PubMed/Medline, ScienceDirect, Mendeley, Science.gov, and Google Scholar are major open databases containing free full-text archives. PubMed/Medline and ScienceDirect databases are focused on biomedical, medical, life sciences and health sciences literature. They are considered as the reference databases for studies of work-related musculoskeletal disorders. Mendeley is a free reference manager containing numerous references, particularly in the healthcare field. Science.gov provides access to millions of scientific research results from U.S. federal agencies. Google Scholar contains most of the peer-reviewed online journals from the major publishers of scientific literature, with nearly 400 million references. These databases provide rapid access to basic information including titles, authors, journal, and year of publication.

Due to the constant evolution of the database content (frequent addition of new publications), the online search was performed on both databases the same day. All potentially relevant publications were collected with the following search formula: “surgeon*” AND “work-related musculoskeletal disorders”. These keywords were searched in the entire text. The wildcard character (∗) was used to allowing variable endings of keywords and then find as many relevant sources as possible. The literature types were limited to articles and review only written in English without limit of publication date.

Data extraction and collection involved several steps. First, all PubMed/Medline search results were exported into Comma Separated Value (CSV) file and directly imported into Microsoft Excel (licensed software). For Google Scholar, the journal articles filter was selected to limit entries to the inclusion criteria. Identified articles were added to the library, exported into a CSV file and added to the Excel file. For ScienceDirect, two filters were applied to the search results: review articles and research articles. Then, the entries were exported in RIS (Research Information Systems) format. For Mendeley, only journal-type articles have been selected. The entries were then downloaded into Mendeley Reference Manager and exported in a RIS file. For Science.gov, as no filter by article type is available, all results were selected, exported to a Science.gov Citation Manager library, and then compiled into a RIS format file. All RIS files were imported into Endnote X5 (licensed software). The corresponding bibliography was then generated in a text file that could be imported into Microsoft Excel 2010. This procedure enabled to obtain the names of the authors, the title, the journal and the year of publication of all selected articles extracted from the 5 databases. From the compiled Excel file containing items extracted from all databases, duplicates were removed. Then, the articles were screened independently by two reviewers. The main inclusion criterion was a study of WMSD in surgeons in the course of their main activity. All specialties and techniques (open, robotic assisted, minimal invasive surgery, etc.) were accepted. On the basis of the title, abstract and, if necessary, the full text, articles that did not meet the inclusion criteria were excluded from the analysis. The discrepancies were discussed and a decision was reached after re-examining the article.

Once the final list had been drawn up, the additional data required for bibliometric analysis was added for each source. The overall number of citations (global citation score: GCS) for each article was extracted from Google Scholar on the same day, to avoid the bias of variations caused by the rapid evolution of the literature. Then, for each article, the region/country of each author, their affiliation, the list of references, the keywords, and all information about the journal were manually added to the Excel file: country, impact factor (IF), Scimago Journal rank (SJR), quartile ranking of a journal in a specific field (Q), International Standard Serial Number (ISSN), subject area, and category (obtained with Scimago – www.scimagojr.com).

Co-authorship, co-citation, and co-occurrence were conducted with VOSviewer software (free software, v1.6.20, Leiden University, Leiden, the Netherlands). Network visualization has been carried out using nodes whose size depends on the occurrence of the respective criteria. Reference analyses include the number of citations (Nc) in the selected articles, while keyword occurrence analyses are also based on the average year of publication (APY). Finally, based on the information gathered, an analysis of publication frequency and citations was carried out using Excel.

The bibliographic search performed on the five databases identified 2338 publications. After removing duplicates (n = 1151), 1003 articles from the 1187 unique sources were excluded as they did not meet the inclusion criteria. As a result, the search included 184 published between 1991 and 2024 articles ( Figure 1), with 174 original research (94.6%) and 10 reviews (5.4%). Figure 2 depicts the number of publications over the period 1991-2023 (full year). Between 1991 and 2015, the number of works published per year is very low, less than 5 publications per year, with 8 years with a single publication (except for the year 2012 which totals 6 publications). Since 2016, the number of publications per year has increased significantly. The linear relationship (Y = 4.1667X – 4.3889, R ² = 0.8693, where X is the year and Y is the number of publications per year) indicated a growth of 4 publications per year, reaching 40 publications in 2023. Fourteen articles have already been published for the first quarter of 2024. It is worth noting that, 87.5% of the publications identified in this field have been published in the last 8 years.

