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Impact and publishing: your journals need you!

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The impact of a paper can be, and is, measured in many ways. This month in 360 we feature a paper from The Lancet which should be read by every orthopaedic surgeon involved in trauma care.1 This is potentially a game-changing article, a randomised control trial suggesting that one of the major “advances” in trauma care may in fact not be an advance at all. The authors conducted a technically and logistically challenging study, and randomised patients to either ATLS standard of care or immediate trauma CT scanning. It is a miraculous study with an interesting result.

Whole-body CT scanning trauma patients is no better than ATLS-directed imaging in experienced hands, yet it poses a significant radiation risk.

But who will read it? The paper is published in The Lancet, where only a handful of orthopaedic surgeons are regular subscribers or readers. Yet this journal has an impact factor of 45. So, on average, the paper will receive 45 citations in the qualifying two-year window which starts the year after publication.

However, I cannot help but think that it is probable that readers will stumble upon a paper such as this by chance during a PubMed search, come across its message in an instructional paper, or - much more likely - read it as a reference in a systematic review or instructional article several years later in a specialty journal. Perhaps most plausible of all, it will completely pass them by.

On the other hand, it seems much more likely that a casual reader will browse Su and Nan’s article on post-traumatic cubitus varus deformity in this month’s The Bone & Joint Journal (BJJ)2 or d’Heurle et al’s article on suprapatellar nailing in distal tibial fractures published in Journal of Orthopaedic Trauma.3 Both have simple take-home messages and are of importance to orthopaedic surgeons in their specialist fields, finding utility on occasion, but neither are what I would call ‘game-changing’.

So why, in an age of supraspecialism, are we publishing our most prestigious and game-changing papers in a journal not read by our peers? The answer, of course, lies in the grant funders, and the academic output appraisals (REF in the UK, but there are other systems). The impact factor itself is taken as a clear marker of the prestige of the journal and is linked to funding. However, there are other markers as well. Orthopaedics is a slow-moving field. The most cited paper in the field of orthopaedics is Bill Harris’ hip score4 which has 6371 citations on Google Scholar. Interestingly, of the 100 most cited articles in orthopaedics, only a handful have been published in general medical journals,5 the majority in the JBJS(Am) and BJJ. We want to publish where our papers will change practice and be read by our peers. So, even by the marker of ‘citations’, impact factor is clearly not the only factor.

How, therefore, in this increasingly competitive world with open access, and the beady eye of the REF exercise casting its shadow over academics, can we publish in our own specialty journal? Well, at the moment clearly the much higher impact journals such as the BMJ and The Lancet will continue to receive the best papers – there is money in it – however, I would urge you all to cite articles published in the premier orthopaedic journals wherever you publish. We are restricted in our ability to cite our own work and with gold standards of a ten- to 20-year follow-up, there is a limit to how quickly research turns around. Nonetheless, this is a self-perpetuating problem. Impact factor, by its very nature, is dynamic and rapidly changing. Next time you send a paper to a journal, whichever one it is, I would urge you to reference recent articles from the BJJ and other top tier orthopaedic journals – improving the impact factor of our community journals is essential in allowing the best research to be published where colleagues will read it. Dissemination in the correct way should be central to evidence-based medicine.


1 Sierink JC , TreskesK, EdwardsMJ, et al.; REACT-2 study group. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet2016;388:673-683.CrossrefPubMed Google Scholar

2 Su Y , NanG. Lateral closing isosceles triangular osteotomy for the treatment of a post-traumatic cubitus varus deformity in children. Bone Joint J2016;98-B:1521-1525.CrossrefPubMed Google Scholar

3 d’Heurle A , KazemiN, ConnellyC, et al.. Prospective randomized comparison of locked plates versus nonlocked plates for the treatment of high-energy pilon fractures. J Orthop Trauma2015;29:420-423.CrossrefPubMed Google Scholar

4 Harris WH . Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg [Am]1969;51-A:737755.PubMed Google Scholar

5 Lefaivre KA , ShadganB, O’BrienPJ. 100 most cited articles in orthopaedic surgery. Clin Orthop Relat Res2011;469:1487-1497.CrossrefPubMed Google Scholar