17]. consecutive cases [17]. Web of Science (Wos); Google Scholar (GS). Table 6: Ranking according to the mean citation number. Rank Author and title Mean citation Masquelet et al. Skin island flaps supplied by the 1 vascular axis of the sensitive superficial nerves: 23.04 anatomic study and clinical experience in the leg [9]. Taylor et al. +e free vascularized bone graft: a clinical 2 20.72 extension of microvascular [8]. Godina. Early microsurgical reconstruction of 3 19.06 complex trauma of the extremities [10]. DeFranzo et al. +e use of vacuum-assisted closure 4 therapy for the treatment of lower-extremity wounds 17.78 with exposed bone [15]. Yazar et al. Outcome comparison between free muscle and free fasciocutaneous flaps for 5 17.33 reconstruction of distal third and ankle traumatic open tibial fractures [26]. Parrett et al. Lower extremity trauma: trends in the 6 management of soft-tissue reconstruction of open 15.44 tibia-fibula fractures [35]. Attinger et al. Angiosomes of the foot and ankle and 7 13.67 clinical implications [45]. Yazar et al. One-stage reconstruction of composite 8 bone and soft-tissue defects in traumatic lower 13.54 extremities [30]. Surgery Research and Practice 7 Table 6: Continued. Rank Author and title Mean citation Gopal et al. Fix and flap: the radical orthopaedic and 9 plastic treatment of severe open fractures of the tibia 13.27 [18]. Ponten. ´ +e fasciocutaneous flap: its use in soft tissue 10 12.73 defects of the lower leg [12]. Baumeister et al. A realistic complication analysis of 11 70 sural artery flaps in a multimorbid patient group 10.67 [41]. Mathes et al. Use of the muscle flap in chronic 12 osteomyelitis: experimental and clinical correlation 10.54 [58]. Taylor et al. Angiosomes of the leg: anatomic study 13 9.59 and clinical implications [23]. Hasegawa et al. +e distally based superficial sural 14 9.33 artery flap [19]. Wei et al. Fibula osteoseptocutaneous flap for 15 8.83 reconstruction of composite mandibular defects [14]. Khouri and Shaw. Reconstruction of the lower 16 extremity with microvascular free flaps: a 10-year 8.81 experience with 304 consecutive cases [17]. Daniel and Taylor. Distant transfer of an island flap 17 by microvascular anastomoses: a clinical technique 8.42 [11]. 18 Almeida et al. Reverse-flow island sural flap [55]. 8.0 19 Byrd et al. Management of open tibial fractures [16]. 7.97 Heller and Levin Lower extremity microsurgical 20 7.28 reconstruction [56]. Cavadas et al. +e medial sural artery perforator free 21 7.2 flap [51]. Nakajima et al. Accompanying arteries of the lesser 22 saphenous vein and sural nerve: anatomic study and 7.0 its clinical applications [49]. Georgiadis et al. Open tibial fractures with severe 23 soft-tissue loss-limb salvage compared with below- 6.36 the-knee amputation [34]. Jeng and Wei. Distally based sural island flap for foot 24 5.94 and ankle reconstruction [53]. Yilmaz et al. +e distally based superficial sural artery 25 island flap: clinical experiences and modifications 5.94 [57]. Yaremchuk et al. Acute and definitive management of 26 traumatic osteocutaneous defects of the lower 5.93 extremity [22]. Francel et al. Microvascular soft-tissue transplantation for reconstruction of acute open tibial 27 5.83 fractures: timing of coverage and long-term functional results [38]. Fischer et al. +e timing of flap coverage, bone- grafting, and intramedullary nailing in patients who 28 5.5 have a fracture of the tibial shaft with extensive soft- tissue injury [40]. Amarante et al. A new distally based fasciocutaneous 29 5.20 flap of the leg [28]. Anthony et al. +e muscle flap in the treatment of 30 chronic lower extremity osteomyelitis: results in 5.08 patients over 5 years after treatment [46]. May et al. Free microvascular muscle flaps with skin 31 graft reconstruction of extensive defects of the 5.07 foot—a clinical and gait analysis study [27]. 8 Surgery Research and Practice Table 6: Continued. Rank Author and title Mean citation Byrd et al. +e management of open tibial fractures 32 with associated soft-tissue loss: external pin fixation 5.06 with early flap coverage [21]. Carriquiry et al. An anatomic study of the 33 5.0 septocutaneous vessels [29]. 34 Masquelet et al. +e lateral supramalleolar flap [37]. 4.96 May et al. Microvascular transfer of free tissue for 35 closure of bone wounds of the distal lower extremity 4.88 [25]. Taylor and Pan. Angiosomes of the leg: anatomic 36 4.88 study and clinical implications [23]. Morrison et al. +e instep of the foot as a 37 fasciocutaneous island and as a free flap for heel 4.72 defects [59]. Donski and Fogdestam. Distally based 38 fasciocutaneous flap from the sural region: a 4.62 preliminary report [31]. Yoshimura et al. Peroneal flap for reconstruction in 39 4.52 the extremity [33]. O’Brien et al. Successful transfer of a large island flap 40 from the groin to the foot by microvascular 4.28 anastomoses [20]. Wee. Reconstruction of the lower leg and foot with 41 the reverse-pedicled anterior tibial flap: preliminary 4.24 report of a new fasciocutaneous flap [44]. Haertsch. +e blood supply to the skin of the leg: a 42 3.68 post-mortem [43]. McCraw et al. +e dorsalis pedis arterialized flap: a 43 3.65 clinical study [32]. Ger. Muscle transposition for treatment and 44 prevention of chronic posttraumatic osteomyelitis of 3.53 the tibia [36]. Serafin et al. Reconstruction of the lower extremity 45 with vascularized composite tissue: improved tissue 3.46 survival and specific indications [47]. Serafin et al. Comparison of free flaps with pedicled 46 3.31 flaps for coverage of defects of the leg or foot [42]. Buncke et al. Free osteocutaneous flap from a rib to 47 3.18 the tibia [48]. McCraw et al. Versatile gastrocnemius myocutaneous 48 3.11 flap [50]. Orticochea. +e musculo-cutaneous flap method: an 49 immediate and heroic substitute for the method of 3.09 delay [39]. Starks. +e use of pedicled muscle flaps in the surgical 50 treatment of chronic osteomyelitis resulting from 1.54 compound fractures [52]. 