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Factors Affecting Perceptions of Open, Mini-Open, and Arthroscopic Rotator Cuff Repair Techniques Among Medical Professionals
Rotator cuff tears are a common condition affecting the shoulder joint. Initial open repair techniques were associated with several complications, including severe early postoperative pain, deltoid detachment and/or weakness, risk for infection, and arthrofibrosis.1-3 In addition, open procedures cannot address other possible diagnoses, such as labral tears and loose bodies. These disadvantages promoted the development of an arthroscopically assisted mini-open technique.4 Superior long-term results, with more than 90% of patients achieving good to excellent results,5-13 established the mini-open rotator cuff repair (RCR) as the gold standard.3,6,10,12,14-16
Recently, as instrumentation for arthroscopy has improved, enthusiasm for all-arthroscopic techniques (hereafter referred to as arthroscopic repair) has grown. The appeal of arthroscopic repair includes potentially less initial pain, ability to treat intra-articular lesions concurrently, smaller skin incisions with better cosmesis, less soft-tissue dissection, and low risk for deltoid detachment.3,17 The potential advantages of arthroscopic repair can lead to perceptions of quicker healing and shorter recovery, which are not supported by the literature. However, arthroscopic repair is technically more challenging, time-consuming, and expensive than open or mini-open repairs,18,19 and though some investigators have reported a trend toward fewer complications,3 the long-term outcome of arthroscopic RCRs has not been shown to be better than that of other techniques.
Given that no differences have been shown between the emerging arthroscopic repair technique and mini-open repair with respect to range of motion or clinical scores in the short term,3 it is unclear what perceptions influence choice of technique for one’s own personal RCR.
We conducted a study to determine which RCR technique medical professionals (orthopedic attendings and residents, anesthesiologists, internal medicine attendings, main operating room nurses, and physical therapists) preferred for their own surgery and to analyze perceptions shaping those opinions. Orthopedic surgeons have the best concept of rotator cuff surgery, but anesthesiologists and nurses have a “front row seat” and opinions on types of rotator cuff surgery. Physical therapists, who treat patients with rotator cuff tears, also have a working knowledge of rotator cuff surgery. Finally, internists represent a rotator cuff injury referral service and may have patients who have undergone rotator cuff surgery. We hypothesized that most medical professionals, irrespective of specialty or career length, would prefer arthroscopic RCR because of its perceived superior outcome and fast recovery.
Materials and Methods
This cross-sectional, descriptive, survey-based study was approved by our institutional review board (IRB) and offered via 3 emails between April 2011 and June 2011 to attendings (orthopedists, internists, anesthesiologists), residents, and allied health professionals (AHPs; operating room nurses, physical therapists) involved in orthopedic care at our institution. Each email contained a hyperlink to the online survey (Appendix), which took about 10 minutes to complete and explored respondent demographics, exposure to the different techniques, and opinions regarding different aspects of RCR surgery and recovery.
There were 84 respondents. The sexes were equally represented, and age ranged from 25 to 78 years (Table 1). Of the respondents, 41 (49%) were attendings, 20 (24%) were residents, and 23 (27%) were AHPs. Of the attendings, 13 (32%) were orthopedic surgeons, 26 (63%) were primary care physicians, and 2 (5%) did not specify their specialty. Four orthopedic surgeons had fellowship training in sports medicine or shoulder and elbow surgery. The attendings were overall more experienced in their profession than the other groups were, with 68% reporting more than 5 years of experience.
Descriptive statistics, including means and standard errors, were calculated. Fisher exact test was used to compare preferences of RCR type according to type of training and years of experience. Significance was set at P ≤ .05.
Results
Overall Responses (Table 2)
Of the 84 respondents, almost half (46%) preferred deferring their choice of RCR to their surgeon. Most of the other respondents preferred the arthroscopic technique (26%) or the mini-open repair (23%). There was no association between technique preference and medical professional type. Most respondents (63%) had never assisted in or performed rotator cuff surgery.
Seventy-four percent of all respondents indicated they thought arthroscopic, mini-open, and open RCRs are safe, and about half thought these procedures are fast. About half expressed no opinion about the cost-effectiveness of arthroscopic, mini-open, or open RCRs (54%, 52%, and 48%, respectively), and slightly more than half expressed no opinion about whether arthroscopic, mini-open, or open RCR provide the best outcome (58%, 60%, and 62%, respectively). Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs, rather than open repairs, promote quick healing (64% and 45%, respectively, vs 15%), good cosmetic results (81% and 51%, respectively, vs 10%), and patient satisfaction (50% and 48%, respectively, vs 30%). However, a significant (P < .05) number also thought arthroscopic and mini-open repairs are harder to learn/more challenging to perform than open repairs (52% and 38%, respectively, vs 17%).
Of all factors considered, safety of arthroscopic repair garnered the highest consensus: 82%. Respondents were least opinionated about the outcome of the open repair technique, with more than 62% expressing no opinion about the outcome. The responses to the questions on the learning curves for the 3 techniques varied the most.
Responses by Group (Table 2)
Attendings. Of the 41 attendings, 24 (59%) responded they would defer to their surgeon’s technique preference for RCR. Of the other 17 who expressed a preference, most indicated arthroscopic or mini-open repair (17% each). There was a difference (P < .05) between years of experience and RCR preference: of the 13 attendings with less than 5 years of experience, arthroscopic repair was preferred by 31%; in contrast, of the 28 attendings with more than 5 years of experience, only 11% preferred arthroscopic repair.
Of the 11 attendings who performed rotator cuff surgery, 55% used the open technique, but most (8) preferred to have their own rotator cuff fixed arthroscopically or according to their surgeon’s preference. Only 1 surgeon preferred open repair for his own rotator cuff. Of the 4 surgeons who performed arthroscopic RCRs, 3 had less than 5 years of experience. Conversely, all 7 surgeons who performed mini-open or open repairs had more than 5 years of experience.
Of the 30 attendings who did not perform rotator cuff surgery, most (20) responded they would defer to their surgeon’s technique preference for RCR.
The attendings’ opinions on factors affecting rotator cuff surgery were similar to those of the other respondents with respect to safety, cost-effectiveness, recovery, cosmesis, patient satisfaction, outcome, and technical difficulty. Unlike the others, however, attendings considered all 3 repair techniques fast.
Residents. Of the 20 residents, 7 preferred arthroscopic, 5 preferred mini-open, and 1 preferred open repair; the other 7 responded they would defer to their surgeon’s preference. Residents’ opinions on each factor were more polarized and consistent across categories than those of the other groups. Residents overwhelmingly thought all 3 techniques (arthroscopic, mini-open, open) are safe (19, 19, and 18, respectively) and cost-effective (12, 14, and 14, respectively). Although most residents considered the open and mini-open repair techniques fast (19 and 15, respectively), only 8 considered arthroscopic RCR fast, and 4 considered it slow. Residents’ opinions about the technique that produces the best outcome were mixed. As with the other respondents, residents thought arthroscopic RCRs heal fast and produce great cosmetic results, but are challenging to perform and have a steep learning curve. Unlike the other respondents, most residents (12) considered open RCR easy to learn (P = .006), with a learning curve of fewer than 20 procedures.
AHPs. No AHP expressed a preference for open RCR. This group was evenly divided among 3 choices: deferring to their surgeon’s preference, arthroscopic repair, and mini-open repair. The 23 AHPs thought arthroscopic, mini-open, and open repairs are safe (17, 15, and 12, respectively), but most indicated they were “equivocal” about which techniques are cost-effective, challenging to perform, and produce the best outcomes. A significantly (P = .014) larger number of AHPs (7) considered open rotator cuff surgery slow compared with arthroscopic (0) and mini-open (2) repair techniques. As with the overall cohort, AHPs reported arthroscopic and mini-open repairs promote quick healing and good cosmetic results, but are challenging to perform.
Discussion
As our population ages and continues to remain active, the demand for RCR has accelerated. National data show that 272,148 ambulatory RCRs and 20,433 inpatient RCRs were performed in 2006—an overall 141% increase in RCR since 1996.20 In 1996, 41 per 100,000 population underwent RCR.20 By 2006, this number ballooned to 98 per 100,000 population.20 There are 3 predominant techniques for repairing the rotator cuff: open, mini-open, and arthroscopic. As RCR use increases, we should consider the factors that medical professionals consider important when choosing a method for their own RCR.
Of the 84 medical professionals in our cohort, 39 (46%) indicated they would defer to their surgeon’s technique preference for RCR. Of the other 45, about equal numbers preferred arthroscopic and mini-open RCRs; only 2 preferred open RCRs. This finding suggests that the individual opinions of surgeons who perform RCRs have a substantial influence on a large proportion of medical professionals’ ultimate choice of RCR method. Interestingly, of the attendings who performed open RCR, only 1 expressed a preference for the open technique for his own RCR. This finding might suggest a shift in opinion and an emerging perception among surgeons performing RCR about the value of this technique.
Several factors may account for these evolving beliefs. We hypothesized that a biased favorable view of arthroscopic repair outcome might influence opinions. However, our results did not support the hypothesis. Medical professionals in our cohort were equivocal about the best RCR technique. No consensus was evident among attendings, residents, or AHPs. This lack of clinical agreement about rotator cuff surgery has been observed elsewhere—for example, among members of the American Academy of Orthopaedic Surgeons (AAOS)21 and the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy.22 Despite theoretical advantages of arthroscopic repair, there has been no documented significant difference in patient outcomes when compared with other techniques.23 To our knowledge, there have been only a few clinical studies comparing the different RCR techniques. A meta-analysis of 5 clinical studies comparing arthroscopic and mini-open RCR techniques showed no difference in clinical outcomes or complication rates.8 The 2012 AAOS clinical practice guidelines for RCR reflect these observations.24 That consortium of leading shoulder surgeons could not recommend a modality of surgical rotator cuff tear repair given the lack of conclusive evidence.24
At our institution, arthroscopic, mini-open, and open RCRs were performed by 36%, 9%, and 55% of our surgeons, respectively. A survey of AAOS surgeons showed that, of those who perform RCRs, 14.5%, 46.2%, and 36.6% used arthroscopic, mini-open, and open techniques, respectively.21 The greater use of open repairs at our institution might reflect the seniority of our faculty. Dunn and colleagues21 found that surgeons who preferred open RCR had been in practice longer than those who preferred the arthroscopic or mini-open technique. Of our 4 faculty who performed arthroscopic repairs, 3 were less than 5 years from completing their training. In contrast, all faculty who performed mini-open or open repairs were more than 5 years from completing their training. Furthermore, mean age of the surgeons who performed arthroscopic repair was 39.8 years (range, 32-51 years), and these surgeons were significantly younger than those who performed mini-open or open repair (mean age, 56.3 years; range, 41-78 years). Younger surgeon age has been associated with higher rates of arthroscopic repair.25
Attendings unaccustomed to arthroscopy may find it more challenging than the younger generation of surgeons, who are exposed to it early in training. Dunn and colleagues21 noted that the likelihood of performing an arthroscopic repair was influenced by the surgeon’s experience level. Fellowship-trained shoulder and sports medicine surgeons are also more likely to perform arthroscopic repairs than those with training limited to orthopedic residency.25 Arthroscopic RCR demands a high level of technical skill that many acquire in fellowship training.26 Mauro and colleagues26 found that surgeons trained in a sports medicine fellowship performed 82.6% of subacromial decompression and/or RCR procedures arthroscopically, compared with 54.5% to 70.1% for surgeons trained in other fellowships. In our cohort, with the exception of 1 surgeon, all fellowship-trained shoulder and sports medicine surgeons performed arthroscopic RCRs.
Although no conclusive evidence in the literature supports arthroscopic over the other repair types, the demand for arthroscopic RCR has rapidly increased relative to that for the others. Between 1996 and 2006, use of arthroscopic RCR increased 600%, from 8 to 58 per 100,000 population.20 In that same period, use of open RCR increased by only 34%.20 Similarly, Mauro and colleagues26 found that the proportion of subacromial decompression and RCRs performed arthroscopically rose from 58.3% in 2004 to 83.7% in 2009. Using the 2006 New York State Ambulatory Surgery Database, Churchill and Ghorai27 found that 74.5% of RCRs with acromioplasty were performed arthroscopically.
Respondent-indicated factors that may have contributed to the more favorable opinion of arthroscopic and mini-open repair include quick healing, good cosmetic results, and better perceived patient satisfaction. The literature supports these perceptions. Baker and Liu14 found shorter hospital stays and quicker return to activity with arthroscopic repair compared with open repair. Vitale and colleagues25 also noted that, compared with open or mini-open repair techniques, arthroscopic repair resulted in shorter hospitalization and quicker overall recovery.
If these selected health care professionals with some inside information on rotator cuff surgery have biases that affect their selection of rotator cuff procedures, we should acknowledge that nonmedical personnel, in particular our patients, also have biases. The knowledge base of patients may be further influenced by friends or family members who have had rotator cuff surgery, by lay publications, and by the Internet. Satisfaction with any surgical procedure depends not only on the success of the surgery and the rehabilitation but also on patient and provider expectations. Such expectations are influenced, in part, by biases.
