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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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McCombes, S. (2023, September 11). How to Write a Literature Review | Guide, Examples, & Templates. Scribbr. Retrieved June 7, 2024, from https://www.scribbr.com/dissertation/literature-review/

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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Literature Review Research Presentation

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A literature review is ‘integral to the success of academic research’ and an indispensable component of a doctoral thesis. Brief versions are particularly important for the Confirmation phase of your candidature. Often this work will form a significant component of the introduction or early chapters of your thesis.

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Learning how to effectively write a literature review is a critical tool for success for an academic, and perhaps even professional career. Being able to summarize and synthesize prior research pertaining to a certain topic not only demonstrates having a good grasp on available information for a topic, but it also assists in the learning process. Although literature reviews are important for one's academic career, they are often misunderstood and underdeveloped. This article is intended to provide both undergraduate and graduate students in the criminal justice field specifically, and social sciences more generally, skills and perspectives on how to develop and/or strengthen their skills in writing a literature review. Included in this discussion are foci on the structure , process, and art of writing a literature review. What is a Literature Review? In essence, a literature review is a comprehensive overview of prior research regarding a specific topic. The overview both shows the reader what is known about a topic, and what is not yet known, thereby setting up the rationale or need for a new investigation, which is what the actual study to which the literature review is attached seeks to do. Stated a bit differently (Creswell 1994, pp. 20, 21) explains: The literature in a research study accomplishes several purposes: (a) It shares with the reader the results of other studies that are closely related to the study being reported (Fraenkel & Wallen, 1990. (b) It relates a study to the larger, ongoing dialog in the literature about a topic, filling in gaps and extending prior studies (Marshall & Rossman, 1989). (c) It provides a framework for establishing the importance of the study. As an overview, a well done literature review includes all of the main themes and subthemes found within the general topic chosen for the study. These themes and subthemes are usually interwoven with the methods or findings of the prior research. Also, a literature review sets the stage for and JOURNAL

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8 Tips for a Literature Review Presentation

by Caleb Youngwerth

Literature reviews for research are very different from any other presentation you may have done before, so prepare to relearn how to present. The goals of research literature reviews are different, the style is different, even the pacing is different. Even if you have previously done a literature review in an academic setting, you will still want to know these tips. I found this out the hard way, so you don’t have to. Also, to clarify, these tips are meant for a literature review of a topic, not a singular study or paper, though many of the tips do apply to both.

1. Highlight current research

The point of a literature review for research is to highlight the current state of research related to your topic, not to simply give background information. Background information is important and should be included, but the focus of the presentation should be showing some current studies that either confirm or challenge the topic you are studying. As much as textbooks from 30 years ago might seem to have all the information you need for your presentation, a research study from this decade does a far better job representing the current state of the topic, which is the end goal of the presentation. Also, since the new research should be the focal point of the presentation, as a general piece of advice, try to give each research study a minimum of one full slide, so you can give a fuller picture of what the study actually concluded and how they reached their conclusion.

2. Alternate old and new

The best way to keep people listening to your presentation is to vary what you include in your presentation. Rather than trying to give all of the background information first and then showcase all the flashy new research, try to use the two interchangeably. Organize the presentation by idea and give all the background needed for the idea, then develop the idea further by using the new research studies to help illustrate your point. By doing this, you not only avoid having to backtrack and reteach the background for each and every new study, but also help keep the presentation interesting for the audience. This method also helps the audience avoid being overwhelmed since only a little bit of new information is introduced at a time. Obviously, you may need to include a brief introductory section that contains nothing but textbook information that is absolutely necessary to understand anything about the topic, but the more varied the presentation, the better.

3. Use complete sentences

Every presentation class up to this point probably has taught you that slides with full sentences are harmful to your presentation because it is distracting to the listener. Unlearn all that information for this style of presentation. Bullet points are still good, but you should have complete ideas (which usually means complete sentences) for every single point. If someone would be able to read your slides and not hear you, and still be able to understand most of your presentation, your literature review is perfect in a research setting. The point of this presentation is to share all the new information you have learned, so hiding it is helping no one. You still do not want to be reading your slides verbatim and can absolutely add information beyond the slides, but all your main ideas should be on the slides.

4. Read smart

I will admit that I stole this tip from Rosy, but it is a very good tip, so I decided to include it. When you read, you want to read as much as you can, but wasting time reading an irrelevant research study is helping no one. When finding a new study, read the abstract, then the conclusion, then the pictures. If it looks like a good study from those three parts, or you personally find it interesting, you then can go over the actual paper and read it, but by reading the less dense parts first, you can get a general idea of the study without actually having to take a lot of time to read the entire paper. Though textbooks and review papers generally are a little more difficult to read using this method, you can still look at the introduction, pictures, and conclusion and save time reading the rest if the source ends up not being interesting or important.

5. Reading is good for you

As much as you want to read smart when you can, the more you read, the more knowledgeable you become. The goal of the presentation is to become an expert on you topic, so the only way you can do that is by reading as much as you can. You should read more information than you present, since many sources you read probably will not fit in a time-constrained presentation. As Rosy likes to say, in anything research, only about 10% of what you know should actually be shared with the world. By reading more, you are better-suited to answer questions, and you also just generally are able to understand what you are studying better because, chances are, the main purpose of this presentation for you is to help you better understand your research. If something looks interesting and is vaguely related to your topic, read it; it will be beneficial to you, even if you do not end up presenting the information.

6. Let pictures talk for you

When reading research papers, the pictures are usually the best part. Your presentation should be the same way. The best way to be able to show the concept you are trying to explain is to literally show it. The best way to show the results of a research study is usually by showing a graph or infographic, so if the paper has a graph that shows the results, you should absolutely use it. Charts, diagrams, and even videos can also help illustrate a piece of background information that might be difficult to put into words. That being said, you should know and be able to explain every single part of the graphic. Otherwise, it loses meaning and makes the audience even more confused. Captions can and should be used to help explain the graphic, not only to remind you, but also let your audience know what the general idea of the graphic is. Since they keep slides interesting, you should probably have some sort of picture on every slide, otherwise the slides will be not only bland, but also likely less informative.

7. Avoid overcrowded slides

Just because you should have a lot of information in your presentation does not mean that your slides need to show that. In fact, a slide with too much information will only harm your presentation since your audience will be distracted trying to read all of a long slide while you are trying to explain it. Doing anything to make slides less dense will help avoid having the audience focused on the slide, so they focus on you more. Transitions that only show one point at a time or wait to reveal an image can be helpful in breaking up an overcrowded slide. Also, simply adding more slides can help since it accomplishes the purpose of putting less information on your slides while still keeping the exact same amount of information. You still want to share as much information as you can with the audience, but overcrowded slides do not accomplish this purpose.

8. Expect questions

Another thing that might be slightly different about a research presentation is questions. Most presentations have the question section after the presenter has finished. Research presentations are different because they allow for questions during the presentation (assuming it is a presentation to a small group). If you get any questions in the middle of the presentation, it is not someone being rude, but simply a fellow researcher who is legitimately curious about your topic. Of course, there will be a question period after the presentation, but you may be asked questions during the presentation. If you read enough information on the topic, you should be able to answer any question easily, but if the question is completely unrelated to anything you read, then it is perfectly reasonable to answer that you did not research the specific area in question. Overall, the questions related to your presentation should not be your biggest worry, but you should definitely be ready.

These are not all the rules for a literature review presentation nor are they set in stone. These are just some tips that I was told or learned that were the most helpful for me, so I hope they will help you too. I had to rewrite my presentation entirely my first literature review because I did not understand some of these differences, so if you give the presentation when you are scheduled to go, you are already better off than I was. Also, do not be afraid to ask anyone in the research group, even Rosy, if you need help. Chances are everyone in the group has given a literature review presentation at some point, so we would be more than happy to help you if you are confused about something. That being said, we are not experts on your topic, so specific questions about organization and content are going to have to be figured out by yourself. Either way, no matter what you do, do not stress out about this presentation. The goal of the presentation is mostly just to help improve your knowledge on a topic, and the presentation is simply to share with the group some of the information you have learned. Best of luck with the presentation, and I hope these tips help clear up what exactly the goal of a literature review presentation in a research setting is.

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Literature Review

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Whether you're a student or an academic, mastering the literature review is a key skill in scholarly writing. This fully customizable Google Slides and PowerPoint template can assist you in structuring your review seamlessly. Featuring a vibrant yellow design with captivating book illustrations, this template is designed to facilitate the organization and presentation of your research. Navigate your audience through chapters, themes, and references with ease and clarity using this versatile academic tool. Utilize this tool to craft an impressive literature review that leaves a lasting impression!

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Literature Review Presentation Slides

A literature review in research is a critical and systematic analysis of existing literature, scholarly articles, books, and other relevant sources that are pertinent to a particular research topic or question. Incorporating a literature review in research is essential for contextualizing the study within existing knowledge, identifying research gaps, and guiding the research design and This Presentation simplifies complex ideas, making your presentation both engaging and informative. This Presentation is explain detailed with Literature images. This template is fully created by green based theme. The template empowers you to concisely convey the essence of your literature review, capturing attention and fostering understanding. This Presentation is fully customized and It is used for researchers, academics, students, and professionals engaged in various fields of study.

