Scientific output collaboration patterns, and thematic evolution in limb amputation research: A bibliometric study of SAARC-affiliated authors

INTRODUCTION

Amputation is a well-established surgical procedure used to treat trauma, diabetes mellitus, peripheral vascular disease, infections, neoplasms, and congenital anomalies.^1-2 In developed countries, vascular disease is responsible for most lower-limb amputations among older adults, whereas in developing countries, trauma remains the leading cause, often affecting younger populations.²

The South Asian region itself is heterogeneous, comprising eight populous countries (India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan, the Maldives, and Afghanistan). Each country is characterized by different healthcare challenges and causes of limb amputation (LA). Numerous scholarly studies have focused on the clinical, rehabilitative, and socio-economic issues of LA in South Asia; however, systematic mapping has not yet been performed. A bibliometric analysis, as a quantitative tool to review scientific publications, would provide a robust methodology for research trends, collaboration networks, and main areas of research that help in understanding the gaps for health policies and clinical practices in the region.³ Bibliometric analysis uses data mining to retrieve substantial amounts of citation data, followed by the use of statistics and mathematics for quantitative examination.⁴ It enables quantitative mapping of research trends, collaboration networks, and thematic evolution within a scientific field.

Bibliometric approaches have previously been used to examine research trends in related areas such as diabetic foot disease, vascular surgery, and global amputation research. These studies have highlighted the growth of scientific publications, the geographic distribution of research output, and the dominance of high-income countries in the production of amputation-related literature. However, despite the substantial burden of trauma- and diabetes-related limb loss in South Asia, a comprehensive bibliometric evaluation focusing specifically on research productivity, collaboration patterns, and thematic evolution within SAARC countries is currently lacking.^5,6

This study analyzed LA research contributed by authors from the SAARC nations to identify trends, productivity, and thematic evolution.

METHODOLOGY

Data refinement

Before analysis in Biblioshiny, data cleaning involved removing duplicates, standardizing author names and institutional affiliations, and verifying missing bibliographic fields. A detailed overview of the process of removing irrelevant articles and capturing the correct ones. Following title evaluation and full-text screening, the results are depicted in Figure 1.

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Figure 1: Flow chart for the research’s search process. SARC: South Asian Association for Regional Cooperation, NCBI: National Centre for Biotechnology Information

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RESULTS

Annual scientific production

The annual publication trends of LA research are presented in Figure 2. A total of 1168 eligible publications were identified between 1967 and 2024, of which the majority were original research articles (68%), followed by review articles (19%), while letters and case reports accounted for smaller proportions. The number of publications increased steadily over the study period, with a marked rise after 2000. Total citations also increased over time, reflecting growing research activity in this field.

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Figure 2: Annual scientific production.

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Thematic map network and thematic evolution

Figure 3 presents the thematic development of LA research between 1967 and 2024, illustrating the emergence and continuity of major research keywords. Each time slice represents a distinct research phase, with arrows indicating continuity or transitions between themes.

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Figure 3: Thematic evolution.

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During the early period (1967–2008), keywords related to trauma and vascular causes of amputation were prominent. Between 2009 and 2018, increased representation of terms such as 'diabetic foot' and 'management' was observed. In the most recent period (2019–2024), keywords associated with prosthetics, rehabilitation, and functional outcomes appeared more frequently.

Figure 4 illustrates the co-occurrence network of keywords in LA research across SAARC countries. Nodes represent keywords and are sized according to their frequency, while connecting lines represent co-occurrence relationships.

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Figure 4: Thematic map network

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Authorship productivity and collaboration network

The collaboration network among authors is presented in Figure 5. Several interconnected clusters of researchers were identified, indicating frequent multi-author collaborations. Central nodes represent authors who are linked to multiple collaborative groups. A prominent collaborative cluster included S.R. Sabapathy, H. Venkataramani, D.J. Dheenadhayalan, and S. Rajasekaran, while additional connected contributors included A. Kumar, V.V. Viswanathan, A. Basit, and B.P. Bhardwaj. Author productivity and citation metrics are summarized in Table 1 and Supplementary Table 3.

