Review Article

Acute Patellar Tendon Ruptures: An Update

on Management

Joseph C. Brinkman, MD
Emily Reeson, BS
Anikar Chhabra, MD
ABSTRACT
Patellar tendon ruptures can be debilitating injuries. When incomplete,
partial tears can be managed nonsurgically with immobilization and
progressive rehabilitation. Although complete ruptures remain a
relatively uncommon injury, they portend a high level of morbidity.
Ruptures typically result from an acute mechanical overload to the
extensor mechanism, such as with forced quadriceps contraction and
knee flexion. However, chronically degenerated tendons are also
predisposed to failure from low-energy injuries. Diagnosis can often be
made clinically with recognition of a palpable defect to the tendon,
localized patellar tendon tenderness, and inability to actively extend
the knee. Diagnosis and surgical planning can be established with
radiograph, ultrasonography, or magnetic resonance imaging.
Surgical repair is the mainstay of treatment, and there have been
many recent advances in repair technique, optimal reconstruction
strategies, and supplemental fixation. Time to surgery for complete
From the Department of Orthopedic Surgery, tears remains the most important prognosticator for success. Direct
Mayo Clinic, Phoenix, AZ (Dr. Brinkman, Dr.
Chhabra), and the Crieghton University School of primary repair can be completed with transosseous tunnels, suture
Medicine, Phoenix, AZ (Ms. Reeson).
anchor repair, or end-to-end repair. Tendon reconstruction can be
Dr. Chhabra or an immediate family member is a
member of a speakers’ bureau or has made paid achieved with or without mechanical or biologic augments.
presentations on behalf of Arthrex; serves as a
paid consultant to Zimmer-Biomet and Trice Rehabilitation programs vary in specifics, but return to sport can be
Medical. Neither of the following authors nor any expected by 6 months postoperatively.
immediate family member has received anything
of value from or has stock or stock options held in
a commercial company or institution related
directly or indirectly to the subject of this article:
Dr. Brinkman and Ms. Reeson.
JAAOS Glob Res Rev 2024;8: e24.00060

P
DOI: 10.5435/JAAOSGlobal-D-24-00060 atellar tendon ruptures are relatively rare injuries that disrupt the distal
Copyright 2024 The Authors. Published by aspect of the extensor mechanism. The injury is most commonly seen
Wolters Kluwer Health, Inc. on behalf of the in men in their third or fourth decade of life and in those with systemic
American Academy of Orthopaedic Surgeons.
This is an open access article distributed under conditions that compromise tendon integrity.1 Primary repair is the mainstay
the terms of the Creative Commons of treatment of complete patellar tendon ruptures. Historically, this was
Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is primarily achieved with transosseous tunnels; however, suture anchors can
permissible to download and share the work also be used and have been reported to be gaining in popularity.1 In acute or
provided it is properly cited. The work cannot be
changed in any way or used commercially
chronic tears where the tendon cannot be adequately repaired, reconstruc-
without permission from the journal. tion can be achieved with various allograft and autograft options.

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Journal of the AAOS Global Research & Reviews ® April 2024, Vol 8, No 4 © American Academy of Orthopaedic Surgeons
Acute Patellar Tendon Ruptures

Anatomy Biomechanics
The patellar tendon comprises the distal aspect of the During active knee extension, force is transferred from
extensor mechanism and extends from the inferior pole the quadriceps muscle group to the tibia through the
of the patella to the tibial tubercle (Figure 1). By defini- patellar tendon and retinaculum. Increasing flexion is
tion, it is a ligament rather than tendon because it ex- associated with a more proximal patellofemoral contact
tends from bone to bone rather than muscle to bone. point, causing the patellar tendon to take on greater stress
However, it is commonly referred to as a tendon because than the quadriceps tendon. Consequently, most patellar
it represents the quadriceps tendon extension distally tendon ruptures occur with the knee in flexion.1 Several
before insertion in the tubercle.1 studies have evaluated the differences in tendon strength
The proximal width of the tendon is that of the inferior and stress based on location. In a cadaveric study, tensile
patella, and it narrows distally before inserting in the stresses were shown to increase in the anterior portion
tibial tubercle. In a series of 53 patients in which the and decrease in the posterior aspect of the tendon
patellar tendon was harvested as a graft, the mean throughout knee flexion.5 Correspondingly, a biome-
patellar length and central width were 39 mm and chanical study of young healthy men showed the ante-
32 mm, respectively.2 Reports of the tendon’s thickness rior portion of the tendon has markedly greater peak
ranged between 4.0 mm and 10.9 mm with tendinop- and yield stress when compared with the posterior fi-
athy indicated with measurements greater than 7.0 bers.6 In the sagittal plane, the end regions of the tendon
mm.3 The blood supply comes from three main sources: near the bony insertions undergo strain that is three to
the inferior-lateral genicular artery, an anastomotic arch fourfold higher than the mid-substance, which may
between the inferior medial genicular artery and ante- explain the higher rate of tears near osseous insertion.7
rior tibial recurrent artery, and retropatellar from Hoffa It is estimated that a force of 17.5 times an individual’s
fat pad. Compared with the well-vascularized mid- body weight is required to rupture the tendon in the
portion, the proximal and distal aspects of the tendon absence of preexisting tendon degeneration.8 Ruptures
are relatively avascular and are consequently the most of the patellar tendon occur in response to extensor
common sites of rupture.4 mechanism tensile overload, most commonly involving