A total of 39 countries/regions contributed to all publications in the field of WMSDs in surgeons. As shown in Table 1, the USA is the overwhelmingly dominant country in this field, with more than a third of publications (37.6% of the 184 publications) and a GCS of 2631. United Kingdom, Canada and Saudi Arabia rank next with 20 (8.4%), 17 (7.2%), and 15 (6.3%) publications respectively, with a GSC 6 to 8 times lower than the USA (GCS: 320-468). The annual publication of the top 3 countries from 1991 to 2024 is displayed in Figure 3A. Conversely, China has the highest average citations per publication (151.3), followed by Netherlands (82.5) and Iran (68.0), respectively ranked 12th, 21st, and 15th in the most productive countries ranking. USA, United Kingdom and Canada rank 11th, 13th and 15th respectively for average citations per publication (respectively, 29.6, 23.4, and 19.5 citations per publication).

Figure 3B depicts the overlay visualization map of country co-authorship analysis performed with VOSviewer. The network visualization was constructed with a threshold at least 1 document for a country and zero citation. The advantage of these thresholds is that all 39 countries are taken into account in the analysis. VOSviewer displays countries as circles whose size is proportional to the number of publications in the field, and whose color indicates the average publication year (APY). The country with the largest circle is USA, whose color is green. This indicates that it is the most productive country with an APY equal to 2020.2 (89 publications). United Kingdom and Canada (ranked 2nd and 3rd by number of publications) have a slightly lower or equal APY, respectively 2020.2 and 2019.8. Very recently, a number of countries (Korea, Russia, Saingapore, Greece) have published work concerning WMSDs in surgeons (in yellow in Figure 3B) with an APY greater than or equal to 2022. Interestingly, the China and Sweden have the lowest APY (APY = 2014.3 and APY = 2017.5 respectively).

Table 2 lists the 6 most prolific authors. Hallbeck MS is the author with the highest number of publications (11 publications), followed by Yu D and Vijendren A (8 and 6 publications respectively). She has the highest h-index of the top 6 (h-index = 35). Three of the 6 authors are affiliated with institutions in the USA, 2 are affiliated with a university in Saudi Arabia and one in the UK. Hallbeck MS also has the highest GCS (601 citations) and ranks first in the top 6 authors with the most citations ( Table 3). The other 5 authors each have 455 citations for 3 publications of which they are all co-authors. Lee BT has the highest h-index (h-index = 48). The 6 authors with the most citations are all affiliated to USA institutions.

Figure 4 presents the network visualization map of co-authorship analysis generated by VOSviewer. Figure 4B shows the most relevant co-authorship cluster composed of 96 authors related to Hallbeck MS, Yu D, and Lowndes BR. This cluster is included in the overall network of 995 authors grouped into 148 different clusters ( Figure 4A).

The 184 publications identified in the field of WMSDs in surgeons are distributed across 113 different journals. The ranking of the most active journals was presented by GCS and Np respectively in Tables 4 and 5. Applied Ergonomics (IF: 2.6; h-index: 119; SJR: 0.92; Q1; United Kingdom) has the highest number of citations (GCS = 455) for 4 publications, followed by JAMA Surgery (IF: 16.9; h-index: 193; SJR: 3.62; Q1; USA) and Journal of Occupational Rehabilitation (IF: 3.3; h-index: 79; SJR: 0.89; Q1; USA) with respectively 365 and 321 citations from 1 publication each.

As shown in Table 5, World Neurosurgery (IF: 2.1; h-index: 106; SJR: 0.59; Q2; USA) and Work (IF: 2.3; h-index: 58; SJR: 0.51; Q2; Netherland) are the two journals with the highest number of publications (Np = 7) on the topic of WMSDs in surgeons. Surgical Endoscopy (IF: 3.1; h-index: 166; SJR: 1.12; Q1; USA) and The American Journal of Surgery (IF: 2.4; h-index: 163; SJR: 0.85; Q1; USA) rank 3rd ex aequo with 5 publications. Q1-ranked journals account for 70% and 57% in Tables 4 and 5 respectively. Figure 5A depicts the network visualization map of journal co-citation analysis performed by VOSviewer. All these journals are related to different areas of research. However, as shown in Figure 5B, Medicine is the most frequently published subject area in all journals (168 publications), far ahead of Social Sciences and Health Professions with 14 and 13 publications respectively.