Table 1: Authors’ local impact (the influence and visibility of each author in the SAARC LA research network, based on performance, productivity, and citation score)

Authors	H _index	G _index	M _index	TC	NP	PY_ start
Viswanathan V	3	18	0.142	600617	18	2005
Kumar A	2	18	0.111	134322	18	2008
Kumar S	2	17	0.153	323	18	2013
Gupta A	1	10	0.05	110	15	2006
Singh S	1	13	0.05	560078	13	2006
Basit A	1	2	0.04	6	12	2011
Ahmad J	1	11	0.066	202002	11	2011
Sagar S	1	10	0.083	110	10	2014
Zubair M	1	9	0.052	202002	9	2007
Rastogi A	1	8	0.111	160012	8	2017
Singh SK	2	8	0.125	221008	8	2010
Singh G	1	8	0.027	221005	8	1990
Jain A	1	8	0.066	1000	8	2011
Miyan Z	1	1	0.055	1	7	2008
Malik A	1	7	0.066	202002	7	2011

h_ index (Hirsch index)- Impact + productivity, g_ index (Egghe’s index)- Emphasizes highly cited works, m_ index (ratio of h_ index to the number of years since the first publication)- time adjusted productivity, TC-total citations, NP-number of paper publications, PY-start year of the first publication, LA: limb amputation, SAARC: South Asian Association for Regional Cooperation

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Figure 5: Author’s collaboration network

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The temporal distribution of author productivity is shown in Figure 6, indicating publication activity among leading authors between 2010 and 2024.

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Figure 6: Author’s production over time

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Distribution and productivity at the country level

The geographical distribution of publications is presented in Figure 7. Among SAARC nations, India contributed the highest number of publications (35), followed by Pakistan (12) and Nepal (11).

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Figure 7: Choropleth map indicating global publication patterns by country of origin

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Outside the SAARC region, England (148) and the United States (138) contributed the highest number of publications in the dataset.

The inclusion criteria required at least one author to be affiliated with a SAARC country; therefore, publications from non-SAARC countries were included when co-authors were affiliated with SAARC institutions.

Trend topics based on authors’ keywords

Figure 8 illustrates the temporal evolution of frequently occurring author keywords. The horizontal axis represents publication years, while each node represents a keyword. Node size reflects keyword frequency, and connecting lines indicate persistence across time.

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Figure 8: Trend topics (here, term frequency refers to how many times a keyword appears across all publications in the given time period)

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Earlier keywords included trauma, infection, and surgery. More recent keywords include diabetic foot, prosthesis, and rehabilitation.

DISCUSSION

Over nearly six decades, from 1967 to 2024, research productivity on LA in SAARC countries showed a linear increase, indicating growing scholarly visibility. The rise in publications after the early 2000s corresponds with global trends in amputation research and coincides with increased recognition of diabetes-related complications and improvements in trauma care worldwide.^[10–12] When compared with bibliometric analyses conducted in other regions, the research output from SAARC countries appears modest but steadily increasing. Global bibliometric studies on amputation research have similarly shown the majority of publications originate from high-income countries, whereas contributions from developing regions remain comparatively lower but are gradually increasing.^5-6 Within the SAARC region, India, followed by Pakistan and Nepal, was the largest contributor. Several factors may explain this dominance. India has the largest population in the region and, consequently, the largest clinical burden of diabetes and trauma-related injuries. In addition, the country has a relatively more extensive network of tertiary-care hospitals, academic institutions, and indexed medical journals, which facilitates research productivity and publication. Greater access to research funding, institutional collaborations, and postgraduate medical training programs may further contribute to India’s leading role in regional research output. Furthermore, the substantial burden of trauma in South Asia may also influence research priorities. Road traffic injuries alone are estimated to account for nearly 3% of the regional gross domestic product (GDP), and a considerable proportion of trauma admissions are due to limb loss. These statistics highlight the growing public health and economic impact of LA in the region and underscore the need for increased research attention toward trauma care, limb salvage strategies, and rehabilitation of amputees.

Although a considerable proportion of the literature focuses on metabolic or malignancy-related causes of amputation, trauma remains an important contributor to limb loss in many developing regions. In many SAARC countries, limited healthcare infrastructure and poor public awareness regarding conditions such as diabetes often result in delayed diagnosis, with patients sometimes presenting for the first time during treatment for traumatic injuries. As a result, trauma surgeons frequently encounter complex cases where underlying metabolic disease compromises limb salvage, posing challenges in determining the level of amputation and planning rehabilitation. Consequently, the management and long-term care of amputees are increasingly coordinated by trauma surgeons as part of multidisciplinary teams rather than being limited to orthopedic or general surgical services.