Features of the templates:

• 100% customizable slides and easy to download.
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10 Best Literature Review Templates for Scholars and Researchers [Free PDF Attached]

Imagine being in a new country and taking a road trip without GPS. You would be so lost. Right? Similarly, think about delving into a topic without having a clue or proper understanding of the reason behind studying it. 

That’s when a well-written literature review comes to the rescue. It provides a proper direction to the topic being studied. 

The literature review furnishes a descriptive overview of the existing knowledge relevant to the research statement. It is a crucial step in the research process as it enables you to establish the theoretical roots of your field of interest, elucidate your ideas, and develop a suitable methodology. A literature review can include information from various sources, such as journals, books, documents, and other academic materials. This promotes in-depth understanding and analytical thinking, thereby helping in critical evaluation.

Regardless of the type of literature review — evaluative, exploratory, instrumental, systematic, and meta-analysis, a well-written article consists of three basic elements: introduction, body, and conclusion. Also its essence blooms in creating new knowledge through the process of review, critique, and synthesis.

But writing a literature review can be difficult. Right?

Relax, our collection of professionally designed templates will leave no room for mistakes or anxious feelings as they will help you present background information concisely. 

10 Designs to Rethink Your Literature Reviews

These designs are fully customizable to help you establish links between your proposition and already existing literature. Our PowerPoint infographics are of the highest quality and contain relevant content. Whether you want to write a short summary or review consisting of several pages, these exclusive layouts will serve the purpose. 

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LITERATURE REVIEW

Jul 22, 2014

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LITERATURE REVIEW. 2.1What is a “Literature Review”?. A literature review is an overview of research on a given topic and answers to related research questions Literature reviews are an important part of research and should be treated as such A well-written literature review:

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• distinguish
• related research questions
• relevant journal articles
• selective use
• low priority
• bibliographic data

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2.1What is a “Literature Review”? • A literature review is an overview of research on a given topic and answers to related research questions • Literature reviews are an important part of research and should be treated as such • A well-written literature review: • Organizes literature • Evaluates literature • Identifies patterns and trends in literature • Synthesizes literature

‘the literature’ means the works you consulted in order to understand and investigate your research problem. • A literature review involves providing a rationale for your selection of literature related to the subject studied.

The literature review familiarizes the reader with the subject and the scope of the research topic. • It helps the reader to define key concepts • Finally it establishes the body of knowledge which will be able to contribute towards the research.

2.2 Writing the Literature Review • Firstly decide what you need to read from a broad spectrum of literature available • Refer to books, periodicals, journals, and websites which will be relevant to your study.

Determine what exactly are your objectives • Provide a current and complete overview of your related topic. • Show that you have read extensively and formed a body of knowledge on the subject of field of study

Purpose of writing a literature Review Your review should be in a form of • critical decision, • showing awareness of differing arguments, theories, approaches and methodologies. It should be a synthesis and analysis of the relevant published work, linked at all times to your objective and rationale of your study.

There are several purposes on why we write a literature review: • it reviews knowledge of previous studies on the subject of research • it identifies a conceptual framework for own research • it provides directions for future research • it provides resources previously unknown to the reader • it identifies gaps in past studies

To sum up, a good literature review is: • critical of what has been written, • identifies areas of controversy, • raises questions and identifies areas which need further research.

2.3 Process of Writing a Literature Review • There are several stages in developing a literature review(Biddlek, 1997). The stages are : • Identify • Record • Relevance • Retrieve • Review • Write

Stage 1 – Identify • Compile a list of references. • Use a kind of index system either a hard copy or a software referencing system. • i)work through key catalogues, databases, indexes, bibliographies and websites for relevant resources • ii)check the references and in the articles you have read • iii)locate and use research reviews

Stage 2-Record • Make a record of any literature that relates to your topic. • You should have citation details, where it is located, and should also write a few sentences that help you remember what the article is about

Stage 3 –Relevance • i)Prioritize the literature, after having read the abstract, rank them if it should be high, medium or low priority • ii)On the website scan through the literature for relevance before you decide to download or print it out • iii) You need to focus on the literature and sources you have identified and ranked as most important, the most recent development from the periodicals. • iv) Distinguish between textbooks and research articles from journals and books. They contain different kinds of information that will be more or less relevant to your research

Stage 4 -Retrieve • i) Make hard copies of the most important literature. Print relevant journal articles from databases and photocopy articles from journals

Stage 5 –Review • Use the reading log which allows you to record different kinds of information: the bibliographic details, a description, and relationship to other readings. • Also record where the literature is located so that you can easily refer to the quotes or ideas paraphrased when you are editing. • As you are taking notes, ensure you are clear about what you are quoting and paraphrasing. You cannot risk unintentionally plagiarizing ideas.

Stage 6 -Write • Start with an introductory paragraph • Discuss the literature on the subject in a logical and coherent way • Conclude with a paragraph that is relevant to the literature of the research

2.4 Five Phases of Writing a Literature Review • Phase 1 – Specify the scope of your review • i)Ensure you have a precise topic • you must be precise about having a topic. It should not be too broad or unspecific. Look at the following topic which is too broad • Example: ‘Life and Times of Sigmund Freud” • The title below seems to be limited, but still considered too broad • Example: “Psychological Theories of Sigmund Freud • However, a more manageable and appropriate topic would be • ‘Freud’s Theory of Personality Applied to Mental Health” • If your research question is too broad or defined vaguely or abstractly, you may end up reading and compiling too much information for your literature review. However if your research question is specified too narrowly or defined concisely, you may miss out more general information

ii)Scope of the Literature Review You have to determine the precise scope of the literature review. Questions which need to be answered are as follows :- • What will I cover in my review? • How comprehensive will it be? • How current are my materials? • What type of materials/documents will be needed?

Phase 2: Locating and Accessing Information • Obtain all the necessary materials for your literature review by searching relevant bibliographies, print indexes and online databases i)Using Existing Literature Reviews • Many journals on different subject areas publish review articles. In these journals you may find commentaries on research articles. You may find these reviews relevant to your literature review.

Phase 3 Recording the Information • You can develop a systematic way of recording information through: note cards with citations • Photocopied articles with points highlighted or underlined with notes in the margins • Traditional taking down notes or in laptops

i)Tips on Recording Information • A quick skimming and scanning through the introduction and the conclusion of an article, would give you an idea of the article and general points. • a)Start with the most recent studies and work backwards. Refer to the list of references on a recent article;   • b)Read, first the report or article’s abstract - this will give you some clues about the article • c)When taking down notes, remember to write out the complete bibliographic citation for each work. It is essential you note down the page numbers as these will be necessary later for footnotes and bibliography. For internet citations note the URL • d)Write all direct quotations precisely when taking down notes. You should use quotations marks, so it can recognize as a directly quoted text and not a paraphrase. If you fail to put a direct text in quotation marks or to credit the authors, it amounts to plagiarism.

Phase 4 Evaluating the Information • After having read all the articles, you must now decide and evaluate what should be included in the review. • Be selective - you have to consider issues and themes that link different articles.

Phase 5 Organizing and Writing the Literature Review • After accessing, reading and evaluating the material, these materials need to be organized. • You may organize the selected readings by theoretical approaches, by specific concepts or issues, and by methodologies

Some tips on writing After you have located, read, analyzed and evaluated the literature, the next stage is actual writing. Here are some tips: • Keep your paragraphs short • Subheadings are essential, as it clarifies the structure. They break up the materials into more readable units • Avoid too many long direct quotations from the studies. Paraphrase other writers’ works rather than quote lengthy passages • Don’t cite references that you haven’t read

Some traps to avoid • Trying to read everything! • not to provide a summary of all the published work that relates to your research, but a survey of the most relevant and significant work. • Reading but not writing! • Writing can help you understand and find relationships between the work you’ve read, so don’t put writing off until you’ve “finished” reading. • Not keeping bibliographic information! - Source: http://www.clpd.bbk.ac.uk/students/litreview web.pdx.edu/~bertini/literature_review.pdf

Final Checklist Here is a checklist from University of Melbourne: (http://www.lib.unimelb.eduau/postgrad/litreview/finalchecklist.html) • Have you indicated the purpose of the review? • Have you ascertained the parameters of the review and are they reasonable? • Have you emphasized on recent development of the research? • Have you focused on primary sources with only selective use of secondary sources? • Is the literature selected relevant to your study? • Is your bibliographic data complete?

