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invasive direct anterior total hip arthroplasty. J Arthroplasty. 2006; 21(8):1206-8. 35 (8.8) NA 48 Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res. 2005; 441:115-24. 34 (8.5) I 49 Ropars M, Morandi X, Huten D, Thomazeau H, Berton E, Darnault P. Anatomical study of the lateral femoral cutaneous nerve with special reference to minimally invasive anterior approach for total hip replacement. Surg Radiol Anat. 2009; 31(3):199-204. 33 (3.3) NA 50 Rathod PA, Orishimo KF, Kremenic IJ, Deshmukh AJ, Rodriguez JA. Similar improvement in gait parameters following direct anterior & posterior approach total hip arthroplasty. J Arthroplasty. 2014; 29(6):1261-4. 31 (6.2) II C.M. Mikhail et al. / Arthroplasty Today 6 (2020) 190e195 193 The top 50 articles were published in 15 different journals. Journal of Arthroplasty was the most prolific journal on the topic of DAA hip arthroplasty with 15 publications (Table 3). This was followed by Clinical Orthopaedics and Related Research with 13 publications, and Orthopedic Clinics of North America ranked third with 6 publications. The 50 publications examined in this study originated from 14 different countries (Fig. 4). The top 2 most represented countries of origin were the United States (33) and Canada (4). Austria, Switzerland, and France tied for third with 3 studies each. Four of the top 50 studies listed multiple countries of origin. Discussion The frequency of citations for any individual article is a valuable measure of the overall impact of that article. Citation analysis is an objective metric for assessing the influence of a publication, and this methodology has been applied broadly in orthopaedics and other specialties [15,16,19]. A particular study may amass a high citation count for a number of reasons, including guidance of clinical practice, quality of the study, or the foundational nature of the work in a particular field. Our analysis revealed a notable trend toward more recent publication among the 50 most influential articles. The most common year of publication was 2009, and more than half of the included articles were published since 2010. This finding contrasts with other citation analysis studies in orthopaedics, which have found that older publications tend to have the greatest number of citations [24,27]. Although DAA hip arthroplasty has been used in clinical practice since the first half of the 20th century, this topic has just recently risen in prominence [9-11]. This likely explains the trend toward more recent studies among influential publications on this topic. In ascending order, the years 2016, 2017, and 2018 had the most total citations across all articles examined in this study. Interest in the topic of DAA hip arthroplasty appears to be increasing based on this positive trend in the total number of citations each year. Apart from publication year, total number of citations was influenced by several other characteristics. We found that the most common location of origin for highly cited studies was the United States (33), which is consistent with several previous studies of orthopaedics topics [20-22,24,28]. This does not come as a surprise, as the United States is the most prolific country in medical research by a significant margin [29]. The most common journals of publication were Journal of Arthroplasty and Clinical Orthopaedics and Related Research, publishing 15 papers and 13 papers, respectively. Both of these are consistently among the highest impact journals in orthopaedics, so it follows that influential articles should often come from these journals [30]. This study differed from prior citation analyses in orthopaedic literature, in which level III evidence was the most commonly represented level of evidence. Furthermore, this research included 32.4% (12/37) level I and II studies. Many prior citation analyses have found that levels IV and V are most common and have found a much smaller percentage of level I and II studies among highly cited papers [17,18,20,22,24,27,31]. This is particularly interesting when considered in conjunction with the recency of the most highly cited papers. It appears DAA hip arthroplasty may be enjoying influence from a recent wave of higher quality research compared with other topics in orthopaedics. One other factor that that should not be ignored in recognizing this pattern is that this study focuses on a single approach for a specific procedure, whereas other citation analyses tend to focus on broader topics. It may be useful for further Table 2 Articles classified by study type. Study type No. of articles Randomized controlled trial 5 Nonrandomized controlled trial 0 Cohort study 22 Case-control study 1 Case series 7 Case report 0 Review article 3 Descriptive 10 Cadaver 2 Figure 3. Total number of articles by level of evidence. Most citations included in the study were found to be level III and IV evidence based, with 5 level I and 7 level II articles included. Articles by Country of Origin* USA (33) Canada (4) Switzerland (4) Austria (4) France (3) Japan (1) Netherlands (1) Sweden (1) Iran (1) Germany (1) Australia (1) Israel (1) Belgium (1) Italy (1) Figure 4. 33 of the 50 articles identified were conducted in the United States of America, followed by Canada (4) and Switzerland (4), Austria (4), and France (3; each with 3 publications). *Totals 57 as a result of articles having multiple countries of
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