Our medical professionals had similar opinions on safety, recovery, cosmesis, and overall outcome of the RCR techniques, but different opinions on procedure durations and associated training requirements. All residents except one indicated open repair was a quick procedure. In contrast, a significant number of AHPs thought open repair was time-consuming. The attendings considered all the methods fast. The residents’ opinions were the most consistent with the true operating times reported. According to the literature, total operating time for mini-open repair ranges from 10 to 16 minutes faster than that for arthroscopic repair.18,20,27 Ultimately, procedure duration did not affect the respondents’ technique preference for RCR.
There was substantial disagreement about the number of procedures needed to become proficient in the different repair techniques. Overall, however, there was consensus that arthroscopic and mini-open repairs had longer learning curves than open repair. Given the lack of agreement among orthopedic department chairmen and sports medicine fellowship directors regarding the minimum exposure needed (during residency) to become proficient in diagnostic shoulder arthroscopy,28 this finding is not surprising. Guttmann and colleagues29 attempted to quantify the learning curve for arthroscopic RCR by tracking operating time as a surrogate measure. They found that RCR operative time decreased rapidly during the initial block of 10 cases to the second block of 10 cases, but thereafter improvement continued at a much lower rate.29 None of our respondents thought the learning curve for arthroscopic RCR was under 10 cases, but no group, not even the attendings who performed RCRs, could agree on the minimum number of cases needed for proficiency. The longer learning curve for arthroscopic RCR did not discourage the respondents who preferred arthroscopic or mini-open RCR.
Cost was not an influential factor in opinions about which RCR method is optimal. Medical professionals were ambivalent about the cost-effectiveness of the different procedures, with most expressing no opinion on cost. Multiple investigators have shown that arthroscopic RCR costs as much as $1144 more than mini-open RCR,18,27 which has many of the advantages of arthroscopic repair but not the costly implants and instruments. As our medical community becomes more cost-conscious, concern about this factor may increase among medical professionals.
Our study had several limitations. Its results must be interpreted carefully, given they represent the viewpoints of a nonrandomized sample of motivated respondents at one institution. A selection bias excluded surgeons who were uncomfortable with RCR and unwilling to report any shortcomings. The conclusions cannot be generalized to other medical professionals or to other institutions. Furthermore, to develop a simple, straightforward survey focused on a specific type of rotator cuff tear, and to avoid confusion, we assumed that the treatment preference for the described tear was generalizable to all encountered tears. However, some surgeons have reported different repair techniques for different types and sizes of rotator cuff tears.25
Conclusion
Most of our surveyed medical professionals were willing to defer to their surgeon’s decision about which technique would be appropriate for their own personal RCR. There is a trend nationally, and at our institution, for increased use of arthroscopic RCR. Although medical professionals readily acknowledge it is unclear which repair method provides the best ultimate outcome, many perceive fast recovery and good cosmetic results with arthroscopic and mini-open repairs. When medical professionals are counseling patients, we need to recognize these personal biases because many patients defer to their surgeon’s counsel. For some medical professionals, cosmesis can be an important factor, but cost, procedure duration, potential technical challenges of arthroscopic repair, and other considerations may make other techniques more desirable for others.
1. Bennett WF. Arthroscopic repair of massive rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy. 2003;19(4):380-390.
2. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): a prospective study with 2- to 4-year follow-up. Arthroscopy. 2003;19(3):249-256.
3. Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am. 2007;89(suppl 3):127-136.
4. Duralde XA, Greene RT. Mini-open rotator cuff repair via an anterosuperior approach. J Shoulder Elbow Surg. 2008;17(5):715-721.
5. Blevins FT, Warren RF, Cavo C, et al. Arthroscopic assisted rotator cuff repair: results using a mini-open deltoid splitting approach. Arthroscopy. 1996;12(1):50-59.
6. Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990;6(1):55-60.
7. Liu SH. Arthroscopically-assisted rotator-cuff repair. J Bone Joint Surg Br. 1994;76(4):592-595.
8. Morse K, Davis AD, Afra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. 2008;36(9):1824-1828.
9. Park JY, Levine WN, Marra G, Pollock RG, Flatow EL, Bigliani LU. Portal-extension approach for the repair of small and medium rotator cuff tears. Am J Sports Med. 2000;28(3):312-316.
10. Paulos LE, Kody MH. Arthroscopically enhanced “miniapproach” to rotator cuff repair. Am J Sports Med. 1994;22(1):19-25.
11. Posada A, Uribe JW, Hechtman KS, Tjin-A-Tsoi EW, Zvijac JE. Mini-deltoid splitting rotator cuff repair: do results deteriorate with time? Arthroscopy. 2000;16(2):137-141.
12. Shinners TJ, Noordsij PG, Orwin JF. Arthroscopically assisted mini-open rotator cuff repair. Arthroscopy. 2002;18(1):21-26.
13. Weber SC. Arthroscopic debridement and acromioplasty versus mini-open repair in the treatment of significant partial-thickness rotator cuff tears. Arthroscopy. 1999;15(2):126-131.
14. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med. 1995;23(1):99-104.
15. Liu SH, Baker CL. Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy. 1994;10(1):54-60.
16. Pollock RG, Flatow EL. The rotator cuff, part II. Full-thickness tears. Mini-open repair. Orthop Clin North Am. 1997;28(2):169-177.
17. Yamaguchi K, Levine WN, Marra G, Galatz LM, Klepps S, Flatow EL. Transitioning to arthroscopic rotator cuff repair: the pros and cons. Instr Course Lect. 2003;52:81-92.
18. Adla DN, Rowsell M, Pandey R. Cost-effectiveness of open versus arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2010;19(2):258-261.
19. Kose KC, Tezen E, Cebesoy O, et al. Mini-open versus all-arthroscopic rotator cuff repair: comparison of the operative costs and the clinical outcomes. Adv Ther. 2008;25(3):249-259.
20. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-233.
21. Dunn WR, Schackman BR, Walsh C, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87(9):1978-1984.
22. Randelli P, Arrigoni P, Cabitza F, Ragone V, Cabitza P. Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons. Knee Surg Sports Traumatol Arthrosc. 2012;20(5):803-815.
23. Aleem AW, Brophy RH. Outcomes of rotator cuff surgery: what does the evidence tell us? Clin Sports Med. 2012;31(4):665-674.
24. Pedowitz RA, Yamaguchi K, Ahmad CS, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: optimizing the management of rotator cuff problems. J Bone Joint Surg Am. 2012;94(2):163-167.
25. Vitale MA, Kleweno CP, Jacir AM, Levine WN, Bigliani LU, Ahmad CS. Training resources in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2007;89(6):1393-1398.
26. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2012;94(16):1492-1499.
27. Churchill RS, Ghorai JK. Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: mini-open versus all-arthroscopic. J Shoulder Elbow Surg. 2010;19(5):716-721.
28. O’Neill PJ, Cosgarea AJ, Freedman JA, Queale WS, McFarland EG. Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy. 2002;18(7):795-800.
29. Guttmann D, Graham RD, MacLennan MJ, Lubowitz JH. Arthroscopic rotator cuff repair: the learning curve. Arthroscopy. 2005;21(4):394-400.
Rotator cuff tears are a common condition affecting the shoulder joint. Initial open repair techniques were associated with several complications, including severe early postoperative pain, deltoid detachment and/or weakness, risk for infection, and arthrofibrosis.1-3 In addition, open procedures cannot address other possible diagnoses, such as labral tears and loose bodies. These disadvantages promoted the development of an arthroscopically assisted mini-open technique.4 Superior long-term results, with more than 90% of patients achieving good to excellent results,5-13 established the mini-open rotator cuff repair (RCR) as the gold standard.3,6,10,12,14-16
Recently, as instrumentation for arthroscopy has improved, enthusiasm for all-arthroscopic techniques (hereafter referred to as arthroscopic repair) has grown. The appeal of arthroscopic repair includes potentially less initial pain, ability to treat intra-articular lesions concurrently, smaller skin incisions with better cosmesis, less soft-tissue dissection, and low risk for deltoid detachment.3,17 The potential advantages of arthroscopic repair can lead to perceptions of quicker healing and shorter recovery, which are not supported by the literature. However, arthroscopic repair is technically more challenging, time-consuming, and expensive than open or mini-open repairs,18,19 and though some investigators have reported a trend toward fewer complications,3 the long-term outcome of arthroscopic RCRs has not been shown to be better than that of other techniques.
Given that no differences have been shown between the emerging arthroscopic repair technique and mini-open repair with respect to range of motion or clinical scores in the short term,3 it is unclear what perceptions influence choice of technique for one’s own personal RCR.
We conducted a study to determine which RCR technique medical professionals (orthopedic attendings and residents, anesthesiologists, internal medicine attendings, main operating room nurses, and physical therapists) preferred for their own surgery and to analyze perceptions shaping those opinions. Orthopedic surgeons have the best concept of rotator cuff surgery, but anesthesiologists and nurses have a “front row seat” and opinions on types of rotator cuff surgery. Physical therapists, who treat patients with rotator cuff tears, also have a working knowledge of rotator cuff surgery. Finally, internists represent a rotator cuff injury referral service and may have patients who have undergone rotator cuff surgery. We hypothesized that most medical professionals, irrespective of specialty or career length, would prefer arthroscopic RCR because of its perceived superior outcome and fast recovery.
Materials and Methods
This cross-sectional, descriptive, survey-based study was approved by our institutional review board (IRB) and offered via 3 emails between April 2011 and June 2011 to attendings (orthopedists, internists, anesthesiologists), residents, and allied health professionals (AHPs; operating room nurses, physical therapists) involved in orthopedic care at our institution. Each email contained a hyperlink to the online survey (Appendix), which took about 10 minutes to complete and explored respondent demographics, exposure to the different techniques, and opinions regarding different aspects of RCR surgery and recovery.
There were 84 respondents. The sexes were equally represented, and age ranged from 25 to 78 years (Table 1). Of the respondents, 41 (49%) were attendings, 20 (24%) were residents, and 23 (27%) were AHPs. Of the attendings, 13 (32%) were orthopedic surgeons, 26 (63%) were primary care physicians, and 2 (5%) did not specify their specialty. Four orthopedic surgeons had fellowship training in sports medicine or shoulder and elbow surgery. The attendings were overall more experienced in their profession than the other groups were, with 68% reporting more than 5 years of experience.
Descriptive statistics, including means and standard errors, were calculated. Fisher exact test was used to compare preferences of RCR type according to type of training and years of experience. Significance was set at P ≤ .05.
Results
Overall Responses (Table 2)
Of the 84 respondents, almost half (46%) preferred deferring their choice of RCR to their surgeon. Most of the other respondents preferred the arthroscopic technique (26%) or the mini-open repair (23%). There was no association between technique preference and medical professional type. Most respondents (63%) had never assisted in or performed rotator cuff surgery.
Seventy-four percent of all respondents indicated they thought arthroscopic, mini-open, and open RCRs are safe, and about half thought these procedures are fast. About half expressed no opinion about the cost-effectiveness of arthroscopic, mini-open, or open RCRs (54%, 52%, and 48%, respectively), and slightly more than half expressed no opinion about whether arthroscopic, mini-open, or open RCR provide the best outcome (58%, 60%, and 62%, respectively). Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs, rather than open repairs, promote quick healing (64% and 45%, respectively, vs 15%), good cosmetic results (81% and 51%, respectively, vs 10%), and patient satisfaction (50% and 48%, respectively, vs 30%). However, a significant (P < .05) number also thought arthroscopic and mini-open repairs are harder to learn/more challenging to perform than open repairs (52% and 38%, respectively, vs 17%).
Of all factors considered, safety of arthroscopic repair garnered the highest consensus: 82%. Respondents were least opinionated about the outcome of the open repair technique, with more than 62% expressing no opinion about the outcome. The responses to the questions on the learning curves for the 3 techniques varied the most.
Responses by Group (Table 2)
Attendings. Of the 41 attendings, 24 (59%) responded they would defer to their surgeon’s technique preference for RCR. Of the other 17 who expressed a preference, most indicated arthroscopic or mini-open repair (17% each). There was a difference (P < .05) between years of experience and RCR preference: of the 13 attendings with less than 5 years of experience, arthroscopic repair was preferred by 31%; in contrast, of the 28 attendings with more than 5 years of experience, only 11% preferred arthroscopic repair.
Of the 11 attendings who performed rotator cuff surgery, 55% used the open technique, but most (8) preferred to have their own rotator cuff fixed arthroscopically or according to their surgeon’s preference. Only 1 surgeon preferred open repair for his own rotator cuff. Of the 4 surgeons who performed arthroscopic RCRs, 3 had less than 5 years of experience. Conversely, all 7 surgeons who performed mini-open or open repairs had more than 5 years of experience.
Of the 30 attendings who did not perform rotator cuff surgery, most (20) responded they would defer to their surgeon’s technique preference for RCR.