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Peer-reviewed

Research Article

Functional connectivity changes in the brain of adolescents with internet addiction: A systematic literature review of imaging studies

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Child and Adolescent Mental Health, Department of Brain Sciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom

Roles Conceptualization, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliation Behavioural Brain Sciences Unit, Population Policy Practice Programme, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom

• Max L. Y. Chang, 
• Irene O. Lee

• Published: June 4, 2024
• https://doi.org/10.1371/journal.pmen.0000022
• Peer Review
• Reader Comments

Internet usage has seen a stark global rise over the last few decades, particularly among adolescents and young people, who have also been diagnosed increasingly with internet addiction (IA). IA impacts several neural networks that influence an adolescent’s behaviour and development. This article issued a literature review on the resting-state and task-based functional magnetic resonance imaging (fMRI) studies to inspect the consequences of IA on the functional connectivity (FC) in the adolescent brain and its subsequent effects on their behaviour and development. A systematic search was conducted from two databases, PubMed and PsycINFO, to select eligible articles according to the inclusion and exclusion criteria. Eligibility criteria was especially stringent regarding the adolescent age range (10–19) and formal diagnosis of IA. Bias and quality of individual studies were evaluated. The fMRI results from 12 articles demonstrated that the effects of IA were seen throughout multiple neural networks: a mix of increases/decreases in FC in the default mode network; an overall decrease in FC in the executive control network; and no clear increase or decrease in FC within the salience network and reward pathway. The FC changes led to addictive behaviour and tendencies in adolescents. The subsequent behavioural changes are associated with the mechanisms relating to the areas of cognitive control, reward valuation, motor coordination, and the developing adolescent brain. Our results presented the FC alterations in numerous brain regions of adolescents with IA leading to the behavioural and developmental changes. Research on this topic had a low frequency with adolescent samples and were primarily produced in Asian countries. Future research studies of comparing results from Western adolescent samples provide more insight on therapeutic intervention.

Citation: Chang MLY, Lee IO (2024) Functional connectivity changes in the brain of adolescents with internet addiction: A systematic literature review of imaging studies. PLOS Ment Health 1(1): e0000022. https://doi.org/10.1371/journal.pmen.0000022

Editor: Kizito Omona, Uganda Martyrs University, UGANDA

Received: December 29, 2023; Accepted: March 18, 2024; Published: June 4, 2024

Copyright: © 2024 Chang, Lee. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The behavioural addiction brought on by excessive internet use has become a rising source of concern [ 1 ] since the last decade. According to clinical studies, individuals with Internet Addiction (IA) or Internet Gaming Disorder (IGD) may have a range of biopsychosocial effects and is classified as an impulse-control disorder owing to its resemblance to pathological gambling and substance addiction [ 2 , 3 ]. IA has been defined by researchers as a person’s inability to resist the urge to use the internet, which has negative effects on their psychological well-being as well as their social, academic, and professional lives [ 4 ]. The symptoms can have serious physical and interpersonal repercussions and are linked to mood modification, salience, tolerance, impulsivity, and conflict [ 5 ]. In severe circumstances, people may experience severe pain in their bodies or health issues like carpal tunnel syndrome, dry eyes, irregular eating and disrupted sleep [ 6 ]. Additionally, IA is significantly linked to comorbidities with other psychiatric disorders [ 7 ].

Stevens et al (2021) reviewed 53 studies including 17 countries and reported the global prevalence of IA was 3.05% [ 8 ]. Asian countries had a higher prevalence (5.1%) than European countries (2.7%) [ 8 ]. Strikingly, adolescents and young adults had a global IGD prevalence rate of 9.9% which matches previous literature that reported historically higher prevalence among adolescent populations compared to adults [ 8 , 9 ]. Over 80% of adolescent population in the UK, the USA, and Asia have direct access to the internet [ 10 ]. Children and adolescents frequently spend more time on media (possibly 7 hours and 22 minutes per day) than at school or sleeping [ 11 ]. Developing nations have also shown a sharp rise in teenage internet usage despite having lower internet penetration rates [ 10 ]. Concerns regarding the possible harms that overt internet use could do to adolescents and their development have arisen because of this surge, especially the significant impacts by the COVID-19 pandemic [ 12 ]. The growing prevalence and neurocognitive consequences of IA among adolescents makes this population a vital area of study [ 13 ].

Adolescence is a crucial developmental stage during which people go through significant changes in their biology, cognition, and personalities [ 14 ]. Adolescents’ emotional-behavioural functioning is hyperactivated, which creates risk of psychopathological vulnerability [ 15 ]. In accordance with clinical study results [ 16 ], this emotional hyperactivity is supported by a high level of neuronal plasticity. This plasticity enables teenagers to adapt to the numerous physical and emotional changes that occur during puberty as well as develop communication techniques and gain independence [ 16 ]. However, the strong neuronal plasticity is also associated with risk-taking and sensation seeking [ 17 ] which may lead to IA.

Despite the fact that the precise neuronal mechanisms underlying IA are still largely unclear, functional magnetic resonance imaging (fMRI) method has been used by scientists as an important framework to examine the neuropathological changes occurring in IA, particularly in the form of functional connectivity (FC) [ 18 ]. fMRI research study has shown that IA alters both the functional and structural makeup of the brain [ 3 ].

We hypothesise that IA has widespread neurological alteration effects rather than being limited to a few specific brain regions. Further hypothesis holds that according to these alterations of FC between the brain regions or certain neural networks, adolescents with IA would experience behavioural changes. An investigation of these domains could be useful for creating better procedures and standards as well as minimising the negative effects of overt internet use. This literature review aims to summarise and analyse the evidence of various imaging studies that have investigated the effects of IA on the FC in adolescents. This will be addressed through two research questions:

• How does internet addiction affect the functional connectivity in the adolescent brain?
• How is adolescent behaviour and development impacted by functional connectivity changes due to internet addiction?

The review protocol was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see S1 Checklist ).

Search strategy and selection process

A systematic search was conducted up until April 2023 from two sources of database, PubMed and PsycINFO, using a range of terms relevant to the title and research questions (see full list of search terms in S1 Appendix ). All the searched articles can be accessed in the S1 Data . The eligible articles were selected according to the inclusion and exclusion criteria. Inclusion criteria used for the present review were: (i) participants in the studies with clinical diagnosis of IA; (ii) participants between the ages of 10 and 19; (iii) imaging research investigations; (iv) works published between January 2013 and April 2023; (v) written in English language; (vi) peer-reviewed papers and (vii) full text. The numbers of articles excluded due to not meeting the inclusion criteria are shown in Fig 1 . Each study’s title and abstract were screened for eligibility.

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https://doi.org/10.1371/journal.pmen.0000022.g001

Quality appraisal

Full texts of all potentially relevant studies were then retrieved and further appraised for eligibility. Furthermore, articles were critically appraised based on the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework to evaluate the individual study for both quality and bias. The subsequent quality levels were then appraised to each article and listed as either low, moderate, or high.

Data collection process

Data that satisfied the inclusion requirements was entered into an excel sheet for data extraction and further selection. An article’s author, publication year, country, age range, participant sample size, sex, area of interest, measures, outcome and article quality were all included in the data extraction spreadsheet. Studies looking at FC, for instance, were grouped, while studies looking at FC in specific area were further divided into sub-groups.

Data synthesis and analysis

Articles were classified according to their location in the brain as well as the network or pathway they were a part of to create a coherent narrative between the selected studies. Conclusions concerning various research trends relevant to particular groupings were drawn from these groupings and subgroupings. To maintain the offered information in a prominent manner, these assertions were entered into the data extraction excel spreadsheet.

With the search performed on the selected databases, 238 articles in total were identified (see Fig 1 ). 15 duplicated articles were eliminated, and another 6 items were removed for various other reasons. Title and abstract screening eliminated 184 articles because they were not in English (number of article, n, = 7), did not include imaging components (n = 47), had adult participants (n = 53), did not have a clinical diagnosis of IA (n = 19), did not address FC in the brain (n = 20), and were published outside the desired timeframe (n = 38). A further 21 papers were eliminated for failing to meet inclusion requirements after the remaining 33 articles underwent full-text eligibility screening. A total of 12 papers were deemed eligible for this review analysis.

Characteristics of the included studies, as depicted in the data extraction sheet in Table 1 provide information of the author(s), publication year, sample size, study location, age range, gender, area of interest, outcome, measures used and quality appraisal. Most of the studies in this review utilised resting state functional magnetic resonance imaging techniques (n = 7), with several studies demonstrating task-based fMRI procedures (n = 3), and the remaining studies utilising whole-brain imaging measures (n = 2). The studies were all conducted in Asiatic countries, specifically coming from China (8), Korea (3), and Indonesia (1). Sample sizes ranged from 12 to 31 participants with most of the imaging studies having comparable sample sizes. Majority of the studies included a mix of male and female participants (n = 8) with several studies having a male only participant pool (n = 3). All except one of the mixed gender studies had a majority male participant pool. One study did not disclose their data on the gender demographics of their experiment. Study years ranged from 2013–2022, with 2 studies in 2013, 3 studies in 2014, 3 studies in 2015, 1 study in 2017, 1 study in 2020, 1 study in 2021, and 1 study in 2022.

https://doi.org/10.1371/journal.pmen.0000022.t001

(1) How does internet addiction affect the functional connectivity in the adolescent brain?

The included studies were organised according to the brain region or network that they were observing. The specific networks affected by IA were the default mode network, executive control system, salience network and reward pathway. These networks are vital components of adolescent behaviour and development [ 31 ]. The studies in each section were then grouped into subsections according to their specific brain regions within their network.