Table 6 lists the 10 most cited publications in the field of WMSDs among surgeons. The articles were published between 1991 and 2024. The first 2 articles in the ranking were cited more than 300 times each. The first article was published in 2018 by Epstein et al. in JAMA Surgery (IF: 16.9; h-index: 193; SJR: 3.62; Q1) and has 365 citations. The authors carried out a systematic review and meta-analysis of MSD prevalence in 4 body zones, i.e. neck (60%), shoulder (52%), back (59%), and upper extremity (35%), considering several assessment tools (Nordic Musculoskeletal Questionnaire, Physical Discomfort Survey). They also studied the various pathologies (degenerative cervical and lumbar spine disease, rotator cuff pathology, carpal tunnel syndrome) affecting surgeons from different specialties (general, orthopedic, ophthalmologic, dematologic, obstetrics and gynecology surgery …) during their practice. The second was published by Szeto et al. (2009) in the Journal of Occupational Rehabilitation (IF: 3.3; h-index: 79; SJR: 0.89; Q1), with 321 citations. Authors examined with a survey the physical and psychosocial factors and their association with WMS among 135 general surgeons in Hong Kong. They studied the relationship between demographics, workload, ergonomic and psychosocial factors and WMSDs symptoms. The neck (82.9%), lower back (68.1%), shoulders (57.8%) and upper back (52.6%) are the areas most exposed to MSD. The main reasons for this are awkward, static postures maintained over a long time. These results illustrate the link between physical factors and the symptoms associated with musculoskeletal disorders, which are likely to worsen in the future, particularly with the development of minimally invasive surgery. Table 7 shows the ranking of the 10 most cited references among the 184 articles retained in this bibliometric analysis. The two previous articles, i.e. Epstein et al. (2018) and Szeto et al. (2009) rank 2nd and 3rd respectively, with 60 and 43 citations. The article published by de Park et al. (2009) takes first place with 62 citations. The network of co-cited references, based on the 1000 most cited references (out of 2929 references), is presented in Figure 6.

A total of 392 different keywords were extracted from the 184 publications. The co-occurrence network of keywords with a minimum number of occurrences of 1 was created with VOSviewer and presented in Figure 7A. The overlay visualization map of keywords was also constructed to highlight the research hotspots in the different periods ( Figure 7B). The size of the nodes is proportional to the occurrence of each keyword, and its color is based on its average publication year (APY, blue for 2016 to yellow for 2024). Figure 7C shows the ranking of the 20 keywords most used by authors (largest nodes in Figure 7A and B). The keyword “Ergonomics” (APY: 2020.79) is the most used by researchers with 70 occurrences out of the 184 studies, followed by the keywords “Musculoskeletal disorders” (APY: 2020.34), “Surgeons” (APY: 2019.03), and “Work-related musculoskeletal disorders” (APY: 2020.34), with 32, 29, and 29 occurrences respectively. As shown in Figure 7D, they were few used before 2015, and then their frequency increased from year to year. This is reflected in an APY for these 4 keywords between 2019 and 2021.

The change in the number of academic publications is an important indicator of how a field is developing. As shown in Figure 1, a variation in publication dynamics has been demonstrated. From 1991 to 2015, the number of scientific publications that considered the healthcare status of surgeons as part of their practice was very low and showed no evolution. This indicates that the impact of surgery on practitioners was not a focus of interest for the medical community during this period. Only 11.5% of scientific publications were published during these 25 years. Since 2016, the number of publications per year has increased significantly, with 87.5% of articles published in just 8 years. This result suggests that the study of WMSDs in surgeons has generated increased attention, and that this interest has grown in recent years. Research is increasingly addressing the health of the practitioner, and not just that of the patients who have undergone surgery. This observation is becoming more widespread among dentists, ³⁷ nurses ³⁸ and healthcare professionals ³⁹ in general. The authors reported that the number of studies focusing on the well-being of healthcare professionals has increased considerably over the last 15 years. Based on the evaluation of recent years and the scientific articles already published up to March 2024 (14 articles), we can predict that the number of publications in this field will continue to rise.