Figure 1

Image showing normal anatomy of the patella and surrounding structures.

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 Joseph C. Brinkman, MD, et al

Review Article
a knee flexion force against an eccentrically contracted also be evident. Importantly, if retinacular tissues remain
quadriceps muscle. In professional athletes, ruptures in continuity, the patient may be able to maintain a
have also been associated with ankle plantarflexion and straight leg raise despite a ruptured patellar tendon.
knee valgus.9 Partial patellar tendon tears are more of an indolent
process and are commonly seen in athletes after contin-
ued activity in the setting of patellar tendinopathy.19
Epidemiology and Risk Factors Workup can include radiographs, ultrasonography,
or magnetic resonance imaging (MRI). On the lateral
Several risk factors for acute patellar tendon rupture have
radiograph, patella alta can be evident and confirmed
been reported. Systemic medical conditions that com-
with an Insall-Salvati20 ratio greater than 1.2,
promise tendon integrity, such as connective tissue dis-
Blackburne-Peel21 ratio greater than 1.0, or Caton
orders, chronic renal failure, systemic lupus
Deschamps22 ratio greater than 1.3 (Figure 2). The
erythematosus or rheumatoid arthritis, as well as
merchant view can also reveal a bare appearing troch-
corticosteroid use increase the risk of tendon rup-
lear groove, or “Empty Merchant Sign”, which has a
ture.10,11 Although the US Food and Drug Adminis-
higher reported specificity and positive predictive value
tration issued a warning of elevated risk of tendon
than lateral radiographs (Figure 3).23
rupture after use of fluoroquinolone antibiotics,12 sev-
High-resolution ultrasonography can be used to
eral studies have shown that tendon rupture after flu-
examine both partial and complete patellar tendon in-
oroquinolone exposure is rare and not clinically
juries.1 With an acute rupture, sagittal images display a
meaningful.13,14 Increasing age and black race have also
confluent area of hypoechogenicity along the hyper-
been identified as risk factors in the military pop-
echoic patellar tendon. Disruption of the normal echo
ulation.15 For local factors, intratendinous cortico-
pattern traversing the full thickness of the tendon in-
steroid injection is believed to stimulate bony or adipose
dicates a complete tear. Similarly, partial tendon rup-
formation within the patellar tendon, predisposing it to
tures can be quantified by measuring the length of the
rupture.10 However, there are limited data or case re-
hypoechoic lesion through the hyperechoic tendon in
ports of this related to the patellar tendon specifically.
longitudinal projection.24 Although ultrasonography is
Another local risk factor involves repeated overuse and
convenient and cost-effective, it is operator dependent,
microtrauma, particularly in jumping athletes, which
and concerns exist regarding its reliability to diagnose
can lead to patellar tendinopathy. This is otherwise
patellar tendon ruptures.1
known as “jumper’s knee” and may predispose to
Evaluation with MRI is the most sensitive modality
partial or complete rupture.16 ln the general population,
and can help determine partial versus full thickness tears,
the reported incidence of patellar tendon ruptures
the location of tear, tendon degeneration, and concomi-
ranges between 0.48 and 1.09 per 100,000 person-
tant soft-tissue injuries.25 The normal patellar tendon
years.17,18 However, in the active military population,
demonstrates homogeneous low signal intensity and
the incidence reaches as high as six per 100,000 person-
smooth and distinct anterior and posterior margins. By
years.15 The incidence of the injury is reported to be
contrast, wavy and discontinuous tendon fibers are
increasing and can potentially be explained by a more
visualized after acute rupture.1 An increase in signal
active aging population.18
intensity on sagittal T2-weighted images can also be
indicative of rupture.26 With a partial tear, MRI can be
used to accurately measure the percentage of tendon
Diagnosis and Radiological Workup torn and guide treatment decisions.19
A history of complete patellar tendon ruptures classically
involves a sudden pain and popping sensation during
loaded eccentric knee flexion. On clinical examination,
patients typically present with tense knee hemarthrosis Partial Thickness Ruptures
and an inability to bear weight on the affected extremity. Popkin and Golman provide a classification for partial
Notable findings more supportive of patellar tendon patellar tendon tears that boasts a high interrater and
rupture compared with intra-articular injury (eg, an interrater reliability.19 The tear classification is based on
anterior cruciate or meniscus tear) include lack of active tendon anterior-posterior thickness and the percentage
knee extension or inability to perform an active straight of tendon torn. The authors also propose that the
leg raise. High-riding patella or palpable tendon gap may classification can be used to assist treatment decision