Default mode network (DMN)/reward network.

Out of the 12 studies, 3 have specifically studied the default mode network (DMN), and 3 observed whole-brain FC that partially included components of the DMN. The effect of IA on the various centres of the DMN was not unilaterally the same. The findings illustrate a complex mix of increases and decreases in FC depending on the specific region in the DMN (see Table 2 and Fig 2 ). The alteration of FC in posterior cingulate cortex (PCC) in the DMN was the most frequently reported area in adolescents with IA, which involved in attentional processes [ 32 ], but Lee et al. (2020) additionally found alterations of FC in other brain regions, such as anterior insula cortex, a node in the DMN that controls the integration of motivational and cognitive processes [ 20 ].

https://doi.org/10.1371/journal.pmen.0000022.g002

The overall changes of functional connectivity in the brain network including default mode network (DMN), executive control network (ECN), salience network (SN) and reward network. IA = Internet Addiction, FC = Functional Connectivity.

https://doi.org/10.1371/journal.pmen.0000022.t002

Ding et al. (2013) revealed altered FC in the cerebellum, the middle temporal gyrus, and the medial prefrontal cortex (mPFC) [ 22 ]. They found that the bilateral inferior parietal lobule, left superior parietal lobule, and right inferior temporal gyrus had decreased FC, while the bilateral posterior lobe of the cerebellum and the medial temporal gyrus had increased FC [ 22 ]. The right middle temporal gyrus was found to have 111 cluster voxels (t = 3.52, p<0.05) and the right inferior parietal lobule was found to have 324 cluster voxels (t = -4.07, p<0.05) with an extent threshold of 54 voxels (figures above this threshold are deemed significant) [ 22 ]. Additionally, there was a negative correlation, with 95 cluster voxels (p<0.05) between the FC of the left superior parietal lobule and the PCC with the Chen Internet Addiction Scores (CIAS) which are used to determine the severity of IA [ 22 ]. On the other hand, in regions of the reward system, connection with the PCC was positively connected with CIAS scores [ 22 ]. The most significant was the right praecuneus with 219 cluster voxels (p<0.05) [ 22 ]. Wang et al. (2017) also discovered that adolescents with IA had 33% less FC in the left inferior parietal lobule and 20% less FC in the dorsal mPFC [ 24 ]. A potential connection between the effects of substance use and overt internet use is revealed by the generally decreased FC in these areas of the DMN of teenagers with drug addiction and IA [ 35 ].

The putamen was one of the main regions of reduced FC in adolescents with IA [ 19 ]. The putamen and the insula-operculum demonstrated significant group differences regarding functional connectivity with a cluster size of 251 and an extent threshold of 250 (Z = 3.40, p<0.05) [ 19 ]. The molecular mechanisms behind addiction disorders have been intimately connected to decreased striatal dopaminergic function [ 19 ], making this function crucial.

Executive Control Network (ECN).

5 studies out of 12 have specifically viewed parts of the executive control network (ECN) and 3 studies observed whole-brain FC. The effects of IA on the ECN’s constituent parts were consistent across all the studies examined for this analysis (see Table 2 and Fig 3 ). The results showed a notable decline in all the ECN’s major centres. Li et al. (2014) used fMRI imaging and a behavioural task to study response inhibition in adolescents with IA [ 25 ] and found decreased activation at the striatum and frontal gyrus, particularly a reduction in FC at inferior frontal gyrus, in the IA group compared to controls [ 25 ]. The inferior frontal gyrus showed a reduction in FC in comparison to the controls with a cluster size of 71 (t = 4.18, p<0.05) [ 25 ]. In addition, the frontal-basal ganglia pathways in the adolescents with IA showed little effective connection between areas and increased degrees of response inhibition [ 25 ].

https://doi.org/10.1371/journal.pmen.0000022.g003

Lin et al. (2015) found that adolescents with IA demonstrated disrupted corticostriatal FC compared to controls [ 33 ]. The corticostriatal circuitry experienced decreased connectivity with the caudate, bilateral anterior cingulate cortex (ACC), as well as the striatum and frontal gyrus [ 33 ]. The inferior ventral striatum showed significantly reduced FC with the subcallosal ACC and caudate head with cluster size of 101 (t = -4.64, p<0.05) [ 33 ]. Decreased FC in the caudate implies dysfunction of the corticostriatal-limbic circuitry involved in cognitive and emotional control [ 36 ]. The decrease in FC in both the striatum and frontal gyrus is related to inhibitory control, a common deficit seen with disruptions with the ECN [ 33 ].

The dorsolateral prefrontal cortex (DLPFC), ACC, and right supplementary motor area (SMA) of the prefrontal cortex were all found to have significantly decreased grey matter volume [ 29 ]. In addition, the DLPFC, insula, temporal cortices, as well as significant subcortical regions like the striatum and thalamus, showed decreased FC [ 29 ]. According to Tremblay (2009), the striatum plays a significant role in the processing of rewards, decision-making, and motivation [ 37 ]. Chen et al. (2020) reported that the IA group demonstrated increased impulsivity as well as decreased reaction inhibition using a Stroop colour-word task [ 26 ]. Furthermore, Chen et al. (2020) observed that the left DLPFC and dorsal striatum experienced a negative connection efficiency value, specifically demonstrating that the dorsal striatum activity suppressed the left DLPFC [ 27 ].

Salience network (SN).

Out of the 12 chosen studies, 3 studies specifically looked at the salience network (SN) and 3 studies have observed whole-brain FC. Relative to the DMN and ECN, the findings on the SN were slightly sparser. Despite this, adolescents with IA demonstrated a moderate decrease in FC, as well as other measures like fibre connectivity and cognitive control, when compared to healthy control (see Table 2 and Fig 4 ).

https://doi.org/10.1371/journal.pmen.0000022.g004

Xing et al. (2014) used both dorsal anterior cingulate cortex (dACC) and insula to test FC changes in the SN of adolescents with IA and found decreased structural connectivity in the SN as well as decreased fractional anisotropy (FA) that correlated to behaviour performance in the Stroop colour word-task [ 21 ]. They examined the dACC and insula to determine whether the SN’s disrupted connectivity may be linked to the SN’s disruption of regulation, which would explain the impaired cognitive control seen in adolescents with IA. However, researchers did not find significant FC differences in the SN when compared to the controls [ 21 ]. These results provided evidence for the structural changes in the interconnectivity within SN in adolescents with IA.

Wang et al. (2017) investigated network interactions between the DMN, ECN, SN and reward pathway in IA subjects [ 24 ] (see Fig 5 ), and found 40% reduction of FC between the DMN and specific regions of the SN, such as the insula, in comparison to the controls (p = 0.008) [ 24 ]. The anterior insula and dACC are two areas that are impacted by this altered FC [ 24 ]. This finding supports the idea that IA has similar neurobiological abnormalities with other addictive illnesses, which is in line with a study that discovered disruptive changes in the SN and DMN’s interaction in cocaine addiction [ 38 ]. The insula has also been linked to the intensity of symptoms and has been implicated in the development of IA [ 39 ].

“+” indicates an increase in behaivour; “-”indicates a decrease in behaviour; solid arrows indicate a direct network interaction; and the dotted arrows indicates a reduction in network interaction. This diagram depicts network interactions juxtaposed with engaging in internet related behaviours. Through the neural interactions, the diagram illustrates how the networks inhibit or amplify internet usage and vice versa. Furthermore, it demonstrates how the SN mediates both the DMN and ECN.

https://doi.org/10.1371/journal.pmen.0000022.g005

(2) How is adolescent behaviour and development impacted by functional connectivity changes due to internet addiction?

The findings that IA individuals demonstrate an overall decrease in FC in the DMN is supported by numerous research [ 24 ]. Drug addict populations also exhibited similar decline in FC in the DMN [ 40 ]. The disruption of attentional orientation and self-referential processing for both substance and behavioural addiction was then hypothesised to be caused by DMN anomalies in FC [ 41 ].

In adolescents with IA, decline of FC in the parietal lobule affects visuospatial task-related behaviour [ 22 ], short-term memory [ 42 ], and the ability of controlling attention or restraining motor responses during response inhibition tests [ 42 ]. Cue-induced gaming cravings are influenced by the DMN [ 43 ]. A visual processing area called the praecuneus links gaming cues to internal information [ 22 ]. A meta-analysis found that the posterior cingulate cortex activity of individuals with IA during cue-reactivity tasks was connected with their gaming time [ 44 ], suggesting that excessive gaming may impair DMN function and that individuals with IA exert more cognitive effort to control it. Findings for the behavioural consequences of FC changes in the DMN illustrate its underlying role in regulating impulsivity, self-monitoring, and cognitive control.

Furthermore, Ding et al. (2013) reported an activation of components of the reward pathway, including areas like the nucleus accumbens, praecuneus, SMA, caudate, and thalamus, in connection to the DMN [ 22 ]. The increased FC of the limbic and reward networks have been confirmed to be a major biomarker for IA [ 45 , 46 ]. The increased reinforcement in these networks increases the strength of reward stimuli and makes it more difficult for other networks, namely the ECN, to down-regulate the increased attention [ 29 ] (See Fig 5 ).