Countries

The total number of publications by a country is an important indicator of its degree of involvement in the theme. The results presented in Table 1 show that the countries of North America, Europe and Asia occupy the top 10 of the most prolific nations. Among these countries, the United States ranks first, well ahead of the United Kingdom and Canada. The United States also stands out for its global citation score, which is six times higher than that of other countries. This result suggests that the scientific literature published by American researchers is relevant and of interest to the entire community addressing the issue of WMSDs in surgeons. Similar results have been reported in the literature on nurses ³⁸ and dentists. ³⁷ This indicates that the United States is ahead of other countries in the management of work-related musculoskeletal disorders among healthcare professionals.

Authors

Among the most active authors ( Table 2), Hallbeck MS from Mayo Clinic, Department of Health Sciences Research, United States, contributed the highest number of publications, followed by fellow American Yu D, from Purdue University, and Vijendren A, Lister Hospital, United Kingdom. Hallbeck MS is also the author with the highest number of citations and is therefore the most influential scientist. In one of her most cited studies, entitled “The impact of intraoperative microbreaks with exercises on surgeons: A multi-center cohort study”, she investigated the effect of microbreaks with exercises on their physical performance, mental concentration and self-reported pain/discomfort in several institutions. The aim was to improve surgeons’ health and patient safety. In particular, the authors demonstrated that intraoperative micro-breaks combined with exercises were more beneficial than simple distraction, as they reduced shoulder discomfort. Surgeons were in favor of incorporating these microbreaks with exercise into their procedures, as they would help mitigate work-related musculoskeletal fatigue, pain and injury. In another study, the authors investigated the presence of pain in cardiovascular surgeons before, during and after surgery. They showed that pain was present before surgery in 75% of practitioners, 92.3% during an operation, and in 96.8% at completion. The authors also showed a positive correlation between self-reported burnout among surgeons and increase of pain. These studies clearly demonstrate that surgeons are highly affected by WMSDs, and that it is important to understand their causes and take action to reduce their occurrence and effects, as has been done in other healthcare professions, notably physiotherapists. ⁴⁰ This work is also supported by studies that highlight the body areas most affected and attempt to make correlations with working conditions in order to formulate recommendations. ^{41, 42}

With regard to citation analysis, the studies by Epstein et al., ³⁰ Szeto et al., ⁴³ and Abramovitz et al. ⁴⁴ rank in the top 3 articles with the highest GCS ( Table 6). Epstein’s top-ranked work (JAMA Surgery, IF: 16.9, h-index: 193, SJR: 3.62, Q1) investigated the pathologies most prevalent among surgeons regardless of specialty, using a meta-analysis. The authors concluded that the neck, back, shoulder and hand/finger were the most exposed areas (prevalence between 35% and 60%). The studies by Epstein et al. and Szeto et al. are also among the top 3 co-cited references ( Table 7). The study by Park et al., ⁴⁵ published in collaboration with Hallbeck MS in the Journal of the American College of Surgeons (IF: 5.2, h-index: 205, SJR: 1.42, Q1), occupies first place with a second study on the effect of microbreaks during surgery. This result shows that some authors can have a major impact in the field with very interesting work without publishing many works. In other words, the number of publications alone does not reflect an author’s academic influence, since a number of other parameters can influence an article’s citation frequency. ⁴⁶

Journals

Publication sources are at the heart of the dissemination of results for academic scientific research. They enable the latest advances in the field to be presented to the community. By analyzing co-citations, journals with the highest productivity or impact can be identified, and therefore those most likely to publish researchers’ work. For WMSDs among surgeons, World Neurosurgery and Work are the most productive, followed by Surgical Endoscopy, The American Journal of Surgery, Applied Ergonomics, Journal of Minimally Invasive Gynecology, and American Journal of Otolaryngology ( Table 5). All these journals have an IF between 2 and 4 and are ranked Q1 and Q2 with an SJR between 0.5 and 1.5, indicating a high quality of published work. Among the most cited sources, top-5 are Q1 journals. Applied Ergonomics ranks first with the highest GCS and 4 publications. JAMA Surgery and Annals of Surgery, respectively 2nd and 4th in this ranking with 1 and 3 publications respectively, have very high IF (≥10) and H-indexes (≥200), indicating that the work published in these journals has a high impact in the field. They are therefore sources of significant interest to the community. In other words, the sources presented in these rankings are those to be promoted for scholars interested in domains, and represent relevant publication targets for researchers working on WMSDs among surgeons.