The attendings’ opinions on factors affecting rotator cuff surgery were similar to those of the other respondents with respect to safety, cost-effectiveness, recovery, cosmesis, patient satisfaction, outcome, and technical difficulty. Unlike the others, however, attendings considered all 3 repair techniques fast.
Residents. Of the 20 residents, 7 preferred arthroscopic, 5 preferred mini-open, and 1 preferred open repair; the other 7 responded they would defer to their surgeon’s preference. Residents’ opinions on each factor were more polarized and consistent across categories than those of the other groups. Residents overwhelmingly thought all 3 techniques (arthroscopic, mini-open, open) are safe (19, 19, and 18, respectively) and cost-effective (12, 14, and 14, respectively). Although most residents considered the open and mini-open repair techniques fast (19 and 15, respectively), only 8 considered arthroscopic RCR fast, and 4 considered it slow. Residents’ opinions about the technique that produces the best outcome were mixed. As with the other respondents, residents thought arthroscopic RCRs heal fast and produce great cosmetic results, but are challenging to perform and have a steep learning curve. Unlike the other respondents, most residents (12) considered open RCR easy to learn (P = .006), with a learning curve of fewer than 20 procedures.
AHPs. No AHP expressed a preference for open RCR. This group was evenly divided among 3 choices: deferring to their surgeon’s preference, arthroscopic repair, and mini-open repair. The 23 AHPs thought arthroscopic, mini-open, and open repairs are safe (17, 15, and 12, respectively), but most indicated they were “equivocal” about which techniques are cost-effective, challenging to perform, and produce the best outcomes. A significantly (P = .014) larger number of AHPs (7) considered open rotator cuff surgery slow compared with arthroscopic (0) and mini-open (2) repair techniques. As with the overall cohort, AHPs reported arthroscopic and mini-open repairs promote quick healing and good cosmetic results, but are challenging to perform.
Discussion
As our population ages and continues to remain active, the demand for RCR has accelerated. National data show that 272,148 ambulatory RCRs and 20,433 inpatient RCRs were performed in 2006—an overall 141% increase in RCR since 1996.20 In 1996, 41 per 100,000 population underwent RCR.20 By 2006, this number ballooned to 98 per 100,000 population.20 There are 3 predominant techniques for repairing the rotator cuff: open, mini-open, and arthroscopic. As RCR use increases, we should consider the factors that medical professionals consider important when choosing a method for their own RCR.
Of the 84 medical professionals in our cohort, 39 (46%) indicated they would defer to their surgeon’s technique preference for RCR. Of the other 45, about equal numbers preferred arthroscopic and mini-open RCRs; only 2 preferred open RCRs. This finding suggests that the individual opinions of surgeons who perform RCRs have a substantial influence on a large proportion of medical professionals’ ultimate choice of RCR method. Interestingly, of the attendings who performed open RCR, only 1 expressed a preference for the open technique for his own RCR. This finding might suggest a shift in opinion and an emerging perception among surgeons performing RCR about the value of this technique.
Several factors may account for these evolving beliefs. We hypothesized that a biased favorable view of arthroscopic repair outcome might influence opinions. However, our results did not support the hypothesis. Medical professionals in our cohort were equivocal about the best RCR technique. No consensus was evident among attendings, residents, or AHPs. This lack of clinical agreement about rotator cuff surgery has been observed elsewhere—for example, among members of the American Academy of Orthopaedic Surgeons (AAOS)21 and the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy.22 Despite theoretical advantages of arthroscopic repair, there has been no documented significant difference in patient outcomes when compared with other techniques.23 To our knowledge, there have been only a few clinical studies comparing the different RCR techniques. A meta-analysis of 5 clinical studies comparing arthroscopic and mini-open RCR techniques showed no difference in clinical outcomes or complication rates.8 The 2012 AAOS clinical practice guidelines for RCR reflect these observations.24 That consortium of leading shoulder surgeons could not recommend a modality of surgical rotator cuff tear repair given the lack of conclusive evidence.24
At our institution, arthroscopic, mini-open, and open RCRs were performed by 36%, 9%, and 55% of our surgeons, respectively. A survey of AAOS surgeons showed that, of those who perform RCRs, 14.5%, 46.2%, and 36.6% used arthroscopic, mini-open, and open techniques, respectively.21 The greater use of open repairs at our institution might reflect the seniority of our faculty. Dunn and colleagues21 found that surgeons who preferred open RCR had been in practice longer than those who preferred the arthroscopic or mini-open technique. Of our 4 faculty who performed arthroscopic repairs, 3 were less than 5 years from completing their training. In contrast, all faculty who performed mini-open or open repairs were more than 5 years from completing their training. Furthermore, mean age of the surgeons who performed arthroscopic repair was 39.8 years (range, 32-51 years), and these surgeons were significantly younger than those who performed mini-open or open repair (mean age, 56.3 years; range, 41-78 years). Younger surgeon age has been associated with higher rates of arthroscopic repair.25
Attendings unaccustomed to arthroscopy may find it more challenging than the younger generation of surgeons, who are exposed to it early in training. Dunn and colleagues21 noted that the likelihood of performing an arthroscopic repair was influenced by the surgeon’s experience level. Fellowship-trained shoulder and sports medicine surgeons are also more likely to perform arthroscopic repairs than those with training limited to orthopedic residency.25 Arthroscopic RCR demands a high level of technical skill that many acquire in fellowship training.26 Mauro and colleagues26 found that surgeons trained in a sports medicine fellowship performed 82.6% of subacromial decompression and/or RCR procedures arthroscopically, compared with 54.5% to 70.1% for surgeons trained in other fellowships. In our cohort, with the exception of 1 surgeon, all fellowship-trained shoulder and sports medicine surgeons performed arthroscopic RCRs.
Although no conclusive evidence in the literature supports arthroscopic over the other repair types, the demand for arthroscopic RCR has rapidly increased relative to that for the others. Between 1996 and 2006, use of arthroscopic RCR increased 600%, from 8 to 58 per 100,000 population.20 In that same period, use of open RCR increased by only 34%.20 Similarly, Mauro and colleagues26 found that the proportion of subacromial decompression and RCRs performed arthroscopically rose from 58.3% in 2004 to 83.7% in 2009. Using the 2006 New York State Ambulatory Surgery Database, Churchill and Ghorai27 found that 74.5% of RCRs with acromioplasty were performed arthroscopically.
Respondent-indicated factors that may have contributed to the more favorable opinion of arthroscopic and mini-open repair include quick healing, good cosmetic results, and better perceived patient satisfaction. The literature supports these perceptions. Baker and Liu14 found shorter hospital stays and quicker return to activity with arthroscopic repair compared with open repair. Vitale and colleagues25 also noted that, compared with open or mini-open repair techniques, arthroscopic repair resulted in shorter hospitalization and quicker overall recovery.
If these selected health care professionals with some inside information on rotator cuff surgery have biases that affect their selection of rotator cuff procedures, we should acknowledge that nonmedical personnel, in particular our patients, also have biases. The knowledge base of patients may be further influenced by friends or family members who have had rotator cuff surgery, by lay publications, and by the Internet. Satisfaction with any surgical procedure depends not only on the success of the surgery and the rehabilitation but also on patient and provider expectations. Such expectations are influenced, in part, by biases.
Our medical professionals had similar opinions on safety, recovery, cosmesis, and overall outcome of the RCR techniques, but different opinions on procedure durations and associated training requirements. All residents except one indicated open repair was a quick procedure. In contrast, a significant number of AHPs thought open repair was time-consuming. The attendings considered all the methods fast. The residents’ opinions were the most consistent with the true operating times reported. According to the literature, total operating time for mini-open repair ranges from 10 to 16 minutes faster than that for arthroscopic repair.18,20,27 Ultimately, procedure duration did not affect the respondents’ technique preference for RCR.
There was substantial disagreement about the number of procedures needed to become proficient in the different repair techniques. Overall, however, there was consensus that arthroscopic and mini-open repairs had longer learning curves than open repair. Given the lack of agreement among orthopedic department chairmen and sports medicine fellowship directors regarding the minimum exposure needed (during residency) to become proficient in diagnostic shoulder arthroscopy,28 this finding is not surprising. Guttmann and colleagues29 attempted to quantify the learning curve for arthroscopic RCR by tracking operating time as a surrogate measure. They found that RCR operative time decreased rapidly during the initial block of 10 cases to the second block of 10 cases, but thereafter improvement continued at a much lower rate.29 None of our respondents thought the learning curve for arthroscopic RCR was under 10 cases, but no group, not even the attendings who performed RCRs, could agree on the minimum number of cases needed for proficiency. The longer learning curve for arthroscopic RCR did not discourage the respondents who preferred arthroscopic or mini-open RCR.
Cost was not an influential factor in opinions about which RCR method is optimal. Medical professionals were ambivalent about the cost-effectiveness of the different procedures, with most expressing no opinion on cost. Multiple investigators have shown that arthroscopic RCR costs as much as $1144 more than mini-open RCR,18,27 which has many of the advantages of arthroscopic repair but not the costly implants and instruments. As our medical community becomes more cost-conscious, concern about this factor may increase among medical professionals.
Our study had several limitations. Its results must be interpreted carefully, given they represent the viewpoints of a nonrandomized sample of motivated respondents at one institution. A selection bias excluded surgeons who were uncomfortable with RCR and unwilling to report any shortcomings. The conclusions cannot be generalized to other medical professionals or to other institutions. Furthermore, to develop a simple, straightforward survey focused on a specific type of rotator cuff tear, and to avoid confusion, we assumed that the treatment preference for the described tear was generalizable to all encountered tears. However, some surgeons have reported different repair techniques for different types and sizes of rotator cuff tears.25
Conclusion
Most of our surveyed medical professionals were willing to defer to their surgeon’s decision about which technique would be appropriate for their own personal RCR. There is a trend nationally, and at our institution, for increased use of arthroscopic RCR. Although medical professionals readily acknowledge it is unclear which repair method provides the best ultimate outcome, many perceive fast recovery and good cosmetic results with arthroscopic and mini-open repairs. When medical professionals are counseling patients, we need to recognize these personal biases because many patients defer to their surgeon’s counsel. For some medical professionals, cosmesis can be an important factor, but cost, procedure duration, potential technical challenges of arthroscopic repair, and other considerations may make other techniques more desirable for others.
Rotator cuff tears are a common condition affecting the shoulder joint. Initial open repair techniques were associated with several complications, including severe early postoperative pain, deltoid detachment and/or weakness, risk for infection, and arthrofibrosis.1-3 In addition, open procedures cannot address other possible diagnoses, such as labral tears and loose bodies. These disadvantages promoted the development of an arthroscopically assisted mini-open technique.4 Superior long-term results, with more than 90% of patients achieving good to excellent results,5-13 established the mini-open rotator cuff repair (RCR) as the gold standard.3,6,10,12,14-16
Recently, as instrumentation for arthroscopy has improved, enthusiasm for all-arthroscopic techniques (hereafter referred to as arthroscopic repair) has grown. The appeal of arthroscopic repair includes potentially less initial pain, ability to treat intra-articular lesions concurrently, smaller skin incisions with better cosmesis, less soft-tissue dissection, and low risk for deltoid detachment.3,17 The potential advantages of arthroscopic repair can lead to perceptions of quicker healing and shorter recovery, which are not supported by the literature. However, arthroscopic repair is technically more challenging, time-consuming, and expensive than open or mini-open repairs,18,19 and though some investigators have reported a trend toward fewer complications,3 the long-term outcome of arthroscopic RCRs has not been shown to be better than that of other techniques.
Given that no differences have been shown between the emerging arthroscopic repair technique and mini-open repair with respect to range of motion or clinical scores in the short term,3 it is unclear what perceptions influence choice of technique for one’s own personal RCR.
We conducted a study to determine which RCR technique medical professionals (orthopedic attendings and residents, anesthesiologists, internal medicine attendings, main operating room nurses, and physical therapists) preferred for their own surgery and to analyze perceptions shaping those opinions. Orthopedic surgeons have the best concept of rotator cuff surgery, but anesthesiologists and nurses have a “front row seat” and opinions on types of rotator cuff surgery. Physical therapists, who treat patients with rotator cuff tears, also have a working knowledge of rotator cuff surgery. Finally, internists represent a rotator cuff injury referral service and may have patients who have undergone rotator cuff surgery. We hypothesized that most medical professionals, irrespective of specialty or career length, would prefer arthroscopic RCR because of its perceived superior outcome and fast recovery.
Materials and Methods
This cross-sectional, descriptive, survey-based study was approved by our institutional review board (IRB) and offered via 3 emails between April 2011 and June 2011 to attendings (orthopedists, internists, anesthesiologists), residents, and allied health professionals (AHPs; operating room nurses, physical therapists) involved in orthopedic care at our institution. Each email contained a hyperlink to the online survey (Appendix), which took about 10 minutes to complete and explored respondent demographics, exposure to the different techniques, and opinions regarding different aspects of RCR surgery and recovery.