Executive control network (ECN).

The numerous IA-affected components in the ECN have a role in a variety of behaviours that are connected to both response inhibition and emotional regulation [ 47 ]. For instance, brain regions like the striatum, which are linked to impulsivity and the reward system, are heavily involved in the act of playing online games [ 47 ]. Online game play activates the striatum, which suppresses the left DLPFC in ECN [ 48 ]. As a result, people with IA may find it difficult to control their want to play online games [ 48 ]. This system thus causes impulsive and protracted gaming conduct, lack of inhibitory control leading to the continued use of internet in an overt manner despite a variety of negative effects, personal distress, and signs of psychological dependence [ 33 ] (See Fig 5 ).

Wang et al. (2017) report that disruptions in cognitive control networks within the ECN are frequently linked to characteristics of substance addiction [ 24 ]. With samples that were addicted to heroin and cocaine, previous studies discovered abnormal FC in the ECN and the PFC [ 49 ]. Electronic gaming is known to promote striatal dopamine release, similar to drug addiction [ 50 ]. According to Drgonova and Walther (2016), it is hypothesised that dopamine could stimulate the reward system of the striatum in the brain, leading to a loss of impulse control and a failure of prefrontal lobe executive inhibitory control [ 51 ]. In the end, IA’s resemblance to drug use disorders may point to vital biomarkers or underlying mechanisms that explain how cognitive control and impulsive behaviour are related.

A task-related fMRI study found that the decrease in FC between the left DLPFC and dorsal striatum was congruent with an increase in impulsivity in adolescents with IA [ 26 ]. The lack of response inhibition from the ECN results in a loss of control over internet usage and a reduced capacity to display goal-directed behaviour [ 33 ]. Previous studies have linked the alteration of the ECN in IA with higher cue reactivity and impaired ability to self-regulate internet specific stimuli [ 52 ].

Salience network (SN)/ other networks.

Xing et al. (2014) investigated the significance of the SN regarding cognitive control in teenagers with IA [ 21 ]. The SN, which is composed of the ACC and insula, has been demonstrated to control dynamic changes in other networks to modify cognitive performance [ 21 ]. The ACC is engaged in conflict monitoring and cognitive control, according to previous neuroimaging research [ 53 ]. The insula is a region that integrates interoceptive states into conscious feelings [ 54 ]. The results from Xing et al. (2014) showed declines in the SN regarding its structural connectivity and fractional anisotropy, even though they did not observe any appreciable change in FC in the IA participants [ 21 ]. Due to the small sample size, the results may have indicated that FC methods are not sensitive enough to detect the significant functional changes [ 21 ]. However, task performance behaviours associated with impaired cognitive control in adolescents with IA were correlated with these findings [ 21 ]. Our comprehension of the SN’s broader function in IA can be enhanced by this relationship.

Research study supports the idea that different psychological issues are caused by the functional reorganisation of expansive brain networks, such that strong association between SN and DMN may provide neurological underpinnings at the system level for the uncontrollable character of internet-using behaviours [ 24 ]. In the study by Wang et al. (2017), the decreased interconnectivity between the SN and DMN, comprising regions such the DLPFC and the insula, suggests that adolescents with IA may struggle to effectively inhibit DMN activity during internally focused processing, leading to poorly managed desires or preoccupations to use the internet [ 24 ] (See Fig 5 ). Subsequently, this may cause a failure to inhibit DMN activity as well as a restriction of ECN functionality [ 55 ]. As a result, the adolescent experiences an increased salience and sensitivity towards internet addicting cues making it difficult to avoid these triggers [ 56 ].

The primary aim of this review was to present a summary of how internet addiction impacts on the functional connectivity of adolescent brain. Subsequently, the influence of IA on the adolescent brain was compartmentalised into three sections: alterations of FC at various brain regions, specific FC relationships, and behavioural/developmental changes. Overall, the specific effects of IA on the adolescent brain were not completely clear, given the variety of FC changes. However, there were overarching behavioural, network and developmental trends that were supported that provided insight on adolescent development.

The first hypothesis that was held about this question was that IA was widespread and would be regionally similar to substance-use and gambling addiction. After conducting a review of the information in the chosen articles, the hypothesis was predictably supported. The regions of the brain affected by IA are widespread and influence multiple networks, mainly DMN, ECN, SN and reward pathway. In the DMN, there was a complex mix of increases and decreases within the network. However, in the ECN, the alterations of FC were more unilaterally decreased, but the findings of SN and reward pathway were not quite clear. Overall, the FC changes within adolescents with IA are very much network specific and lay a solid foundation from which to understand the subsequent behaviour changes that arise from the disorder.

The second hypothesis placed emphasis on the importance of between network interactions and within network interactions in the continuation of IA and the development of its behavioural symptoms. The results from the findings involving the networks, DMN, SN, ECN and reward system, support this hypothesis (see Fig 5 ). Studies confirm the influence of all these neural networks on reward valuation, impulsivity, salience to stimuli, cue reactivity and other changes that alter behaviour towards the internet use. Many of these changes are connected to the inherent nature of the adolescent brain.

There are multiple explanations that underlie the vulnerability of the adolescent brain towards IA related urges. Several of them have to do with the inherent nature and underlying mechanisms of the adolescent brain. Children’s emotional, social, and cognitive capacities grow exponentially during childhood and adolescence [ 57 ]. Early teenagers go through a process called “social reorientation” that is characterised by heightened sensitivity to social cues and peer connections [ 58 ]. Adolescents’ improvements in their social skills coincide with changes in their brains’ anatomical and functional organisation [ 59 ]. Functional hubs exhibit growing connectivity strength [ 60 ], suggesting increased functional integration during development. During this time, the brain’s functional networks change from an anatomically dominant structure to a scattered architecture [ 60 ].

The adolescent brain is very responsive to synaptic reorganisation and experience cues [ 61 ]. As a result, one of the distinguishing traits of the maturation of adolescent brains is the variation in neural network trajectory [ 62 ]. Important weaknesses of the adolescent brain that may explain the neurobiological change brought on by external stimuli are illustrated by features like the functional gaps between networks and the inadequate segregation of networks [ 62 ].

The implications of these findings towards adolescent behaviour are significant. Although the exact changes and mechanisms are not fully clear, the observed changes in functional connectivity have the capacity of influencing several aspects of adolescent development. For example, functional connectivity has been utilised to investigate attachment styles in adolescents [ 63 ]. It was observed that adolescent attachment styles were negatively associated with caudate-prefrontal connectivity, but positively with the putamen-visual area connectivity [ 63 ]. Both named areas were also influenced by the onset of internet addiction, possibly providing a connection between the two. Another study associated neighbourhood/socioeconomic disadvantage with functional connectivity alterations in the DMN and dorsal attention network [ 64 ]. The study also found multivariate brain behaviour relationships between the altered/disadvantaged functional connectivity and mental health and cognition [ 64 ]. This conclusion supports the notion that the functional connectivity alterations observed in IA are associated with specific adolescent behaviours as well as the fact that functional connectivity can be utilised as a platform onto which to compare various neurologic conditions.

Limitations/strengths

There were several limitations that were related to the conduction of the review as well as the data extracted from the articles. Firstly, the study followed a systematic literature review design when analysing the fMRI studies. The data pulled from these imaging studies were namely qualitative and were subject to bias contrasting the quantitative nature of statistical analysis. Components of the study, such as sample sizes, effect sizes, and demographics were not weighted or controlled. The second limitation brought up by a similar review was the lack of a universal consensus of terminology given IA [ 47 ]. Globally, authors writing about this topic use an array of terminology including online gaming addiction, internet addiction, internet gaming disorder, and problematic internet use. Often, authors use multiple terms interchangeably which makes it difficult to depict the subtle similarities and differences between the terms.

Reviewing the explicit limitations in each of the included studies, two major limitations were brought up in many of the articles. One was relating to the cross-sectional nature of the included studies. Due to the inherent qualities of a cross-sectional study, the studies did not provide clear evidence that IA played a causal role towards the development of the adolescent brain. While several biopsychosocial factors mediate these interactions, task-based measures that combine executive functions with imaging results reinforce the assumed connection between the two that is utilised by the papers studying IA. Another limitation regarded the small sample size of the included studies, which averaged to around 20 participants. The small sample size can influence the generalisation of the results as well as the effectiveness of statistical analyses. Ultimately, both included study specific limitations illustrate the need for future studies to clarify the causal relationship between the alterations of FC and the development of IA.

Another vital limitation was the limited number of studies applying imaging techniques for investigations on IA in adolescents were a uniformly Far East collection of studies. The reason for this was because the studies included in this review were the only fMRI studies that were found that adhered to the strict adolescent age restriction. The adolescent age range given by the WHO (10–19 years old) [ 65 ] was strictly followed. It is important to note that a multitude of studies found in the initial search utilised an older adolescent demographic that was slightly higher than the WHO age range and had a mean age that was outside of the limitations. As a result, the results of this review are biased and based on the 12 studies that met the inclusion and exclusion criteria.