However, the growing global burden of diabetes and peripheral vascular disorders remains a significant factor, particularly as the leading cause of lower LA.^12,13 As clinical and technological advancements continue to grow, the focus has naturally shifted toward long-term functional outcomes and quality of life.¹⁴ While vascular disease and diabetes are now recognized as the leading causes of LA in many developed countries, trauma continues to remain a major cause of limb loss in several developing nations, including those in the SAARC region.²

From a clinical perspective, the increasing focus on diabetic foot research has important implications for healthcare systems in the region. Diabetes-related amputations contribute substantially to disability and healthcare expenditure. Research addressing preventive care, early detection of foot complications, multidisciplinary management, and rehabilitation strategies may therefore play an important role in reducing amputation rates and improving long-term patient outcomes. Importantly, trauma surgeons in the SAARC region frequently manage patients with complex limb injuries who also have underlying comorbidities such as diabetes or peripheral vascular disease, which may significantly influence limb salvage decisions and postoperative outcomes. Therefore, the growing research emphasis on diabetic limb complications is also relevant to trauma care, as these conditions may complicate the management of traumatic limb injuries and influence the risk of amputation.

Future research in the SAARC region would benefit from longitudinal cohort studies, multicentric collaborations, and enhanced data integration to more effectively evaluate long-term functional outcomes after LA. Strengthening methodological and technological approaches can help address the increasing public health impact of diabetes- and trauma-related amputations in the region and improve patient outcomes.

The collaboration analysis revealed stable author clusters largely driven by Indian researchers, with limited cross-border collaboration. A possible explanation for the relatively low level of regional collaboration is the limited availability of shared trauma and amputation registries across SAARC nations. In many healthcare settings within the region, patient data are still recorded primarily through paper-based systems, which restrict systematic data sharing and multicentric research initiatives. Digital data systems are more commonly maintained within governmental or law-enforcement platforms for policy formulation rather than integrated hospital-based clinical registries. Establishing coordinated trauma and amputation registry networks across hospitals in SAARC countries could significantly improve data availability, facilitate collaborative research, and support evidence-based policy development aimed at improving long-term outcomes for amputees. This trend is in agreement with other bibliometric assessments, where high intra-national yet low inter-regional cooperation commonly characterizes this area of research.¹⁴ Collaboration with researchers from the United Kingdom and the United States indicates integration of SAARC research into international scientific networks. However, addressing context-specific challenges such as trauma-related amputations, rural rehabilitation infrastructure, and cost-effective prosthetic design may require stronger intra-regional collaboration.

Strengthening regional collaboration among SAARC institutions may help diversify research participation and promote multicentric studies.

Regional journals such as the Indian Journal of Surgery and the International Journal of Lower Extremity Wounds accounted for the highest number of publications, reflecting the strength of local platforms. The same patterns are observed in the bibliometric analyses of diabetic foot research and rehabilitation,¹⁵ suggesting that, despite an increase in research volume, achieving global visibility remains a persistent challenge. Increasing publication diversity and interdisciplinary research collaborations could improve both citation impact and translational value.

Overall, the thematic evolution observed in this study suggests that LA research in the SAARC region is transitioning from descriptive clinical reports toward more analytical and multidisciplinary investigations addressing chronic disease management, surgical outcomes, and rehabilitation.

LIMITATIONS

This bibliometric analysis has several limitations. Although multiple comprehensive databases were used, some relevant studies may have been missed due to indexing or access restrictions. The initial screening of retrieved records was performed using the Rayyan reference management platform. However, because Biblioshiny (an R-based bibliometric analysis tool) supports direct import only from selected databases, the consolidated BibTeX file exported from Rayyan required manual formatting before analysis. During this process, some metadata fields, particularly author affiliation details, may have been partially lost, which could affect the completeness of institutional mapping. Additionally, inconsistencies in citation-related metadata generated during the integration of records from multiple databases resulted in unreliable citation counts for some articles; therefore, citation-based indicators were not included in the final analysis. Citation-based indicators are also time-dependent and may change as publications accrue citations. Furthermore, the inclusion criterion requiring at least one author affiliated with a SAARC country may have resulted in the inclusion of studies conducted outside the region through international collaborations, which may not exclusively represent patient populations from SAARC countries. Finally, restricting the analysis to English-language publications may have excluded relevant regional literature.

CONCLUSION

Overall, this analysis emphasizes that the current state of scientific research on LA in the SAARC region is shifting from descriptive and case-based studies to analytical, outcome-focused, and collaborative efforts. Ongoing investment in multicenter, multidisciplinary research is crucial to align local practices with international standards for prosthetic and rehabilitative care following LA.