There were 84 respondents. The sexes were equally represented, and age ranged from 25 to 78 years (Table 1). Of the respondents, 41 (49%) were attendings, 20 (24%) were residents, and 23 (27%) were AHPs. Of the attendings, 13 (32%) were orthopedic surgeons, 26 (63%) were primary care physicians, and 2 (5%) did not specify their specialty. Four orthopedic surgeons had fellowship training in sports medicine or shoulder and elbow surgery. The attendings were overall more experienced in their profession than the other groups were, with 68% reporting more than 5 years of experience.
Descriptive statistics, including means and standard errors, were calculated. Fisher exact test was used to compare preferences of RCR type according to type of training and years of experience. Significance was set at P ≤ .05.
Results
Overall Responses (Table 2)
Of the 84 respondents, almost half (46%) preferred deferring their choice of RCR to their surgeon. Most of the other respondents preferred the arthroscopic technique (26%) or the mini-open repair (23%). There was no association between technique preference and medical professional type. Most respondents (63%) had never assisted in or performed rotator cuff surgery.
Seventy-four percent of all respondents indicated they thought arthroscopic, mini-open, and open RCRs are safe, and about half thought these procedures are fast. About half expressed no opinion about the cost-effectiveness of arthroscopic, mini-open, or open RCRs (54%, 52%, and 48%, respectively), and slightly more than half expressed no opinion about whether arthroscopic, mini-open, or open RCR provide the best outcome (58%, 60%, and 62%, respectively). Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs, rather than open repairs, promote quick healing (64% and 45%, respectively, vs 15%), good cosmetic results (81% and 51%, respectively, vs 10%), and patient satisfaction (50% and 48%, respectively, vs 30%). However, a significant (P < .05) number also thought arthroscopic and mini-open repairs are harder to learn/more challenging to perform than open repairs (52% and 38%, respectively, vs 17%).
Of all factors considered, safety of arthroscopic repair garnered the highest consensus: 82%. Respondents were least opinionated about the outcome of the open repair technique, with more than 62% expressing no opinion about the outcome. The responses to the questions on the learning curves for the 3 techniques varied the most.
Responses by Group (Table 2)
Attendings. Of the 41 attendings, 24 (59%) responded they would defer to their surgeon’s technique preference for RCR. Of the other 17 who expressed a preference, most indicated arthroscopic or mini-open repair (17% each). There was a difference (P < .05) between years of experience and RCR preference: of the 13 attendings with less than 5 years of experience, arthroscopic repair was preferred by 31%; in contrast, of the 28 attendings with more than 5 years of experience, only 11% preferred arthroscopic repair.
Of the 11 attendings who performed rotator cuff surgery, 55% used the open technique, but most (8) preferred to have their own rotator cuff fixed arthroscopically or according to their surgeon’s preference. Only 1 surgeon preferred open repair for his own rotator cuff. Of the 4 surgeons who performed arthroscopic RCRs, 3 had less than 5 years of experience. Conversely, all 7 surgeons who performed mini-open or open repairs had more than 5 years of experience.
Of the 30 attendings who did not perform rotator cuff surgery, most (20) responded they would defer to their surgeon’s technique preference for RCR.
The attendings’ opinions on factors affecting rotator cuff surgery were similar to those of the other respondents with respect to safety, cost-effectiveness, recovery, cosmesis, patient satisfaction, outcome, and technical difficulty. Unlike the others, however, attendings considered all 3 repair techniques fast.
Residents. Of the 20 residents, 7 preferred arthroscopic, 5 preferred mini-open, and 1 preferred open repair; the other 7 responded they would defer to their surgeon’s preference. Residents’ opinions on each factor were more polarized and consistent across categories than those of the other groups. Residents overwhelmingly thought all 3 techniques (arthroscopic, mini-open, open) are safe (19, 19, and 18, respectively) and cost-effective (12, 14, and 14, respectively). Although most residents considered the open and mini-open repair techniques fast (19 and 15, respectively), only 8 considered arthroscopic RCR fast, and 4 considered it slow. Residents’ opinions about the technique that produces the best outcome were mixed. As with the other respondents, residents thought arthroscopic RCRs heal fast and produce great cosmetic results, but are challenging to perform and have a steep learning curve. Unlike the other respondents, most residents (12) considered open RCR easy to learn (P = .006), with a learning curve of fewer than 20 procedures.
AHPs. No AHP expressed a preference for open RCR. This group was evenly divided among 3 choices: deferring to their surgeon’s preference, arthroscopic repair, and mini-open repair. The 23 AHPs thought arthroscopic, mini-open, and open repairs are safe (17, 15, and 12, respectively), but most indicated they were “equivocal” about which techniques are cost-effective, challenging to perform, and produce the best outcomes. A significantly (P = .014) larger number of AHPs (7) considered open rotator cuff surgery slow compared with arthroscopic (0) and mini-open (2) repair techniques. As with the overall cohort, AHPs reported arthroscopic and mini-open repairs promote quick healing and good cosmetic results, but are challenging to perform.
Discussion
As our population ages and continues to remain active, the demand for RCR has accelerated. National data show that 272,148 ambulatory RCRs and 20,433 inpatient RCRs were performed in 2006—an overall 141% increase in RCR since 1996.20 In 1996, 41 per 100,000 population underwent RCR.20 By 2006, this number ballooned to 98 per 100,000 population.20 There are 3 predominant techniques for repairing the rotator cuff: open, mini-open, and arthroscopic. As RCR use increases, we should consider the factors that medical professionals consider important when choosing a method for their own RCR.
Of the 84 medical professionals in our cohort, 39 (46%) indicated they would defer to their surgeon’s technique preference for RCR. Of the other 45, about equal numbers preferred arthroscopic and mini-open RCRs; only 2 preferred open RCRs. This finding suggests that the individual opinions of surgeons who perform RCRs have a substantial influence on a large proportion of medical professionals’ ultimate choice of RCR method. Interestingly, of the attendings who performed open RCR, only 1 expressed a preference for the open technique for his own RCR. This finding might suggest a shift in opinion and an emerging perception among surgeons performing RCR about the value of this technique.
Several factors may account for these evolving beliefs. We hypothesized that a biased favorable view of arthroscopic repair outcome might influence opinions. However, our results did not support the hypothesis. Medical professionals in our cohort were equivocal about the best RCR technique. No consensus was evident among attendings, residents, or AHPs. This lack of clinical agreement about rotator cuff surgery has been observed elsewhere—for example, among members of the American Academy of Orthopaedic Surgeons (AAOS)21 and the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy.22 Despite theoretical advantages of arthroscopic repair, there has been no documented significant difference in patient outcomes when compared with other techniques.23 To our knowledge, there have been only a few clinical studies comparing the different RCR techniques. A meta-analysis of 5 clinical studies comparing arthroscopic and mini-open RCR techniques showed no difference in clinical outcomes or complication rates.8 The 2012 AAOS clinical practice guidelines for RCR reflect these observations.24 That consortium of leading shoulder surgeons could not recommend a modality of surgical rotator cuff tear repair given the lack of conclusive evidence.24
At our institution, arthroscopic, mini-open, and open RCRs were performed by 36%, 9%, and 55% of our surgeons, respectively. A survey of AAOS surgeons showed that, of those who perform RCRs, 14.5%, 46.2%, and 36.6% used arthroscopic, mini-open, and open techniques, respectively.21 The greater use of open repairs at our institution might reflect the seniority of our faculty. Dunn and colleagues21 found that surgeons who preferred open RCR had been in practice longer than those who preferred the arthroscopic or mini-open technique. Of our 4 faculty who performed arthroscopic repairs, 3 were less than 5 years from completing their training. In contrast, all faculty who performed mini-open or open repairs were more than 5 years from completing their training. Furthermore, mean age of the surgeons who performed arthroscopic repair was 39.8 years (range, 32-51 years), and these surgeons were significantly younger than those who performed mini-open or open repair (mean age, 56.3 years; range, 41-78 years). Younger surgeon age has been associated with higher rates of arthroscopic repair.25
Attendings unaccustomed to arthroscopy may find it more challenging than the younger generation of surgeons, who are exposed to it early in training. Dunn and colleagues21 noted that the likelihood of performing an arthroscopic repair was influenced by the surgeon’s experience level. Fellowship-trained shoulder and sports medicine surgeons are also more likely to perform arthroscopic repairs than those with training limited to orthopedic residency.25 Arthroscopic RCR demands a high level of technical skill that many acquire in fellowship training.26 Mauro and colleagues26 found that surgeons trained in a sports medicine fellowship performed 82.6% of subacromial decompression and/or RCR procedures arthroscopically, compared with 54.5% to 70.1% for surgeons trained in other fellowships. In our cohort, with the exception of 1 surgeon, all fellowship-trained shoulder and sports medicine surgeons performed arthroscopic RCRs.
Although no conclusive evidence in the literature supports arthroscopic over the other repair types, the demand for arthroscopic RCR has rapidly increased relative to that for the others. Between 1996 and 2006, use of arthroscopic RCR increased 600%, from 8 to 58 per 100,000 population.20 In that same period, use of open RCR increased by only 34%.20 Similarly, Mauro and colleagues26 found that the proportion of subacromial decompression and RCRs performed arthroscopically rose from 58.3% in 2004 to 83.7% in 2009. Using the 2006 New York State Ambulatory Surgery Database, Churchill and Ghorai27 found that 74.5% of RCRs with acromioplasty were performed arthroscopically.
Respondent-indicated factors that may have contributed to the more favorable opinion of arthroscopic and mini-open repair include quick healing, good cosmetic results, and better perceived patient satisfaction. The literature supports these perceptions. Baker and Liu14 found shorter hospital stays and quicker return to activity with arthroscopic repair compared with open repair. Vitale and colleagues25 also noted that, compared with open or mini-open repair techniques, arthroscopic repair resulted in shorter hospitalization and quicker overall recovery.
If these selected health care professionals with some inside information on rotator cuff surgery have biases that affect their selection of rotator cuff procedures, we should acknowledge that nonmedical personnel, in particular our patients, also have biases. The knowledge base of patients may be further influenced by friends or family members who have had rotator cuff surgery, by lay publications, and by the Internet. Satisfaction with any surgical procedure depends not only on the success of the surgery and the rehabilitation but also on patient and provider expectations. Such expectations are influenced, in part, by biases.
Our medical professionals had similar opinions on safety, recovery, cosmesis, and overall outcome of the RCR techniques, but different opinions on procedure durations and associated training requirements. All residents except one indicated open repair was a quick procedure. In contrast, a significant number of AHPs thought open repair was time-consuming. The attendings considered all the methods fast. The residents’ opinions were the most consistent with the true operating times reported. According to the literature, total operating time for mini-open repair ranges from 10 to 16 minutes faster than that for arthroscopic repair.18,20,27 Ultimately, procedure duration did not affect the respondents’ technique preference for RCR.
There was substantial disagreement about the number of procedures needed to become proficient in the different repair techniques. Overall, however, there was consensus that arthroscopic and mini-open repairs had longer learning curves than open repair. Given the lack of agreement among orthopedic department chairmen and sports medicine fellowship directors regarding the minimum exposure needed (during residency) to become proficient in diagnostic shoulder arthroscopy,28 this finding is not surprising. Guttmann and colleagues29 attempted to quantify the learning curve for arthroscopic RCR by tracking operating time as a surrogate measure. They found that RCR operative time decreased rapidly during the initial block of 10 cases to the second block of 10 cases, but thereafter improvement continued at a much lower rate.29 None of our respondents thought the learning curve for arthroscopic RCR was under 10 cases, but no group, not even the attendings who performed RCRs, could agree on the minimum number of cases needed for proficiency. The longer learning curve for arthroscopic RCR did not discourage the respondents who preferred arthroscopic or mini-open RCR.
Cost was not an influential factor in opinions about which RCR method is optimal. Medical professionals were ambivalent about the cost-effectiveness of the different procedures, with most expressing no opinion on cost. Multiple investigators have shown that arthroscopic RCR costs as much as $1144 more than mini-open RCR,18,27 which has many of the advantages of arthroscopic repair but not the costly implants and instruments. As our medical community becomes more cost-conscious, concern about this factor may increase among medical professionals.
Our study had several limitations. Its results must be interpreted carefully, given they represent the viewpoints of a nonrandomized sample of motivated respondents at one institution. A selection bias excluded surgeons who were uncomfortable with RCR and unwilling to report any shortcomings. The conclusions cannot be generalized to other medical professionals or to other institutions. Furthermore, to develop a simple, straightforward survey focused on a specific type of rotator cuff tear, and to avoid confusion, we assumed that the treatment preference for the described tear was generalizable to all encountered tears. However, some surgeons have reported different repair techniques for different types and sizes of rotator cuff tears.25
Conclusion
Most of our surveyed medical professionals were willing to defer to their surgeon’s decision about which technique would be appropriate for their own personal RCR. There is a trend nationally, and at our institution, for increased use of arthroscopic RCR. Although medical professionals readily acknowledge it is unclear which repair method provides the best ultimate outcome, many perceive fast recovery and good cosmetic results with arthroscopic and mini-open repairs. When medical professionals are counseling patients, we need to recognize these personal biases because many patients defer to their surgeon’s counsel. For some medical professionals, cosmesis can be an important factor, but cost, procedure duration, potential technical challenges of arthroscopic repair, and other considerations may make other techniques more desirable for others.