Regarding the global nature of the research, although the journals that the studies were published in were all established western journals, the collection of studies were found to all originate from Asian countries, namely China and Korea. Subsequently, it pulls into question if the results and measures from these studies are generalisable towards a western population. As stated previously, Asian countries have a higher prevalence of IA, which may be the reasoning to why the majority of studies are from there [ 8 ]. However, in an additional search including other age groups, it was found that a high majority of all FC studies on IA were done in Asian countries. Interestingly, western papers studying fMRI FC were primarily focused on gambling and substance-use addiction disorders. The western papers on IA were less focused on fMRI FC but more on other components of IA such as sleep, game-genre, and other non-imaging related factors. This demonstrated an overall lack of western fMRI studies on IA. It is important to note that both western and eastern fMRI studies on IA presented an overall lack on children and adolescents in general.

Despite the several limitations, this review provided a clear reflection on the state of the data. The strengths of the review include the strict inclusion/exclusion criteria that filtered through studies and only included ones that contained a purely adolescent sample. As a result, the information presented in this review was specific to the review’s aims. Given the sparse nature of adolescent specific fMRI studies on the FC changes in IA, this review successfully provided a much-needed niche representation of adolescent specific results. Furthermore, the review provided a thorough functional explanation of the DMN, ECN, SN and reward pathway making it accessible to readers new to the topic.

Future directions and implications

Through the search process of the review, there were more imaging studies focused on older adolescence and adulthood. Furthermore, finding a review that covered a strictly adolescent population, focused on FC changes, and was specifically depicting IA, was proven difficult. Many related reviews, such as Tereshchenko and Kasparov (2019), looked at risk factors related to the biopsychosocial model, but did not tackle specific alterations in specific structural or functional changes in the brain [ 66 ]. Weinstein (2017) found similar structural and functional results as well as the role IA has in altering response inhibition and reward valuation in adolescents with IA [ 47 ]. Overall, the accumulated findings only paint an emerging pattern which aligns with similar substance-use and gambling disorders. Future studies require more specificity in depicting the interactions between neural networks, as well as more literature on adolescent and comorbid populations. One future field of interest is the incorporation of more task-based fMRI data. Advances in resting-state fMRI methods have yet to be reflected or confirmed in task-based fMRI methods [ 62 ]. Due to the fact that network connectivity is shaped by different tasks, it is critical to confirm that the findings of the resting state fMRI studies also apply to the task based ones [ 62 ]. Subsequently, work in this area will confirm if intrinsic connectivity networks function in resting state will function similarly during goal directed behaviour [ 62 ]. An elevated focus on adolescent populations as well as task-based fMRI methodology will help uncover to what extent adolescent network connectivity maturation facilitates behavioural and cognitive development [ 62 ].

A treatment implication is the potential usage of bupropion for the treatment of IA. Bupropion has been previously used to treat patients with gambling disorder and has been effective in decreasing overall gambling behaviour as well as money spent while gambling [ 67 ]. Bae et al. (2018) found a decrease in clinical symptoms of IA in line with a 12-week bupropion treatment [ 31 ]. The study found that bupropion altered the FC of both the DMN and ECN which in turn decreased impulsivity and attentional deficits for the individuals with IA [ 31 ]. Interventions like bupropion illustrate the importance of understanding the fundamental mechanisms that underlie disorders like IA.

The goal for this review was to summarise the current literature on functional connectivity changes in adolescents with internet addiction. The findings answered the primary research questions that were directed at FC alterations within several networks of the adolescent brain and how that influenced their behaviour and development. Overall, the research demonstrated several wide-ranging effects that influenced the DMN, SN, ECN, and reward centres. Additionally, the findings gave ground to important details such as the maturation of the adolescent brain, the high prevalence of Asian originated studies, and the importance of task-based studies in this field. The process of making this review allowed for a thorough understanding IA and adolescent brain interactions.

Given the influx of technology and media in the lives and education of children and adolescents, an increase in prevalence and focus on internet related behavioural changes is imperative towards future children/adolescent mental health. Events such as COVID-19 act to expose the consequences of extended internet usage on the development and lifestyle of specifically young people. While it is important for parents and older generations to be wary of these changes, it is important for them to develop a base understanding of the issue and not dismiss it as an all-bad or all-good scenario. Future research on IA will aim to better understand the causal relationship between IA and psychological symptoms that coincide with it. The current literature regarding functional connectivity changes in adolescents is limited and requires future studies to test with larger sample sizes, comorbid populations, and populations outside Far East Asia.

This review aimed to demonstrate the inner workings of how IA alters the connection between the primary behavioural networks in the adolescent brain. Predictably, the present answers merely paint an unfinished picture that does not necessarily depict internet usage as overwhelmingly positive or negative. Alternatively, the research points towards emerging patterns that can direct individuals on the consequences of certain variables or risk factors. A clearer depiction of the mechanisms of IA would allow physicians to screen and treat the onset of IA more effectively. Clinically, this could be in the form of more streamlined and accurate sessions of CBT or family therapy, targeting key symptoms of IA. Alternatively clinicians could potentially prescribe treatment such as bupropion to target FC in certain regions of the brain. Furthermore, parental education on IA is another possible avenue of prevention from a public health standpoint. Parents who are aware of the early signs and onset of IA will more effectively handle screen time, impulsivity, and minimize the risk factors surrounding IA.

Additionally, an increased attention towards internet related fMRI research is needed in the West, as mentioned previously. Despite cultural differences, Western countries may hold similarities to the eastern countries with a high prevalence of IA, like China and Korea, regarding the implications of the internet and IA. The increasing influence of the internet on the world may contribute to an overall increase in the global prevalence of IA. Nonetheless, the high saturation of eastern studies in this field should be replicated with a Western sample to determine if the same FC alterations occur. A growing interest in internet related research and education within the West will hopefully lead to the knowledge of healthier internet habits and coping strategies among parents with children and adolescents. Furthermore, IA research has the potential to become a crucial proxy for which to study adolescent brain maturation and development.

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pmen.0000022.s001

S1 Appendix. Search strategies with all the terms.

https://doi.org/10.1371/journal.pmen.0000022.s002

S1 Data. Article screening records with details of categorized content.

https://doi.org/10.1371/journal.pmen.0000022.s003

Acknowledgments

The authors thank https://www.stockio.com/free-clipart/brain-01 (with attribution to Stockio.com); and https://www.rawpixel.com/image/6442258/png-sticker-vintage for the free images used to create Figs 2 – 4 .

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• Open access
• Published: 08 June 2024

Diagnostic and prognostic relevance of plain radiographs for periprosthetic joint infections of the hip: a literature review

• Ulf Krister Hofmann 1 ,
• Georgios Eleftherakis 2 ,
• Filippo Migliorini 1 , 3 ,
• Bernd Fink 4 , 5 &
• Moritz Mederake 6  

European Journal of Medical Research volume  29 , Article number:  314 ( 2024 ) Cite this article

Metrics details

Conventional radiography is regularly used to evaluate complications after total hip arthroplasty. In various recent consensus meetings, however, plain radiographs of a potentially infected hip joint have been judged as being only relevant to exclude diagnoses other than infection. Solid data on radiographic presentations of periprosthetic joint infection (PJI) are scarce. As a result, the prognostic value of radiological features in low-grade PJI remains uncertain. The present review article aims to present an overview of the available literature and to develop ideas on future perspectives to define the diagnostic possibilities of radiography in PJIs of the hip. The primary outcome of interest of this systematic review was the radiologic presentation of periprosthetic joint infections of the hip. As secondary outcome of interest served the sensitivity and specificity of the radiologic presentation of periprosthetic joint infections. Of the included articles, 26 were reviews, essays, or case reports and only 18 were clinical studies. Typical radiologic abnormalities of PJI were a periosteal reaction, a wide band of radiolucency at the cement–bone or metal–bone interface, patchy osteolysis, implant loosening, bone resorption around the implant, and transcortical sinus tracts. The frequency of their occurrence is still inadequately defined. A deeper understanding of the underlying causes and the relation between microorganisms to radiologic abnormalities can probably help clinicians in the future to diagnose a PJI. This is why further research shall focus on the radiographic features of PJI.

Introduction

Conventional radiography is regularly used to evaluate joint prostheses after implantation and during follow-up, as X-rays can detect potential abnormalities involving both the implant and the surrounding bone. Such abnormalities could be for example periprosthetic fracture, dislocation, osteolysis due to third body wear, or sinking of the shaft. One of the major complications after arthroplasty is periprosthetic joint infection (PJI). In various recent consensus meetings, however, plain radiographs of a potentially infected hip joint have been judged as being only relevant to exclude diagnoses other than infection [ 1 , 2 , 3 ]. In the consensus statement published by Romano and colleagues in 2020, for example, the diagnostic performance of conventional radiography in detecting PJI would be very low.