4.2. Anatomical Studies and New Flaps. As more flaps are 4.2.1. Musculocutaneous Flaps. +e article written in 1972 being designed, the anatomical description behind these new by Orticochea [39] describing a musculocutaneous flap surgical techniques is more and more precise. +e oldest allowed a way to have immediate wound coverage without anatomical study for the lower extremity in this review was the useful delay technique. It assured a good blood supply performed by Haertsch in 1981 [43] describing the cuta- and a viable flap without the need for microvascular neous vessels of the legs. It was followed shortly after by the anastomoses. It also paved the way for the description of description of septocutaneous vessels by Carriquiry et al. in further musculocutaneous flap to be used for reconstruction. 1985 [29] and the introduction of the notion of angiosomes +is was achieved with the gastrocnemius myocutaneous by Taylor and Pan [23, 62] that opened the doors to a flap described by McCraw et al. [50] in 1976 and the medial multitude of new flap possibilities. gastrocnemius flap in 1978 by Feldman et al. [63]. +ese flaps Surgery Research and Practice 9 –5 1980 1990 2000 2010 1995 2000 2005 2010 2015 Years Years (a) (b) Figure 2: Example of citation patterns. were described as an attempt to find a local alternative for superficial nerves [9],” written in 1992, has the most citations coverage of wounds of the lower thigh and below this level. It per year. +ey introduced the concept of neuroskin flaps, provided another option to the then over used cross leg flap and their findings allowed the description of many new flaps and the growing field of microsurgery for free flap transfer. based on arteries accompanying the sural, saphenous, and peroneal nerves. It allowed sparing of the main underlying With its long arc of rotation, the medial gastrocnemius flap is still widely used for reconstruction of the knee area. arteries while providing coverage for distal wounds such as with the distally based superficial sural artery flap [19]. Based on this study and previous anatomical description, Nakajima 4.2.2. Free Flap Transfer. 2 articles had a major impact in et al. then described flaps based on arteries accompanying this area for the reconstruction of lower extremity. Both the lesser saphenous vein [65]. Daniel and Taylor [11] and O’Brien et al. [20] described in 1973 the feasibility of the transfer of an island flap from a 4.2.5. Soft Tissue Reconstruction of the Foot Area. +e lack of distant location for coverage of wounds in the lower ex- soft tissue associated with the anatomy of the foot makes tremity. Two years later in 1975, Taylor et al. described the reconstruction of the foot even more challenging. Re- first free vascularized bone graft for osseous reconstruction construction can be obtained with a wide variety of free flaps using a harvested fibula [8]. Buncke et al. went on in 1977 to or locoregional flaps, such as with the distally based su- transfer an island of skin with the underlying bone to re- perficial sural artery flap or the lateral supramalleolar flap construct a tibia [48]. +ese 4 pioneer studies paved the way which are in the list of most cited articles. +e dorsalis for further work concerning free bone transfer and osteo- arterialized flap described by McCraw in 1975 [32] is the septocutaneous flap (Wei et al. [64], Yoshimura et al. [33].) only local flap for dorsal foot resurfacing that has been highly cited. +e reason might be for its role in the reconstruction 4.2.3. Fasciocutaneous Flap. +e fasciocutaneous flap was of heel defects, and the fact that it also allowed the de- introduced by Ponten ´ in 1981 [12]. It gave reconstructive scription of the dorsalis pedis free flap which is a valuable surgeons yet another mean for wound coverage in the lower neurovascular free flap in areas where thin skin is needed extremity. It also gave the alternative to spare the muscle and (i.e., hand reconstruction). Nevertheless, one limitation with have more versatility for wound coverage. Ponten showed this flap is the potential donor site complications. that flaps could be vascularized through the fascia, allowing coverage from the knee down to the foot with the possibility 4.3. Evidence-Based Medicine. A large proportion of highly to harvest larger flaps with no need for ratio consideration. cited articles are not actually new flaps description, but they Amarante et al. [28], Donski and Fogdestam [31], and