1. Bennett WF. Arthroscopic repair of massive rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy. 2003;19(4):380-390.
2. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): a prospective study with 2- to 4-year follow-up. Arthroscopy. 2003;19(3):249-256.
3. Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am. 2007;89(suppl 3):127-136.
4. Duralde XA, Greene RT. Mini-open rotator cuff repair via an anterosuperior approach. J Shoulder Elbow Surg. 2008;17(5):715-721.
5. Blevins FT, Warren RF, Cavo C, et al. Arthroscopic assisted rotator cuff repair: results using a mini-open deltoid splitting approach. Arthroscopy. 1996;12(1):50-59.
6. Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990;6(1):55-60.
7. Liu SH. Arthroscopically-assisted rotator-cuff repair. J Bone Joint Surg Br. 1994;76(4):592-595.
8. Morse K, Davis AD, Afra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. 2008;36(9):1824-1828.
9. Park JY, Levine WN, Marra G, Pollock RG, Flatow EL, Bigliani LU. Portal-extension approach for the repair of small and medium rotator cuff tears. Am J Sports Med. 2000;28(3):312-316.
10. Paulos LE, Kody MH. Arthroscopically enhanced “miniapproach” to rotator cuff repair. Am J Sports Med. 1994;22(1):19-25.
11. Posada A, Uribe JW, Hechtman KS, Tjin-A-Tsoi EW, Zvijac JE. Mini-deltoid splitting rotator cuff repair: do results deteriorate with time? Arthroscopy. 2000;16(2):137-141.
12. Shinners TJ, Noordsij PG, Orwin JF. Arthroscopically assisted mini-open rotator cuff repair. Arthroscopy. 2002;18(1):21-26.
13. Weber SC. Arthroscopic debridement and acromioplasty versus mini-open repair in the treatment of significant partial-thickness rotator cuff tears. Arthroscopy. 1999;15(2):126-131.
14. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med. 1995;23(1):99-104.
15. Liu SH, Baker CL. Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy. 1994;10(1):54-60.
16. Pollock RG, Flatow EL. The rotator cuff, part II. Full-thickness tears. Mini-open repair. Orthop Clin North Am. 1997;28(2):169-177.
17. Yamaguchi K, Levine WN, Marra G, Galatz LM, Klepps S, Flatow EL. Transitioning to arthroscopic rotator cuff repair: the pros and cons. Instr Course Lect. 2003;52:81-92.
18. Adla DN, Rowsell M, Pandey R. Cost-effectiveness of open versus arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2010;19(2):258-261.
19. Kose KC, Tezen E, Cebesoy O, et al. Mini-open versus all-arthroscopic rotator cuff repair: comparison of the operative costs and the clinical outcomes. Adv Ther. 2008;25(3):249-259.
20. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-233.
21. Dunn WR, Schackman BR, Walsh C, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87(9):1978-1984.
22. Randelli P, Arrigoni P, Cabitza F, Ragone V, Cabitza P. Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons. Knee Surg Sports Traumatol Arthrosc. 2012;20(5):803-815.
23. Aleem AW, Brophy RH. Outcomes of rotator cuff surgery: what does the evidence tell us? Clin Sports Med. 2012;31(4):665-674.
24. Pedowitz RA, Yamaguchi K, Ahmad CS, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: optimizing the management of rotator cuff problems. J Bone Joint Surg Am. 2012;94(2):163-167.
25. Vitale MA, Kleweno CP, Jacir AM, Levine WN, Bigliani LU, Ahmad CS. Training resources in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2007;89(6):1393-1398.
26. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2012;94(16):1492-1499.
27. Churchill RS, Ghorai JK. Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: mini-open versus all-arthroscopic. J Shoulder Elbow Surg. 2010;19(5):716-721.
28. O’Neill PJ, Cosgarea AJ, Freedman JA, Queale WS, McFarland EG. Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy. 2002;18(7):795-800.
29. Guttmann D, Graham RD, MacLennan MJ, Lubowitz JH. Arthroscopic rotator cuff repair: the learning curve. Arthroscopy. 2005;21(4):394-400.
1. Bennett WF. Arthroscopic repair of massive rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy. 2003;19(4):380-390.
2. Bennett WF. Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): a prospective study with 2- to 4-year follow-up. Arthroscopy. 2003;19(3):249-256.
3. Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am. 2007;89(suppl 3):127-136.
4. Duralde XA, Greene RT. Mini-open rotator cuff repair via an anterosuperior approach. J Shoulder Elbow Surg. 2008;17(5):715-721.
5. Blevins FT, Warren RF, Cavo C, et al. Arthroscopic assisted rotator cuff repair: results using a mini-open deltoid splitting approach. Arthroscopy. 1996;12(1):50-59.
6. Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy. 1990;6(1):55-60.
7. Liu SH. Arthroscopically-assisted rotator-cuff repair. J Bone Joint Surg Br. 1994;76(4):592-595.
8. Morse K, Davis AD, Afra R, Kaye EK, Schepsis A, Voloshin I. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. 2008;36(9):1824-1828.
9. Park JY, Levine WN, Marra G, Pollock RG, Flatow EL, Bigliani LU. Portal-extension approach for the repair of small and medium rotator cuff tears. Am J Sports Med. 2000;28(3):312-316.
10. Paulos LE, Kody MH. Arthroscopically enhanced “miniapproach” to rotator cuff repair. Am J Sports Med. 1994;22(1):19-25.
11. Posada A, Uribe JW, Hechtman KS, Tjin-A-Tsoi EW, Zvijac JE. Mini-deltoid splitting rotator cuff repair: do results deteriorate with time? Arthroscopy. 2000;16(2):137-141.
12. Shinners TJ, Noordsij PG, Orwin JF. Arthroscopically assisted mini-open rotator cuff repair. Arthroscopy. 2002;18(1):21-26.
13. Weber SC. Arthroscopic debridement and acromioplasty versus mini-open repair in the treatment of significant partial-thickness rotator cuff tears. Arthroscopy. 1999;15(2):126-131.
14. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med. 1995;23(1):99-104.
15. Liu SH, Baker CL. Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. Arthroscopy. 1994;10(1):54-60.
16. Pollock RG, Flatow EL. The rotator cuff, part II. Full-thickness tears. Mini-open repair. Orthop Clin North Am. 1997;28(2):169-177.
17. Yamaguchi K, Levine WN, Marra G, Galatz LM, Klepps S, Flatow EL. Transitioning to arthroscopic rotator cuff repair: the pros and cons. Instr Course Lect. 2003;52:81-92.
18. Adla DN, Rowsell M, Pandey R. Cost-effectiveness of open versus arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2010;19(2):258-261.
19. Kose KC, Tezen E, Cebesoy O, et al. Mini-open versus all-arthroscopic rotator cuff repair: comparison of the operative costs and the clinical outcomes. Adv Ther. 2008;25(3):249-259.
20. Colvin AC, Egorova N, Harrison AK, Moskowitz A, Flatow EL. National trends in rotator cuff repair. J Bone Joint Surg Am. 2012;94(3):227-233.
21. Dunn WR, Schackman BR, Walsh C, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87(9):1978-1984.
22. Randelli P, Arrigoni P, Cabitza F, Ragone V, Cabitza P. Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons. Knee Surg Sports Traumatol Arthrosc. 2012;20(5):803-815.
23. Aleem AW, Brophy RH. Outcomes of rotator cuff surgery: what does the evidence tell us? Clin Sports Med. 2012;31(4):665-674.
24. Pedowitz RA, Yamaguchi K, Ahmad CS, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: optimizing the management of rotator cuff problems. J Bone Joint Surg Am. 2012;94(2):163-167.
25. Vitale MA, Kleweno CP, Jacir AM, Levine WN, Bigliani LU, Ahmad CS. Training resources in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2007;89(6):1393-1398.
26. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2012;94(16):1492-1499.
27. Churchill RS, Ghorai JK. Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: mini-open versus all-arthroscopic. J Shoulder Elbow Surg. 2010;19(5):716-721.
28. O’Neill PJ, Cosgarea AJ, Freedman JA, Queale WS, McFarland EG. Arthroscopic proficiency: a survey of orthopaedic sports medicine fellowship directors and orthopaedic surgery department chairs. Arthroscopy. 2002;18(7):795-800.
29. Guttmann D, Graham RD, MacLennan MJ, Lubowitz JH. Arthroscopic rotator cuff repair: the learning curve. Arthroscopy. 2005;21(4):394-400.
The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine
Orthopedics and the sports medicine subspecialty are continually evolving fields that depend on research investigation and publication to further knowledge and advance practice. Research has produced new findings that have changed the way we practice sports medicine. In this review, we identify the most widely referenced sports medicine topics and articles, which we believe by their permeative presence in the literature have made lasting contributions to the field.
Many factors can be used to quantify the influence of an academic article on the practice of medicine. Citation analysis is one method that reflects the impact of a publication on the academic medical community.1-3 Total citations record the number of times a journal article has been credited by another study. Therefore, citation count indirectly highlights the articles that are widespread, relevant, and that form the foundation for other investigations on the topic. Related to the impact of the article is the impact of the journal that published the study. We examined journals by impact factor, a score based on the mean number of citations a published article received during the preceding 2 years.
Similar analyses have been performed of publication history in orthopedics and other medical fields. Investigators have examined which historical articles were the most influential in orthopedics as a whole,4 pediatric orthopedics,5,6 shoulder surgery,7 and arthroscopy.8 This influence has also been studied in general surgery,9 otolaryngology,10 plastic surgery,11 dermatology,12 critical care,13 and other disciplines. To our knowledge, the present study is the first bibliometric analysis of the highest-impact articles in orthopedic sports medicine.
Our goal was to identify the 100 articles that have had the highest impact on the clinical orthopedic sports medicine literature. We hypothesized that the most widely recognized articles would be from the highest-impact journals and may also have earlier publication dates. We describe the topics and objectives of these articles to highlight the sports medicine areas on which most research has focused during the past century.
Materials and Methods
Our bibliometric analysis used the Thomson Reuters Web of Knowledge, which consists of all publications from 1900 to the present. This research modality ranks journal articles by frequency of citation. Similar analyses have identified the most often cited articles in pediatric orthopedics,5 shoulder surgery,7 and arthroscopy.8 In our analysis, we included the top 25 journals by impact factor in the field of sports medicine, as rated by the Journal Citation Reports database. Within the highest-impact journals, we sorted all articles by those most often cited, and read them all to identify which ones discuss conditions commonly encountered in the clinical practice of sports medicine. We focused on clinical articles only and therefore excluded related basic science and cadaveric biomechanical studies. The 100 most cited articles were then further evaluated by primary author, journal of publication, institution, country of origin, year of publication, topic, and total number of citations. One-way analysis of variance (ANOVA) and linear regression analyses were used to determine if publication date correlated with mean number of citations.
Results
Eighty authors wrote the top 100 articles in sports medicine, and each publication garnered several hundred citations, ranging from 229 to 1629 with a mean of 408 (Table 114-113). Most of these articles were written in the past 3 decades, with equal distribution from the 1980s, 1990s, and 2000s (Figure 1A). We ran a linear regression to determine if publication date correlated with higher number of citations by virtue of longer time available for citation. The analysis poorly modeled the variability (R2 = 0.05), revealing no correlation between number of citations and publication date. Further, 1-way ANOVA found no significant difference between the number of citations per decade, F(5, 93) = 1.60, P = .17 (Figure 1B). Despite this finding, the oldest cited article, written by Fairbank39 in 1948, ranked high (position 7). Of these top 100 publications, the most recent, written by Knutsen and colleagues69 in 2007, ranked in the second half at position 66.
Seven journals published the top 100 articles, with the American volume of the Journal of Bone and Joint Surgery publishing nearly half (44%) (Table 2). In second place, with 28 articles, was the American Journal of Sports Medicine, followed by the British volume of the Journal of Bone and Joint Surgery, with 10 articles.
Thirty different topics were investigated in this collection of articles, encompassing nearly every major research area of sports medicine. There was a heavy emphasis on anterior cruciate ligament (ACL) injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation (Table 3).
In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes88-92 (5 articles), Neer81-84 (4 articles), and Rowe,102-104 Daniel,35-37 Peterson,97-99 and Hewett52-54 (3 articles each) (Table 417,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113). Articles from authors with multiple publications had a common topic.
Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.
Discussion
Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.114 The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.
The most cited sports medicine article was written by Insall and colleagues62 in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.32 This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.113 This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.
A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign82 and the Hawkins-Kennedy test51 are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score113 complements other functional scores (eg, Lysholm knee score74). For grading joint cartilage breakdown, the Outerbridge classification system96 is commonly used. The Fairbank test39 is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification47 is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,101 measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification84 of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.
As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,105 and Beck was listed as third author on 1 other article,42 raising their totals to 4 and 3, respectively.