Furthermore, conventional radiography would show demineralization only when more than 30–50% of bone mass has been lost. Abnormalities of bone around the implant would usually be non-specific for infection. In addition, up to 50% of conventional X - ray exams would give negative results [ 1 ]. In another recent consensus statement published by Signore et al. [ 2 , 3 ], the authors state that “Regarding PJI, conventional radiography often yields normal results or may detect non-specific signs of soft-tissue swelling. Serial plain radiography has been reported to have a sensitivity of 14% and specificity of 70% in detecting implant-associated infections [ 4 ]. Radiographic signs that may reveal PJI with high specificity are gas formation and active, immature periostitis. Radiographic signs with low specificity include soft-tissue swelling, periprosthetic lucency, and component loosening. However, differentiation between septic and aseptic periprosthetic lucency and component loosening is almost impossible in conventional radiography. Also, these signs are visible only when almost 30% of the bone mass has been lost; thus, 50% of radiographs remain normal despite the presence of infection”. These consensus statements are, however, only based on three references [ 5 , 6 , 7 ].

Most of the studies to which these statements relate date to the late 80 s and early 90 s [ 5 , 7 , 8 ]. The foundations of the data referenced here are also quite weak, such as in the study from Tigges et al., [ 7 ] with 20 confirmed infected hip arthroplasties, or Lyons et al. [ 5 ] 50 painful hip arthroplasties. The largest series presented was from Thoren and Hallin in 1989 [ 8 ], where the authors analysed 102 hip revisions. Of these, however, only 47 were infected and the prostheses analysed were original Charnley prostheses which possessed a 22.225-mm head in ultra-high molecular weight polyethylene (UHMW PE) in an all-cemented technique and a metal-on PE bearing. The arthroplasty landscape has, however, largely changed since then. Today's arthroplasties often contain an uncemented cup and a ceramic head. Depending on the country the stem is often uncemented ranging from 37% in the National Joint Registry in Great Britain to 78% in the German Arthroplasty Registry in Germany [ 9 ]. Uncemented stems usually consist of titanium which altogether changes the immunogenicity of the wear particles generated. Moreover, the annual number of patients treated with arthroplasties has multiplied and as such the surgical technique and postoperative rehabilitation protocols have been optimized and largely standardized. In addition, life expectancy has increased with people in old age having multiple comorbidities in addition to joint replacement. This supposedly changes the spectrum of bacteria responsible for infections. While we are quite effective in treating acute PJIs, the successful management of low-grade infections is still a challenge. This includes reliable, sensitive and specific diagnostics of such low-grade PJIs. Nevertheless, substantial progress has been made in the diagnosis of such an event with improvements in the histopathological analysis of the periprosthetic membrane [ 10 , 11 ], the advent of PCR analyses [ 12 ], and synovial fluid analysis including the analysis of PMNs, alpha-defensin or leukocyte esterase-levels [ 13 , 14 , 15 , 16 ]. Other newer markers are presently under investigation, such as pentraxin-3 [ 17 ], calprotectin [ 18 ], or myeloperoxidase [ 19 ]. Of note, thresholds for leukocytes in low-grade PJIs have been constantly lowered over the past decades ranging now—depending on the joint—between 1000 and 2000 leukocytes/µl only [ 20 ]. Cultivation techniques for bacteria have also been more and more standardized. We can assume that the overall sensitivity and specificity have increased over the past 30 years. Similarly, the technique of acquiring radiographs has also improved with the widespread introduction of digital radiography. The digital data set allows for post-imaging optimization of each X-ray to visualize structures that were difficult to discern in traditional images intended for a good bone contrast only. Nevertheless, solid data on radiographic presentations of PJI are scarce. As a result, the prognostic value of radiological features in low-grade PJI remains uncertain. The present review article aims to present an overview of the available literature and to develop ideas on future perspectives to define the diagnostic possibilities of radiography in PJIs of the hip.

Materials and methods

Eligibility criteria.

All published articles related to the radiographic presentation of PJI of the hip were accessed. Only articles available in English, French, Spanish or German were eligible. Original studies with a level of evidence of I to IV according to the Oxford Centre of Evidence-Based Medicine [ 21 ] plus review articles and essays were considered.

Search strategy

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement [ 22 ]. On July 24, 2023, PubMed and Web of Science were accessed. The following keywords were used: "periprosthetic joint infection hip radiograph"; "Prosthesis-Related Infections"[Mesh] AND "Radiography"[Mesh]) AND "Hip"[Mesh]; "Radiography"[Mesh]) AND "Hip"[Mesh]) AND "Infections"[Mesh]; "radiography" "hip arthroplasty" "infection"; "x-ray" "hip arthroplasty" "infection"; "x-ray" "periprosthetic joint infection" "hip"; "periprosthetic joint infection" "hip" "radiograph"; "heterotopic ossification" "hip arthroplasty" "infection"; "heterotopic ossification" "hip" "periprosthetic joint infection". No filters were applied.

Selection and data collection

Three authors (UKH; MM; GE) independently performed the database search. All the resulting titles were screened and, if suitable, the abstract was accessed. The full text of the abstracts, which matched the topic, was accessed. A cross-reference of the bibliography of the full-text articles was also screened for inclusion. If the full text was not accessible or available, the article was not considered for inclusion. Disagreements were debated before final inclusion into the study.

Data items and outcome of interest

The following data at baseline were extracted: author, year of publication and journal, PMID/PCMID/DOI, type of analysis performed, country of origin, main study outline, number of patients used for the relevant statements, and statements made regarding radiography and PJI of the hip. A suitable level of evidence was attributed to each study. The primary outcome of interest was the radiologic presentation of PJI of the hip. As secondary outcome of interest served the sensitivity and specificity of the described image characteristics.

Study selection

The literature search resulted in 1248 articles (Fig.  1 ). After the removal of duplicates, 1121 articles were screened. Having screened titles and abstracts, the original manuscript was accessed for 71 studies. Of these 44 finally met the inclusion criteria, the other publications were either in Chinese ( n =  3), not retrievable ( n =  10), retracted ( n =  1), were not related to the research question ( n =  6), or did not directly report radiographic parameters ( n =  7). Of the finally included articles, 26 were reviews, essays, or case reports. Only 18 publications were clinical studies with a level of evidence between IV and II.

Flowchart of the literature search

Review summary

Summarizing the statements provided in the review articles, essays, and case reports (Table  1 ), a few commonly reported traits can be made out: claimed radiographic signs of infection are periosteal reaction [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ], formation of lamellae [ 23 ], focal osteolysis or bone destruction [ 7 , 23 , 24 , 26 , 28 , 31 , 33 , 34 , 35 , 36 , 37 , 38 ], a wide radiolucent zone [ 23 , 32 , 36 , 39 ], signs of loosening in a previously well-fixed implant [ 24 , 27 , 28 , 32 , 34 ], heterotopic bone formation [ 28 , 40 ], mottling [ 31 ], an intracortical sinus tract [ 24 , 28 ], periprosthetic fractures [ 27 ], adjacent soft-tissue collection [ 29 , 30 , 32 ], and rapid disease progression [ 25 ]. Aseptic loosening tends to produce uniform radiolucency, whereas particle disease produces multifocal radiolucencies related to localized osteolysis. Infection can produce either of these patterns [ 41 , 42 ] with an osteolysis of > 2 mm being indicative of infection [ 41 ]. The radiographic presentation thereby seems to be a function of time, with early infections presenting without radiological features and late infections presenting with inflammatory and reactive osteoproliferative changes of the bone [ 34 , 43 ]. These signs are only present in a subpopulation of all PJI and thus have a low sensitivity while having a reasonable specificity.

Original data

Looking at the original data (Table  2 ), the numbers on which statements are based are generally low ranging from 2 to 50 with a median of 15. The discrepancies in the reported data are, however, extreme: radiographic abnormalities are visible in all cases of PJI of the hip [ 44 , 45 , 46 , 47 ]. Other authors only report very low incidences of such findings [ 48 , 49 , 50 ]. Related features are periosteal reaction [ 5 , 45 ], a radiolucent zone [ 7 , 45 ], sinking of the prosthesis or loosening [ 45 , 49 , 50 , 51 ], periprosthetic osteolysis or scalloped endosteal bone resorption [ 5 , 7 , 38 , 50 , 52 ], scalloping [ 45 ], and in cemented shafts cement mantle irregularities [ 51 ]. The first changes appear to be visible 3 months after the onset of symptoms [ 45 ]. The absence of periprosthetic osteolysis was reported to be predictive of aseptic loosening [ 52 ]. Lyons et al., reported a sensitivity of 47% and a specificity of 96% for scalloped bone resorption whereas laminated periosteal new bone had only a 25% sensitivity with, however, also a 92% specificity ( n =  16) [ 5 ].

Heterotopic bone formation can occur in PJIs [ 53 ], but it can also be present in cases of aseptic loosening or just idiopathic [ 52 ]. In a retrospective study including 168 patients, Manrique et al. [ 54 ], reported an incidence of heterotopic ossifications following surgical treatment of PJI of the hip 84% and in aseptic revision cases of only 11%. Cases after periprosthetic joint infection in that study also had significantly higher Brooker grades [ 54 ]. In a CT-based study, Isern-Kebschull et al., reported a sensitivity for periarticular ossifications of 20% (8.4–36.9), a specificity of 79% (66.3–88.1), a positive predictive value of 35 (15.4–59.2), and a negative predictive value of 63 (51.3–73.9) [ 55 ].