Wee bring the clinical evidence of these previously described [44] are amongst the most cited authors for their contri- flaps. It is critical for reconstructive surgeons to know the bution to the coverage of the distal lower limb wounds with outcome of different techniques on a large scale of patients their fasciocutaneous flap techniques. or to have comparison data of various techniques. +ese articles will most likely remain highly cited until larger series or more accurate ones are produced 4.2.4. Neuroskin Island Flaps. Masquelet et al.’s article “Skin island flaps supplied by the vascular axis of the sensitive [17, 26, 33, 35, 41, 42, 47, 56]. Citations Citations 10 Surgery Research and Practice to predict citation patterns [73, 74], but predicting citation 4.4. Quality of Life and Functional Results after Reconstruction. Lower extremity reconstruction is not only complex because numbers still remain challenging. Most highly cited articles were published in PRS which is the osseous structure has to be properly aligned and covered with soft tissue. +e goal of the reconstruction is also to currently the plastic surgery journal with the highest impact restore the functionality. A few studies have looked spe- factor. Even though authors aim for a high impact factor cifically at the quality of life, the patient’s satisfaction, and journal when submitting an article, they have to keep in the functional results post-reconstruction. In their study, mind that it is a biased number. A more reliable way to May et al. [27] were able to address the role of cutaneous identify the impact of an article is by observing how it is cited sensibility in successful long-term reconstruction of weight over time by other authors. With effective search engines such as Medline and Google Scholar and the possibility of bearing surfaces of the foot with a gait analysis, an issue that had not been previously solved. Francel et al. [38] in their open access publications, if an article brings an important contribution to its field, it will become highly cited over time. classical article also looked at the functional outcome post- reconstruction but in relation to the quality of life of pa- Authors should not focus on being published in prestigious journals but rather evaluate their contribution by their tients. +is study helped reconstructive surgeons realize that a traumatic limb should not always be salvaged. More re- number of citations, which is now mentioned in platforms cently, studies from the LEAP group (lower extremity as- such as ResearchGate. sessment project) have also produced data that are redefining reconstructive surgery by establishing evidence- 5. Conclusion based criteria on when to salvage a traumatic extremity. Flap designs and reconstructive techniques of the lower limb Although these studies bring insights into the field, they do have been influenced by a wide variety of articles. Most not specifically address the subject set up in this article and highly cited articles have been anatomical studies allowing were therefore not included. the design of new flaps. Only a small portion of articles are +ese are not the only interesting studies that we were focusing on the effect of these procedures on the quality of not able to include is this classical citation paper. Another life of patients. Furthermore, the timing of these procedures highly referred article is the one written by Gustilo and has also been taken into consideration. Clinical studies have Anderson [61], for the classification of open fractures. then been put in place to validate these results. Clinician and Although it is cited in a vast majority of papers dealing with researchers alike need also to focus on this neglected area of reconstructive surgery of the lower limb, its topic is too research and follow the trend started by our predecessors diverse. Other articles simply did not have sufficient ci- towards a minimally invasive and safe surgery with the best tations to be listed in this article but will probably be in a functional results for our patients without focusing on the near future. Such is the case with propeller perforator flaps. journal of publication. +ey have gained approval in their use for lower limb reconstruction because of their low donor site morbidity [66]. Conflicts of Interest Citation do not always give an author deserved recog- +e authors declare that they have no conflicts of interest. nition as many factors can cause an original article and an author to be incorrectly cited such as the language of Acknowledgments publication and the access to the article [67–69]. Likewise, breakthrough techniques that become common knowledge +e authors would like to thank Dr. Lystra B. Wilson stops being cited [70]. Also, some authors can be overcited Celestine for her input and thorough review. for these same reasons or because of self-citations. We did not evaluate all these multiple limitations in- References herent to such study. To counteract the possible time bias, we calculated the mean citation per year by including all years [1] P. O. Larsen and M. Von Ins, “+e rate of growth in scientific since the articles’ first publication. Loonen et al. 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