A criticism of bibliometric analysis is its use of number of citations as an accurate measure of academic contribution. However, other methods for measuring the productivity and impact of researchers (eg, the recently developed Hirsch Index) have their own drawbacks,115,116 including being able to compare authors only at the same point in their careers and self-citation. It is important to note that our analyses focused strictly on publications related to clinical sports medicine, with the exclusion of basic science and cadaveric biomechanical studies.
Through bibliometric citation analysis, we have identified the authors who have made lasting contributions to the field of sports medicine, and we have highlighted the publications that have been cited by hundreds to thousands of authors. This list identifies trends within the articles that have become “classic,” by nature of their deep permeation into subsequent sports medicine literature, and offers guidance for trainees interested in studying the most high-yield sports medicine literature. Given that 69 institutions in 15 countries conducted these studies, we have also shown that orthopedic research can be readily disseminated internationally. Last, our study provides a thorough overview of the sports medicine literature over the past century and provides a strong framework for future research in our field.
1. Adams AB, Simonson D. Publication, citations, and impact factors of leading investigators in critical care medicine. Respir Care. 2004;49(3):276-281.
2. Bhandari M, Busse J, Devereaux PJ, et al. Factors associated with citation rates in the orthopedic literature. Can J Surg. 2007;50(2):119-123.
3. Cheek J, Garnham B, Quan J. What’s in a number? Issues in providing evidence of impact and quality of research(ers). Qual Health Res. 2006;16(3):423-435.
4. Kelly JC, Glynn RW, O’Briain DE, Felle P, McCabe JP. The 100 classic papers of orthopaedic surgery: a bibliometric analysis. J Bone Joint Surg Br. 2010;92(10):1338-1343.
5. Kavanagh RG, Kelly JC, Kelly PM, Moore DP. The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis. J Bone Joint Surg Am. 2013;95(18):e134.
6. Mehlman CT, Wenger DR. The top 25 at 25: citation classics in the Journal of Pediatric Orthopaedics. J Pediatr Orthop. 2006;26(5):691-694.
7. Namdari S, Baldwin K, Kovatch K, Huffman GR, Glaser D. Fifty most cited articles in orthopedic shoulder surgery. J Shoulder Elbow Surg. 2012;21(12):1796-1802.
8. Cassar Gheiti AJ, Downey RE, Byrne DP, Molony DC, Mulhall KJ. The 25 most cited articles in arthroscopic orthopaedic surgery. Arthroscopy. 2012;28(4):548-564.
9. Paladugu R, Schein M, Gardezi S, Wise L. One hundred citation classics in general surgical journals. World J Surg. 2002;26(9):1099-1105.
10. Fenton JE, Roy D, Hughes JP, Jones AS. A century of citation classics in otolaryngology-head and neck surgery journals. J Laryngol Otol. 2002;116(7):494-498.
11. Loonen MPJ, Hage JJ, Kon M. Plastic surgery classics: characteristics of 50 top-cited articles in four plastic surgery journals since 1946. Plast Reconstr Surg. 2008;121(5):320e-327e.
12. Dubin D, Hafner AW, Arndt KA. Citation classics in clinical dermatologic journals. Citation analysis, biomedical journals, and landmark articles, 1945–1990. Arch Dermatol. 1993;129(9):1121-1129.
13. Baltussen A, Kindler CH. Citation classics in critical care medicine. Intensive Care Med. 2004;30(5):902-910.
14. Aglietti P, Buzzi R, Zaccherotti G, De Biase P. Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med. 1994;22(2):211-218.
15. Allen PR, Denham RA, Swan AV. Late degenerative changes after meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg Br. 1984;66(5):666-671.
16. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73(1):105-112.
17. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med. 1985;13(5):337-341.
18. Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 1995;23(6):694-701.
19. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988;16(2):113-122.
20. Barrack RL, Skinner HB, Buckley SL. Proprioception in the anterior cruciate deficient knee. Am J Sports Med. 1989;17(1):1-6.
21. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br. 2005;87(5):640-645.
22. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87(7):1012-1018.
23. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;(418):67-73.
24. Bentley G, Biant LC, Carrington RWJ, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br. 2003;85(2):223-230.
25. Berchuck M, Andriacchi TP, Bach BR, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am. 1990;72(6):871-877.
26. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959;41(6):988-1020.
27. Binkley JM, Stratford PW, Lott SA, Riddle DL, North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther. 1999;79(4):371-383.
28. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-1240.
29. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16(7):677-694.
30. Clancy WG Jr, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am. 1982;64(3):352-359.
31. Clancy WG Jr, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. 1983;65(3):310-322.
32. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-164.
33. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med. 1999;27(3):444-454.
34. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy. 1997;13(4):456-460.
35. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. 1985;67(5):720-726.
36. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994;22(5):632-644.
37. Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med. 1985;13(6):401-407.
38. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136-1144.
39. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30(4):664-670.
40. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31(1):2-11.
41. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224.
42. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):111-119.
43. Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after rotator cuff repair. Clin Orthop Relat Res. 1994;(304):43-53.
44. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505-515.
45. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73(3):389-394.
46. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli D, Perry J. Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am. 1988;70(2):220-226.
47. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78-83.
48. Guskiewicz KM, Weaver NL, Padua DA, Garrett WE Jr. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643-650.
49. Hangody L, Fules P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am. 2003;85(suppl 2):25-32.
50. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.
51. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-157.
52. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27(6):699-706.
53. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.
54. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996;24(6):765-773.
55. Homminga GN, Bulstra SK, Bouwmeester PSM, van der Linden AJ. Perichondral grafting for cartilage lesions of the knee. J Bone Joint Surg Br. 1990;72(6):1003-1007.
56. Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85(2):185-192.
57. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-1684.
58. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159-172.
59. Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996;24(4):427-436.
60. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am. 1991;73(1):17-29.
61. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. A prospective study. J Bone Joint Surg Am. 1976;58(1):1-8.
62. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-14.
63. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29(5):600-613.
64. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80(8):1132-1145.
65. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
66. Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(3):719-729.
67. Jones HH, Priest JD, Hayes WC, Tichenor CC, Nagel DA. Humeral hypertrophy in response to exercise. J Bone Joint Surg Am. 1977;59(2):204-208.
68. Jones KG. Reconstruction of the anterior cruciate ligament: a technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
69. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Joint Surg Am. 2007;89(10):2105-2112.
70. Knutsen G, Engebretsen L, Ludvigsen TC, et al. Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am. 2004;86(3):455-464.
71. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-163.
72. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
73. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291.
74. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154.
75. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-1010.
76. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med. 1991;19(5):478-484.
77. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58.
78. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption. Arthroscopy. 1993;9(3):318-321.
79. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am. 1980;62(5):696-705.
80. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14(6):553-565.
81. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50.
82. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77.
83. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65(9):1232-1244.
84. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980;62(6):897-908.
85. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839.
86. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg Am. 1981;63(3):394-399.
87. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
88. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513-518.
89. Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62(5):687-695, 757.
90. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate–deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983;65(2):163-174.
91. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate–deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am. 1983;65(2):154-162.
92. Noyes FR, Stabler CL. A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med. 1989;17(4):505-513.
93. O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL. Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Joint Surg Am. 1991;73(2):278-286.
94. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440-446.
95. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med. 2004;32(4):1002-1012.
96. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43(4):752-757.
97. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12.
98. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am. 2003;85(suppl 2):17-24.
99. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000;(374):212-234.
100. Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998;80(9):1276-1284.
101. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28(2):88-96.
102. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38(5):957-977.
103. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60(1):1-16.
104. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am. 1981;63(6):863-872.
105. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med. 1989;17(6):760-765.
106. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65(4):456-460.
107. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18(3):292-299.
108. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders [see comments]. J Bone Joint Surg Am. 1995;77(1):10-15.
109. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85(2):278-286.
110. Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987;15(3):207-213.
111. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy. 2003;19(5):477-484.
112. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526.
113. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-49.
114. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660-667.
115. Bartneck C, Kokkelmans S. Detecting h-index manipulation through self-citation analysis. Scientometrics. 2011;87(1):85-98.
116. Bornmann L, Daniel HD. The state of h index research. Is the h index the ideal way to measure research performance? EMBO Rep. 2009;10(1):2-6.
Orthopedics and the sports medicine subspecialty are continually evolving fields that depend on research investigation and publication to further knowledge and advance practice. Research has produced new findings that have changed the way we practice sports medicine. In this review, we identify the most widely referenced sports medicine topics and articles, which we believe by their permeative presence in the literature have made lasting contributions to the field.
Many factors can be used to quantify the influence of an academic article on the practice of medicine. Citation analysis is one method that reflects the impact of a publication on the academic medical community.1-3 Total citations record the number of times a journal article has been credited by another study. Therefore, citation count indirectly highlights the articles that are widespread, relevant, and that form the foundation for other investigations on the topic. Related to the impact of the article is the impact of the journal that published the study. We examined journals by impact factor, a score based on the mean number of citations a published article received during the preceding 2 years.
Similar analyses have been performed of publication history in orthopedics and other medical fields. Investigators have examined which historical articles were the most influential in orthopedics as a whole,4 pediatric orthopedics,5,6 shoulder surgery,7 and arthroscopy.8 This influence has also been studied in general surgery,9 otolaryngology,10 plastic surgery,11 dermatology,12 critical care,13 and other disciplines. To our knowledge, the present study is the first bibliometric analysis of the highest-impact articles in orthopedic sports medicine.
Our goal was to identify the 100 articles that have had the highest impact on the clinical orthopedic sports medicine literature. We hypothesized that the most widely recognized articles would be from the highest-impact journals and may also have earlier publication dates. We describe the topics and objectives of these articles to highlight the sports medicine areas on which most research has focused during the past century.
Materials and Methods
Our bibliometric analysis used the Thomson Reuters Web of Knowledge, which consists of all publications from 1900 to the present. This research modality ranks journal articles by frequency of citation. Similar analyses have identified the most often cited articles in pediatric orthopedics,5 shoulder surgery,7 and arthroscopy.8 In our analysis, we included the top 25 journals by impact factor in the field of sports medicine, as rated by the Journal Citation Reports database. Within the highest-impact journals, we sorted all articles by those most often cited, and read them all to identify which ones discuss conditions commonly encountered in the clinical practice of sports medicine. We focused on clinical articles only and therefore excluded related basic science and cadaveric biomechanical studies. The 100 most cited articles were then further evaluated by primary author, journal of publication, institution, country of origin, year of publication, topic, and total number of citations. One-way analysis of variance (ANOVA) and linear regression analyses were used to determine if publication date correlated with mean number of citations.
Results
Eighty authors wrote the top 100 articles in sports medicine, and each publication garnered several hundred citations, ranging from 229 to 1629 with a mean of 408 (Table 114-113). Most of these articles were written in the past 3 decades, with equal distribution from the 1980s, 1990s, and 2000s (Figure 1A). We ran a linear regression to determine if publication date correlated with higher number of citations by virtue of longer time available for citation. The analysis poorly modeled the variability (R2 = 0.05), revealing no correlation between number of citations and publication date. Further, 1-way ANOVA found no significant difference between the number of citations per decade, F(5, 93) = 1.60, P = .17 (Figure 1B). Despite this finding, the oldest cited article, written by Fairbank39 in 1948, ranked high (position 7). Of these top 100 publications, the most recent, written by Knutsen and colleagues69 in 2007, ranked in the second half at position 66.
Seven journals published the top 100 articles, with the American volume of the Journal of Bone and Joint Surgery publishing nearly half (44%) (Table 2). In second place, with 28 articles, was the American Journal of Sports Medicine, followed by the British volume of the Journal of Bone and Joint Surgery, with 10 articles.
Thirty different topics were investigated in this collection of articles, encompassing nearly every major research area of sports medicine. There was a heavy emphasis on anterior cruciate ligament (ACL) injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation (Table 3).
In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes88-92 (5 articles), Neer81-84 (4 articles), and Rowe,102-104 Daniel,35-37 Peterson,97-99 and Hewett52-54 (3 articles each) (Table 417,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113). Articles from authors with multiple publications had a common topic.
Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.
Discussion
Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.114 The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.
The most cited sports medicine article was written by Insall and colleagues62 in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.32 This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.113 This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.
A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign82 and the Hawkins-Kennedy test51 are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score113 complements other functional scores (eg, Lysholm knee score74). For grading joint cartilage breakdown, the Outerbridge classification system96 is commonly used. The Fairbank test39 is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification47 is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,101 measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification84 of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.
As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,105 and Beck was listed as third author on 1 other article,42 raising their totals to 4 and 3, respectively.
A criticism of bibliometric analysis is its use of number of citations as an accurate measure of academic contribution. However, other methods for measuring the productivity and impact of researchers (eg, the recently developed Hirsch Index) have their own drawbacks,115,116 including being able to compare authors only at the same point in their careers and self-citation. It is important to note that our analyses focused strictly on publications related to clinical sports medicine, with the exclusion of basic science and cadaveric biomechanical studies.