Regarding risk factors for infection, an interesting observation was made by Rey Fernandez et al. who described that patients with more than 60 mm soft-tissue thickness over the greater trochanter had a sevenfold higher risk of infection [ 56 ].

Only one study explicitly elaborated on the detected bacteria and described the associated radiologic findings: Barrack et al. [ 44 ], reported 5 cases infected with S. epidermidis and found periostitis (3×), focal lysis (1×), diffuse lysis with endosteal scalloping (1×) and heterotopic ossification (2×). One case with Strept. sanguis had focal lyses around the implant.

PJI is one of the most serious complications after total hip arthroplasty and poses major diagnostic challenges for clinicians. Radiological imaging, especially plain radiographs, is part of every diagnostic workup in case of suspected complications after total hip arthroplasty. There are plenty of reviews and original works dealing with the diagnostic algorithm of PJI. This review aimed to summarize and analyse the available information about the radiologic presentation of PJI and the frequency of appearance. Furthermore, we raised the question of whether the causative microorganisms differ regarding the radiologic presentation.

The first observation of this review is the lack of original data evaluating the radiologic characteristics of PJI of the hip. There are more reviews ( n =  26) repeating findings of other studies than original works ( n =  18). These reviews mainly concentrate on the diagnosis of PJI, however, they do not focus on the radiographic presentation of PJIs. As described in the section "results", the main statements regarding the radiologic presentation in the reviews are the above-mentioned radiologic pathologies. They do not report on the frequency of the radiologic findings and no correlation to causative microorganisms was analysed. Furthermore, the findings regarding the radiologic presentation of PJI of original works are often coproducts of other primary endpoints [ 5 , 44 , 46 , 48 , 50 , 51 , 53 ].

The next interesting finding of this review is the frequency of radiologic abnormalities in the case of a proven PJI of the hip. While some authors report radiographic changes in all of their PJI cases (100%) [ 44 , 45 , 47 ], other authors only presented abnormalities in 14–63% [ 48 , 49 , 50 , 57 ]. Multiple reasons could explain this wide range. Therefore, having a closer look at the original works reporting the frequencies is necessary. The first possible explanation is the lack of a standardized follow-up to classify radiologic changes in the case of PJI. Some authors present radiographs already 6 months after surgery while other authors describe X-rays taken nine years postoperatively. The given collectives are mostly very small with numbers of patients between 6 and 20. Such collectives are not big enough to give sufficient information about the frequency of the appearance of radiological abnormalities.

Furthermore, the oldest and latest works reporting frequencies are separated by more than 40 years of medical evolution [ 45 , 47 ]. The definition and the diagnostic algorithm have, however, relevantly changed since then and therefore these studies lack comparability [ 58 , 59 ]. Similarly, the technique of acquiring radiographs has also improved with the advent of digital radiography. This allows post-imaging optimization of each X-ray to visualize also structures such as soft tissues that were difficult to discern in traditional images intended for a good bone contrast only.

When using radiographs not only to exclude differential diagnoses, but also to diagnose a PJI, sensitivity and specificity are crucial. Two original works are reporting about the diagnostic value with similar results. The sensitivity could be classified as low at 20–25% while the specificity of periosteal reactions and periarticular calcifications is moderate to good (79–92%) [ 5 , 52 ]. Consequently, plain radiographs could be used to confirm PJI in the presence of characteristic radiologic abnormalities. Especially in the case of early PJI, the majority of cases of early PJI radiographs are still usually normal [ 43 ]. As a consequence, the question of how to interpret and use radiographs to diagnose late PJIs and the diagnostic value of this technique remains equivocal with the analysed literature.

Having a look at radiographs taken after septic revisions of hip arthroplasties, three original works report heterotopic ossifications. Incidences range depending on the collective analysis between 12 and 84%. Brooker grades presented were mainly between one and three [ 53 , 54 , 60 ]. Interestingly, when comparing aseptic and septic revisions, heterotopic ossifications are significantly more likely in septic cases (11 vs. 84%) and present with significantly higher Brooker grades [ 54 ]. Consequently, some kind of interaction between soft tissue and the causing microorganisms can be assumed. This assumption is highlighted by the observation of Rey Fernández et al., that there is an association between higher soft-tissue thickness and risk for PJI after primary total hip replacements. Furthermore, patients with more than 60 mm soft-tissue thickness around the major trochanter had a sevenfold higher risk of PJI [ 56 ]. Unfortunately, there are no data available considering the association between the causing microorganisms and soft-tissue changes.

Historically and as presented in the analysed reviews, characteristics that are described to recognize a PJI of the hip on a plain radiograph are periosteal reaction, a wide band of radiolucency at the cement–bone or metal–bone interface, patchy osteolysis, implant loosening, bone resorption around the implant, and transcortical sinus tracts. In cases of aseptic loosening, there is slow and progressive evolution, while in cases of infectious loosening, this loosening occurs rapidly, in a more aggressive manner and with greater bone destruction [ 7 , 61 ]. Data regarding the frequency of occurrence of the named radiologic abnormalities in cases of PJI are insufficient. Prospective or at least retrospective analyses with larger collectives are necessary to evaluate the frequency and to define the diagnostic value of the radiologic presentation for the diagnosis of PJI. Furthermore, there is a lack of data analysing the association between the causative microorganisms and the radiologic appearance. Although imaging techniques like computer tomography [ 52 , 55 , 62 ] or magnetic resonance imaging [ 63 ] have been reported to also provide additional and helpful clues concerning the presence of a PJI such as periosteal reaction, capsule oedema, and intramuscular oedema, the mainstay in diagnosing PJI to date remains plain radiographs.

Typical radiologic abnormalities of PJI are periosteal reaction, a wide band of radiolucency at the cement–bone or metal–bone interface, patchy osteolysis, implant loosening, bone resorption around the implant, and transcortical sinus tracts. The frequency of their occurrence is still inadequately defined. A deeper understanding of the underlying causes and the relation to microorganisms can probably help clinicians in the future to diagnose a PJI. This is why further research should still further evaluate the radiographic features and value in the context of PJI.

Availability of data and materials

The datasets generated during and/or analysed during the current study are available throughout the manuscript.

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Voices from the north: exploring sámi people’s perspectives on environmental change and mental well-being: a systematic literature review  †.

1. Introduction

Research objectives.

• To explore Circumpolar Indigenous People’s perspectives, as described in published peer-reviewed scientific literature, on the interconnection between environmental change and mental well-being, with a special focus on their perspectives on protective factors and factors promoting resilience.
• To explore Sámi People’s perspectives, as described in published peer-reviewed scientific literature, on the interconnection between environmental change and mental well-being, with a special focus on their perspectives on protective factors and factors promoting resilience.
• To compare the findings of the first and second objectives.

2. Materials and Methods

• What are Circumpolar Indigenous People’s perspectives on the interconnection between environmental change and mental well-being, as described in published peer-reviewed scientific literature?
• What are Sámi People’s perspectives on the interconnection between environmental change and mental well-being, as described in the published peer-reviewed scientific literature?

2.1. Study Population: The Sámi

2.2. search strategy, 2.3. eligibility criteria, 2.4. databases, 2.5. search concepts, 2.6. study selection, 2.7. quality assessment, 2.8. data analysis, 2.9. ethical considerations, 3.1. summary of results, 3.2. study characteristics, 3.3. quality assessment, 3.4. thematic analysis, 3.4.1. encounters with environmental changes, 3.4.2. interrelation between environmental change and mental well-being, layered burden on mental well-being, worries and mental stress, feeling ignored and threatened, community norms and the impact on identity, 3.4.3. protective factors, strong family ties and community participation, interconnection with the environment and traditional knowledge, traditional practices and cultural identity, involvement in reindeer herding and physical activity, 3.4.4. factors promoting resilience, adaptation strategies and active engagement, 3.5. summary of findings, 4. discussion, 4.1. limitations, 4.2. conclusions, supplementary materials, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Venhof, V.S.M.; Stephens, C.; Martens, P. Voices from the North: Exploring Sámi People’s Perspectives on Environmental Change and Mental Well-Being: A Systematic Literature Review. Challenges 2024 , 15 , 30. https://doi.org/10.3390/challe15020030

Venhof VSM, Stephens C, Martens P. Voices from the North: Exploring Sámi People’s Perspectives on Environmental Change and Mental Well-Being: A Systematic Literature Review. Challenges . 2024; 15(2):30. https://doi.org/10.3390/challe15020030

Venhof, Valesca S. M., Carolyn Stephens, and Pim Martens. 2024. "Voices from the North: Exploring Sámi People’s Perspectives on Environmental Change and Mental Well-Being: A Systematic Literature Review" Challenges 15, no. 2: 30. https://doi.org/10.3390/challe15020030

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