The authors’ keywords are the most representative terms of a scientific work and are selected to explain the subject of the research and position it within a theme. The keyword co-occurrence network map with VOSviewer was presented in Figure 7A. Among the 392 keywords identified in the 184 articles, the most frequently used was “Ergonomics”, with 70 occurrences followed by “musculoskeletal disorders” (32 occurrences), “work-related musculoskeletal disorders” (29 occurrences), and “Surgeons” (29 occurrences, Figure 7C). Link and cluster analysis revealed two main lines of research. The first is a subjective medical approach, using qualitative tools such as surveys or questionnaires to highlight the prevalence of MSDs among surgeons in the course of their practice. The keywords often associated are “musculoskeletal disorders”, “pain” and “injury”, as well as the identification of pathologies from which surgeons may suffer. ²⁵ Auerbach et al. ⁴⁷ reported on the most common sources of pain in 561 surgeons. The prevalence of pain in the elbow, first, and fingers was around 25% and that in the neck, lower back, and shoulder was over 50%. The authors also reported the most common self-reported diagnoses of these different joints, with prevalence ranging from 2 to 40%. The second approach is based on ergonomic analysis using quantitative parameters obtained from measurement tools (EMG, posture, motion analysis, ergonomic tools …) to prevent the onset of WMSDs. ^{48– 50}

Figure 7B shows keyword co-occurrence overlay map. The size of the circles is proportional to the number of occurrences, and the color corresponds to the average year of publication (APY): blue for the oldest keywords and yellow for the most recent. The four most frequently used keywords have an APY of 2019-2020 (green color), with peaks in 2022-2023 ( Figure 7D). This result reflects the youthfulness of study on the investigation and prevention of WMSDs in surgeons. It shows that this research topic still has challenges ahead that could define the frontiers of research in the near future. Recent studies have used meta-analyses to highlight the evidence and issues involved. On the one hand, like all healthcare professionals, surgeons are highly exposed to WMSDs. ¹⁸ Their working conditions require them to maintain awkward postures for long durations. ⁵¹ In addition to the physical strain, there is stress and mental fatigue due to high level of concentration required to perform highly precise gestures. It therefore seems important to improve surgeons’ working conditions to reduce their exposition to MSDs. On the other hand, a high degree of heterogeneity was observed in the results. This was due in part to the great difference between the experimental and working conditions, and the characteristics of the samples tested. As has already been done in a number of studies, more specific studies by category could be carried out in the future to refine the assessment of prevalence and propose specific recommendations. ^{52– 54}

The present study has certain strengths compared with previous studies that have adopted only meta-analyses. This is the first bibliometric analysis to address the issue of WMSD among surgeons based on 5 scientific databases without publication year restriction. In addition, a selection was made after database extraction to retain only those articles relevant to the scientific question. Several tools/software were used to perform the bibliometric analysis and visualization in order to enrich the results with respect to several criteria: countries, sources, authors, references, research areas, citations and keywords. However, some limitations could be addressed. Firstly, the analysis was carried out on 5 free databases. As a result, some publications may not have been taken into account, whereas they would have been with other paying databases, such as (Web of Science, Scopus, Embase …). However, the use of several databases means that data must be homogenized in order to use classic bibliometric analysis tools ( Vosviewer, CiteSpace, etc.). Indeed, the format and nature of the data provided varies from one database to another. Thus, the information had to be completed and several parameters have been added such as impact factor, global citations score, journal rank and quartile rank in the field, to enrich the results and make the present work more qualitative. Secondly, given that VOSviewer does not analyze the full text of articles, it is possible that some information has been ignored. Thirdly, only articles published in English were considered. As a result, some relevant work written in another language may have been omitted. Finally, it is important to keep in mind that very high quality papers may not appear in some rankings due to their recent publication.