Through bibliometric citation analysis, we have identified the authors who have made lasting contributions to the field of sports medicine, and we have highlighted the publications that have been cited by hundreds to thousands of authors. This list identifies trends within the articles that have become “classic,” by nature of their deep permeation into subsequent sports medicine literature, and offers guidance for trainees interested in studying the most high-yield sports medicine literature. Given that 69 institutions in 15 countries conducted these studies, we have also shown that orthopedic research can be readily disseminated internationally. Last, our study provides a thorough overview of the sports medicine literature over the past century and provides a strong framework for future research in our field.
Orthopedics and the sports medicine subspecialty are continually evolving fields that depend on research investigation and publication to further knowledge and advance practice. Research has produced new findings that have changed the way we practice sports medicine. In this review, we identify the most widely referenced sports medicine topics and articles, which we believe by their permeative presence in the literature have made lasting contributions to the field.
Many factors can be used to quantify the influence of an academic article on the practice of medicine. Citation analysis is one method that reflects the impact of a publication on the academic medical community.1-3 Total citations record the number of times a journal article has been credited by another study. Therefore, citation count indirectly highlights the articles that are widespread, relevant, and that form the foundation for other investigations on the topic. Related to the impact of the article is the impact of the journal that published the study. We examined journals by impact factor, a score based on the mean number of citations a published article received during the preceding 2 years.
Similar analyses have been performed of publication history in orthopedics and other medical fields. Investigators have examined which historical articles were the most influential in orthopedics as a whole,4 pediatric orthopedics,5,6 shoulder surgery,7 and arthroscopy.8 This influence has also been studied in general surgery,9 otolaryngology,10 plastic surgery,11 dermatology,12 critical care,13 and other disciplines. To our knowledge, the present study is the first bibliometric analysis of the highest-impact articles in orthopedic sports medicine.
Our goal was to identify the 100 articles that have had the highest impact on the clinical orthopedic sports medicine literature. We hypothesized that the most widely recognized articles would be from the highest-impact journals and may also have earlier publication dates. We describe the topics and objectives of these articles to highlight the sports medicine areas on which most research has focused during the past century.
Materials and Methods
Our bibliometric analysis used the Thomson Reuters Web of Knowledge, which consists of all publications from 1900 to the present. This research modality ranks journal articles by frequency of citation. Similar analyses have identified the most often cited articles in pediatric orthopedics,5 shoulder surgery,7 and arthroscopy.8 In our analysis, we included the top 25 journals by impact factor in the field of sports medicine, as rated by the Journal Citation Reports database. Within the highest-impact journals, we sorted all articles by those most often cited, and read them all to identify which ones discuss conditions commonly encountered in the clinical practice of sports medicine. We focused on clinical articles only and therefore excluded related basic science and cadaveric biomechanical studies. The 100 most cited articles were then further evaluated by primary author, journal of publication, institution, country of origin, year of publication, topic, and total number of citations. One-way analysis of variance (ANOVA) and linear regression analyses were used to determine if publication date correlated with mean number of citations.
Results
Eighty authors wrote the top 100 articles in sports medicine, and each publication garnered several hundred citations, ranging from 229 to 1629 with a mean of 408 (Table 114-113). Most of these articles were written in the past 3 decades, with equal distribution from the 1980s, 1990s, and 2000s (Figure 1A). We ran a linear regression to determine if publication date correlated with higher number of citations by virtue of longer time available for citation. The analysis poorly modeled the variability (R2 = 0.05), revealing no correlation between number of citations and publication date. Further, 1-way ANOVA found no significant difference between the number of citations per decade, F(5, 93) = 1.60, P = .17 (Figure 1B). Despite this finding, the oldest cited article, written by Fairbank39 in 1948, ranked high (position 7). Of these top 100 publications, the most recent, written by Knutsen and colleagues69 in 2007, ranked in the second half at position 66.
Seven journals published the top 100 articles, with the American volume of the Journal of Bone and Joint Surgery publishing nearly half (44%) (Table 2). In second place, with 28 articles, was the American Journal of Sports Medicine, followed by the British volume of the Journal of Bone and Joint Surgery, with 10 articles.
Thirty different topics were investigated in this collection of articles, encompassing nearly every major research area of sports medicine. There was a heavy emphasis on anterior cruciate ligament (ACL) injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation (Table 3).
In several cases, an author contributed more than 1 classic article. In fact, 31 of the top 100 articles were by an individual who had coauthored 2 or more of the publications on this list. The researchers with the largest number of first-authored articles were Noyes88-92 (5 articles), Neer81-84 (4 articles), and Rowe,102-104 Daniel,35-37 Peterson,97-99 and Hewett52-54 (3 articles each) (Table 417,19,21-24,29-31,35-37,42,44,45,52-54,58,61-65,69,70,72,74,80-84,87-92,97-99,101-105,107,109,110,113). Articles from authors with multiple publications had a common topic.
Last, these articles originated from a number of different countries and institutions. Of the 15 source countries (Figure 2), the United States contributed the most (61 articles). Other countries had prominent representation: Sweden and Switzerland (8 each), United Kingdom (5), and Canada, France, and Norway (3 each). These articles originated from 69 universities, hospitals, and clinics; 21 institutions had 2 or more articles (Table 5). The 5 institutions with the highest number of articles were Hospital for Special Surgery, University of Bern, Columbia College of Physicians and Surgeons/Columbia-Presbyterian Medical Center, Cincinnati Sports Medicine and Orthopaedic Center, and Massachusetts General Hospital.
Discussion
Several trends can be ascertained from analyzing the top 100 clinical articles cited in sports medicine. The 5 most frequent topics discussed were ACL injury and reconstruction, knee rating systems for injury and function, rotator cuff reconstruction, chondrocyte transplantation, and femoroacetabular impingement (Table 3). Of those 5 topics, only ACL injury and reconstruction falls within the top 10 most common orthopedic surgical procedures performed in the United States reported by one analysis.114 The most common orthopedic surgical procedure, knee arthroscopy, ranks 10th of all topics covered by the top 100 articles, whereas the second most common procedure, shoulder arthroscopy, was not discussed by any of those 100 articles. Also notable is the high frequency of knee rating system studies, which correlates well with the fact that 4 of the most common orthopedic surgical procedures are knee procedures. The prevalence of rating system articles reflects the importance of and need for accurate methods in the diagnosis of injuries in sports medicine.
The most cited sports medicine article was written by Insall and colleagues62 in 1989, more than 2 decades ago. In this article, “Rationale of the Knee Society Clinical Rating System,” they reported on a rigorous system that rates knee function and ability to walk and climb stairs. The second most cited article, “A Clinical Method of Functional Assessment of the Shoulder,” was written in 1987 by Constant and Murley.32 This article discusses another rating system but offers a functional assessment of the shoulder that is highly reproducible and time-efficient. “Rating Systems in the Evaluation of Knee Ligament Injuries,” the third most cited article, was written in 1985 by Tegner and Lysholm.113 This article details the complexities and variable uses of different knee ligament injury rating systems. These top 3 articles were all published in Clinical Orthopaedics and Related Research. In addition, all 3 discussed rating systems, reinforcing the need for accurate scoring systems to standardize the diagnosis of injury across the field of orthopedics and qualify outcomes after injury.
A number of studies have introduced physical examination findings, clinical tests, and rating systems used in the clinical setting of sports medicine (and named after the contributing authors). For example, the Neer sign82 and the Hawkins-Kennedy test51 are used to determine shoulder impingement. In knee ligament injuries, the Tegner knee activity score113 complements other functional scores (eg, Lysholm knee score74). For grading joint cartilage breakdown, the Outerbridge classification system96 is commonly used. The Fairbank test39 is used to gauge knee instability. In evaluating fatty degeneration of rotator cuff muscles through computed tomography scans, the Goutallier classification47 is used. Other metrics, such as the Knee Injury and Osteoarthritis Outcome Score, introduced by Roos and colleagues,101 measure knee injury and osteoarthritis. In other scenarios, studies have improved on surgical techniques—for example, the Neer open modification84 of the Bankart procedure. Many of these rating systems and named clinical findings are so ingrained in the practice and vernacular of orthopedics that it is possible they are in fact undercited in the literature.
As in other bibliometric analyses, one concession made here was to credit the first author listed for making the primary contribution to an article. As a result of journal variability and inconsistency, we were precluded from analyzing senior authors. When analyzed for authorship at any position, 3 of the top authors (Table 4) showed contributions to additional articles in the top 100 list. Noyes was listed as last author on 2 other articles,52,54 raising his total to 7. Daniel was listed as second author on 1 additional article,105 and Beck was listed as third author on 1 other article,42 raising their totals to 4 and 3, respectively.
A criticism of bibliometric analysis is its use of number of citations as an accurate measure of academic contribution. However, other methods for measuring the productivity and impact of researchers (eg, the recently developed Hirsch Index) have their own drawbacks,115,116 including being able to compare authors only at the same point in their careers and self-citation. It is important to note that our analyses focused strictly on publications related to clinical sports medicine, with the exclusion of basic science and cadaveric biomechanical studies.
Through bibliometric citation analysis, we have identified the authors who have made lasting contributions to the field of sports medicine, and we have highlighted the publications that have been cited by hundreds to thousands of authors. This list identifies trends within the articles that have become “classic,” by nature of their deep permeation into subsequent sports medicine literature, and offers guidance for trainees interested in studying the most high-yield sports medicine literature. Given that 69 institutions in 15 countries conducted these studies, we have also shown that orthopedic research can be readily disseminated internationally. Last, our study provides a thorough overview of the sports medicine literature over the past century and provides a strong framework for future research in our field.
1. Adams AB, Simonson D. Publication, citations, and impact factors of leading investigators in critical care medicine. Respir Care. 2004;49(3):276-281.
2. Bhandari M, Busse J, Devereaux PJ, et al. Factors associated with citation rates in the orthopedic literature. Can J Surg. 2007;50(2):119-123.
3. Cheek J, Garnham B, Quan J. What’s in a number? Issues in providing evidence of impact and quality of research(ers). Qual Health Res. 2006;16(3):423-435.
4. Kelly JC, Glynn RW, O’Briain DE, Felle P, McCabe JP. The 100 classic papers of orthopaedic surgery: a bibliometric analysis. J Bone Joint Surg Br. 2010;92(10):1338-1343.
5. Kavanagh RG, Kelly JC, Kelly PM, Moore DP. The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis. J Bone Joint Surg Am. 2013;95(18):e134.
6. Mehlman CT, Wenger DR. The top 25 at 25: citation classics in the Journal of Pediatric Orthopaedics. J Pediatr Orthop. 2006;26(5):691-694.
7. Namdari S, Baldwin K, Kovatch K, Huffman GR, Glaser D. Fifty most cited articles in orthopedic shoulder surgery. J Shoulder Elbow Surg. 2012;21(12):1796-1802.
8. Cassar Gheiti AJ, Downey RE, Byrne DP, Molony DC, Mulhall KJ. The 25 most cited articles in arthroscopic orthopaedic surgery. Arthroscopy. 2012;28(4):548-564.
9. Paladugu R, Schein M, Gardezi S, Wise L. One hundred citation classics in general surgical journals. World J Surg. 2002;26(9):1099-1105.
10. Fenton JE, Roy D, Hughes JP, Jones AS. A century of citation classics in otolaryngology-head and neck surgery journals. J Laryngol Otol. 2002;116(7):494-498.
11. Loonen MPJ, Hage JJ, Kon M. Plastic surgery classics: characteristics of 50 top-cited articles in four plastic surgery journals since 1946. Plast Reconstr Surg. 2008;121(5):320e-327e.
12. Dubin D, Hafner AW, Arndt KA. Citation classics in clinical dermatologic journals. Citation analysis, biomedical journals, and landmark articles, 1945–1990. Arch Dermatol. 1993;129(9):1121-1129.
13. Baltussen A, Kindler CH. Citation classics in critical care medicine. Intensive Care Med. 2004;30(5):902-910.
14. Aglietti P, Buzzi R, Zaccherotti G, De Biase P. Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med. 1994;22(2):211-218.
15. Allen PR, Denham RA, Swan AV. Late degenerative changes after meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg Br. 1984;66(5):666-671.
16. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73(1):105-112.
17. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med. 1985;13(5):337-341.
18. Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 1995;23(6):694-701.
19. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988;16(2):113-122.
20. Barrack RL, Skinner HB, Buckley SL. Proprioception in the anterior cruciate deficient knee. Am J Sports Med. 1989;17(1):1-6.
21. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br. 2005;87(5):640-645.
22. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87(7):1012-1018.
23. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;(418):67-73.
24. Bentley G, Biant LC, Carrington RWJ, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br. 2003;85(2):223-230.
25. Berchuck M, Andriacchi TP, Bach BR, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am. 1990;72(6):871-877.
26. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959;41(6):988-1020.
27. Binkley JM, Stratford PW, Lott SA, Riddle DL, North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther. 1999;79(4):371-383.
28. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-1240.
29. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16(7):677-694.
