Equity in Orthopaedic Knowledge, Open-Access Trends Among the Top 1,000 Cited Articles in Orthopaedic Surgery.

Abstract

Highly cited articles in orthopaedic surgery are important in shaping practice and education. However, their accessibility through open access (OA) remains unclear despite increasing emphasis on equitable research dissemination. The aim of this study was to evaluate the prevalence of open access among the 1000 most-cited publications pertinent to orthopaedic surgery and examine trends by journal, decade, and study design. It was hypothesized that access to most of the most-cited orthopaedic publications is behind paywalls. We conducted a cross-sectional bibliometric analysis of the top 1000 most-cited orthopaedic surgery journal articles indexed in Scopus from 1980 to 2025. OA status was determined using the Unpaywall criteria adapted by Scopus, which categorizes publications as gold, green, bronze, hybrid, or closed. Descriptive statistics, chi-square tests, and nonparametric comparisons were used to evaluate OA prevalence across article types, journals, and decades. Citation density and OA status were compared using Mann-Whitney U tests and negative binomial regression. Among the top 1000 cited articles, 724 (72.4%) were not available through some form of OA. 276 (27.6%) were available through OA. Most open access was tagged as bronze (12.4%) or green (11.3%), while only 3.9% were published in fully OA journals. No hybrid OA articles were identified. OA prevalence varied among top journals, with Clinical Orthopaedics and Related Research showing the highest proportion (43.2%) and the American Journal of Sports Medicine the lowest (8.1%). OA availability differed significantly by article type (χ2 = 15.88, P = 0.0032); randomized controlled trials and preclinical studies were more likely to be open than cohort studies. OA prevalence increased significantly over time, from 0% in the 1980s to 63.6% after 2020s. OA articles had higher annual citation densities (28.0 vs. 23.9 citations/year; P < 0.0001), although OA status was not a notable predictor of total citations in multivariable models. Despite positive trends in open access, most influential knowledge in orthopaedic surgery remains closed access, representing a notable barrier to the global orthopaedic community.