30. Clancy WG Jr, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am. 1982;64(3):352-359.
31. Clancy WG Jr, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. 1983;65(3):310-322.
32. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-164.
33. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med. 1999;27(3):444-454.
34. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy. 1997;13(4):456-460.
35. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. 1985;67(5):720-726.
36. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994;22(5):632-644.
37. Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med. 1985;13(6):401-407.
38. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136-1144.
39. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30(4):664-670.
40. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31(1):2-11.
41. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224.
42. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):111-119.
43. Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after rotator cuff repair. Clin Orthop Relat Res. 1994;(304):43-53.
44. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505-515.
45. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73(3):389-394.
46. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli D, Perry J. Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am. 1988;70(2):220-226.
47. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78-83.
48. Guskiewicz KM, Weaver NL, Padua DA, Garrett WE Jr. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643-650.
49. Hangody L, Fules P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am. 2003;85(suppl 2):25-32.
50. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.
51. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-157.
52. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27(6):699-706.
53. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.
54. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996;24(6):765-773.
55. Homminga GN, Bulstra SK, Bouwmeester PSM, van der Linden AJ. Perichondral grafting for cartilage lesions of the knee. J Bone Joint Surg Br. 1990;72(6):1003-1007.
56. Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85(2):185-192.
57. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-1684.
58. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159-172.
59. Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996;24(4):427-436.
60. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am. 1991;73(1):17-29.
61. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. A prospective study. J Bone Joint Surg Am. 1976;58(1):1-8.
62. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-14.
63. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29(5):600-613.
64. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80(8):1132-1145.
65. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
66. Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(3):719-729.
67. Jones HH, Priest JD, Hayes WC, Tichenor CC, Nagel DA. Humeral hypertrophy in response to exercise. J Bone Joint Surg Am. 1977;59(2):204-208.
68. Jones KG. Reconstruction of the anterior cruciate ligament: a technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
69. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Joint Surg Am. 2007;89(10):2105-2112.
70. Knutsen G, Engebretsen L, Ludvigsen TC, et al. Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am. 2004;86(3):455-464.
71. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-163.
72. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
73. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291.
74. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154.
75. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-1010.
76. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med. 1991;19(5):478-484.
77. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58.
78. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption. Arthroscopy. 1993;9(3):318-321.
79. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am. 1980;62(5):696-705.
80. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14(6):553-565.
81. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50.
82. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77.
83. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65(9):1232-1244.
84. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980;62(6):897-908.
85. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839.
86. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg Am. 1981;63(3):394-399.
87. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
88. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513-518.
89. Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62(5):687-695, 757.
90. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate–deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983;65(2):163-174.
91. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate–deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am. 1983;65(2):154-162.
92. Noyes FR, Stabler CL. A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med. 1989;17(4):505-513.
93. O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL. Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Joint Surg Am. 1991;73(2):278-286.
94. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440-446.
95. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med. 2004;32(4):1002-1012.
96. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43(4):752-757.
97. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12.
98. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am. 2003;85(suppl 2):17-24.
99. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000;(374):212-234.
100. Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998;80(9):1276-1284.
101. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28(2):88-96.
102. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38(5):957-977.
103. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60(1):1-16.
104. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am. 1981;63(6):863-872.
105. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med. 1989;17(6):760-765.
106. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65(4):456-460.
107. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18(3):292-299.
108. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders [see comments]. J Bone Joint Surg Am. 1995;77(1):10-15.
109. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85(2):278-286.
110. Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987;15(3):207-213.
111. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy. 2003;19(5):477-484.
112. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526.
113. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-49.
114. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660-667.
115. Bartneck C, Kokkelmans S. Detecting h-index manipulation through self-citation analysis. Scientometrics. 2011;87(1):85-98.
116. Bornmann L, Daniel HD. The state of h index research. Is the h index the ideal way to measure research performance? EMBO Rep. 2009;10(1):2-6.
1. Adams AB, Simonson D. Publication, citations, and impact factors of leading investigators in critical care medicine. Respir Care. 2004;49(3):276-281.
2. Bhandari M, Busse J, Devereaux PJ, et al. Factors associated with citation rates in the orthopedic literature. Can J Surg. 2007;50(2):119-123.
3. Cheek J, Garnham B, Quan J. What’s in a number? Issues in providing evidence of impact and quality of research(ers). Qual Health Res. 2006;16(3):423-435.
4. Kelly JC, Glynn RW, O’Briain DE, Felle P, McCabe JP. The 100 classic papers of orthopaedic surgery: a bibliometric analysis. J Bone Joint Surg Br. 2010;92(10):1338-1343.
5. Kavanagh RG, Kelly JC, Kelly PM, Moore DP. The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis. J Bone Joint Surg Am. 2013;95(18):e134.
6. Mehlman CT, Wenger DR. The top 25 at 25: citation classics in the Journal of Pediatric Orthopaedics. J Pediatr Orthop. 2006;26(5):691-694.
7. Namdari S, Baldwin K, Kovatch K, Huffman GR, Glaser D. Fifty most cited articles in orthopedic shoulder surgery. J Shoulder Elbow Surg. 2012;21(12):1796-1802.
8. Cassar Gheiti AJ, Downey RE, Byrne DP, Molony DC, Mulhall KJ. The 25 most cited articles in arthroscopic orthopaedic surgery. Arthroscopy. 2012;28(4):548-564.
9. Paladugu R, Schein M, Gardezi S, Wise L. One hundred citation classics in general surgical journals. World J Surg. 2002;26(9):1099-1105.
10. Fenton JE, Roy D, Hughes JP, Jones AS. A century of citation classics in otolaryngology-head and neck surgery journals. J Laryngol Otol. 2002;116(7):494-498.
11. Loonen MPJ, Hage JJ, Kon M. Plastic surgery classics: characteristics of 50 top-cited articles in four plastic surgery journals since 1946. Plast Reconstr Surg. 2008;121(5):320e-327e.
12. Dubin D, Hafner AW, Arndt KA. Citation classics in clinical dermatologic journals. Citation analysis, biomedical journals, and landmark articles, 1945–1990. Arch Dermatol. 1993;129(9):1121-1129.
13. Baltussen A, Kindler CH. Citation classics in critical care medicine. Intensive Care Med. 2004;30(5):902-910.
14. Aglietti P, Buzzi R, Zaccherotti G, De Biase P. Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med. 1994;22(2):211-218.
15. Allen PR, Denham RA, Swan AV. Late degenerative changes after meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg Br. 1984;66(5):666-671.
16. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73(1):105-112.
17. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med. 1985;13(5):337-341.
18. Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med. 1995;23(6):694-701.
19. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D’Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988;16(2):113-122.
20. Barrack RL, Skinner HB, Buckley SL. Proprioception in the anterior cruciate deficient knee. Am J Sports Med. 1989;17(1):1-6.
21. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br. 2005;87(5):640-645.
22. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87(7):1012-1018.
23. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;(418):67-73.
24. Bentley G, Biant LC, Carrington RWJ, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br. 2003;85(2):223-230.
25. Berchuck M, Andriacchi TP, Bach BR, Reider B. Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Joint Surg Am. 1990;72(6):871-877.
26. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959;41(6):988-1020.
27. Binkley JM, Stratford PW, Lott SA, Riddle DL, North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther. 1999;79(4):371-383.
28. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87(6):1229-1240.
29. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16(7):677-694.
30. Clancy WG Jr, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am. 1982;64(3):352-359.
31. Clancy WG Jr, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. 1983;65(3):310-322.
32. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-164.
33. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med. 1999;27(3):444-454.
34. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy. 1997;13(4):456-460.
35. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. 1985;67(5):720-726.
36. Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994;22(5):632-644.
37. Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med. 1985;13(6):401-407.
38. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136-1144.
39. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30(4):664-670.
40. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31(1):2-11.
41. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86(2):219-224.
42. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):111-119.
43. Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after rotator cuff repair. Clin Orthop Relat Res. 1994;(304):43-53.
44. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505-515.
45. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73(3):389-394.
46. Glousman R, Jobe F, Tibone J, Moynes D, Antonelli D, Perry J. Dynamic electromyographic analysis of the throwing shoulder with glenohumeral instability. J Bone Joint Surg Am. 1988;70(2):220-226.
47. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):78-83.
48. Guskiewicz KM, Weaver NL, Padua DA, Garrett WE Jr. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643-650.
49. Hangody L, Fules P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg Am. 2003;85(suppl 2):25-32.
50. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA 3rd. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73(7):982-989.
51. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-157.
52. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study. Am J Sports Med. 1999;27(6):699-706.
53. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501.
54. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in female athletes. Decreased impact forces and increased hamstring torques. Am J Sports Med. 1996;24(6):765-773.
55. Homminga GN, Bulstra SK, Bouwmeester PSM, van der Linden AJ. Perichondral grafting for cartilage lesions of the knee. J Bone Joint Surg Br. 1990;72(6):1003-1007.
56. Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85(2):185-192.
57. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-1684.
58. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am. 1976;58(2):159-172.
59. Huston LJ, Wojtys EM. Neuromuscular performance characteristics in elite female athletes. Am J Sports Med. 1996;24(4):427-436.
60. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am. 1991;73(1):17-29.
61. Insall J, Falvo KA, Wise DW. Chondromalacia patellae. A prospective study. J Bone Joint Surg Am. 1976;58(1):1-8.
62. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-14.
63. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29(5):600-613.
64. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80(8):1132-1145.
65. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br. 2001;83(2):171-176.
66. Johnson RJ, Kettelkamp DB, Clark W, Leaverton P. Factors affecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(3):719-729.
67. Jones HH, Priest JD, Hayes WC, Tichenor CC, Nagel DA. Humeral hypertrophy in response to exercise. J Bone Joint Surg Am. 1977;59(2):204-208.
68. Jones KG. Reconstruction of the anterior cruciate ligament: a technique using the central one-third of the patellar ligament. J Bone Joint Surg Am. 1963;45(5):925-932.
69. Knutsen G, Drogset JO, Engebretsen L, et al. A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Joint Surg Am. 2007;89(10):2105-2112.
70. Knutsen G, Engebretsen L, Ludvigsen TC, et al. Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial. J Bone Joint Surg Am. 2004;86(3):455-464.
71. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy. 1993;9(2):159-163.
72. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-1769.
73. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80(3):276-291.
74. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med. 1982;10(3):150-154.
75. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-1010.
76. Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons. Am J Sports Med. 1991;19(5):478-484.
77. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58.
78. Matsusue Y, Yamamuro T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament disruption. Arthroscopy. 1993;9(3):318-321.
79. McDaniel WJ Jr, Dameron TB Jr. Untreated ruptures of the anterior cruciate ligament. A follow-up study. J Bone Joint Surg Am. 1980;62(5):696-705.
80. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14(6):553-565.
81. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50.
82. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77.
83. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65(9):1232-1244.
84. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980;62(6):897-908.
85. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979;61(6):832-839.
86. Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg Am. 1981;63(3):394-399.
87. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
88. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513-518.
89. Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. 1980;62(5):687-695, 757.
90. Noyes FR, Matthews DS, Mooar PA, Grood ES. The symptomatic anterior cruciate–deficient knee. Part II: the results of rehabilitation, activity modification, and counseling on functional disability. J Bone Joint Surg Am. 1983;65(2):163-174.
91. Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate–deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am. 1983;65(2):154-162.
92. Noyes FR, Stabler CL. A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med. 1989;17(4):505-513.
93. O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL. Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Joint Surg Am. 1991;73(2):278-286.
94. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am. 1991;73(3):440-446.
95. Olsen OE, Myklebust G, Engebretsen L, Bahr R. Injury mechanisms for anterior cruciate ligament injuries in team handball: a systematic video analysis. Am J Sports Med. 2004;32(4):1002-1012.
96. Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. 1961;43(4):752-757.
97. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12.
98. Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte transplantation: results at two to ten years. J Bone Joint Surg Am. 2003;85(suppl 2):17-24.
99. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000;(374):212-234.
100. Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB. Magnetic resonance imaging of articular cartilage in the knee. An evaluation with use of fast-spin-echo imaging. J Bone Joint Surg Am. 1998;80(9):1276-1284.
101. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)—development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998;28(2):88-96.
102. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956;38(5):957-977.
103. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978;60(1):1-16.
104. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am. 1981;63(6):863-872.
105. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med. 1989;17(6):760-765.
106. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65(4):456-460.
107. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18(3):292-299.
108. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders [see comments]. J Bone Joint Surg Am. 1995;77(1):10-15.
109. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003;85(2):278-286.
110. Solomonow M, Baratta R, Zhou BH, et al. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med. 1987;15(3):207-213.
111. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy. 2003;19(5):477-484.
112. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517-526.
113. Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;(198):43-49.
114. Garrett WE Jr, Swiontkowski MF, Weinstein JN, et al. American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88(3):660-667.
115. Bartneck C, Kokkelmans S. Detecting h-index manipulation through self-citation analysis. Scientometrics. 2011;87(1):85-98.
116. Bornmann L, Daniel HD. The state of h index research. Is the h index the ideal way to measure research performance? EMBO Rep. 2009;10(1):2-6.