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Acute Patellar Tendon Ruptures

Figure 2

Radiographs showing the measures of Insall-Salvati, Blackburne-Peel, and Caton Deschamps ratios.

making, with surgical débridement and possible repair rehabilitation, dry needling, percutaneous ultrasonic
recommended for grade 4 tears that fail 6 months of débridement, and extracorporeal shockwave therapy
conservative treatment (Table 1). have been reported with variable efficacy.27-29
Partial thickness ruptures are usually managed with Select investigations have quantified the rate at which
nonsurgical strategies. Acute incomplete ruptures with partial patellar tendon tears require surgical interven-
intact extensor mechanisms are typically treated in tion. In the Golman et al19 series of 56 partial patellar
immobilization in full extension with weight bearing in a tendon tears, 11 (20%) patients underwent surgery. Of
hinged knee brace. For rehabilitation, Karlsson et al24 them, nine underwent débridement alone, and two
reports a protocol that progresses through three phases: underwent suture anchor fixation. As all 11 surgical
the acute phase, the rehabilitation phase, and the return- patients had a tear .50% tendon thickness, the authors
to-activity phase. The acute phase lasts 0 to 14 days and report that a tear greater than 55% of tendon thickness
aims to mitigate the effects of immobilization through is predictive of need for surgical treatment. Karlsson
isometric quadriceps exercises and stretching. Rehabil- et al24 report on a separate series of partial ruptures that
itation and return-to-activity phases are integrated, comprised 91 knees. Altogether, 27 (29.6%) knees were
lasting 3 to 6 months. The rehabilitation phase involves treated with surgery involving débridement and curet-
full mobilization, concentric and eccentric exercises, and tage where necessary. In this series, partial ruptures were
jogging exercises. In the return-to-activity phase, graded according to length of tear as measured on
dynamic exercises are added to stimulate elasticity of the ultrasonography: Grade 1 , 10 mm, grade II 10 to
tendon and improve coordination. In addition to 20 mm, grade III .20 mm. Overall need for surgery was
highest in grade III (38.5%) and lowest in grade I
(6.6%). The authors conclude that failure of conser-
Figure 3 vative management can be predicted to some degree by
measuring tear length. Outcomes of partial patellar
tendon repair are limited; however, in the Karlsson
series, short-term results were excellent or good in 25
(92.5%) of surgical patients. The ideal timing of surgery
in cases of partial tears remains unknown.

Complete Thickness Rupture

Technique
The standard treatment of complete patellar tendon
Images demonstrating the “empty merchant” sign. White ruptures is surgical repair to afford restoration of the
dotted line outlines the patella retracted proximally, out of the
groove and tilted with the inferior pole pointing anteriorly. extensor mechanism and thus return to function. Most
From Mirzayan et al. with permission.19 complete patellar tendon ruptures occur near its insertion

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 Joseph C. Brinkman, MD, et al

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Table 1. Popkin-Golman Classification
Grade Definition Treatment
1 No tear, tendon thickness , 8 mm Bracing treatment, PT, 1/2 NSAIDs
2 Tear thickness ,25% Bracing treatment, PT, 1/2 NSAIDs, PRP, ESWT
3 Tear thickness 25-50% Bracing treatment, PT, 1/2 NSAIDs, PRP, ESWT,
dry needling
4 Tear thickness .50% Bracing treatment, PT, 1/2 NSAIDs, PRP, ESWT,
dry needling, surgery after 6 months

Popkin-Golman classification for partial thickness patellar tendon ruptures. PT, physical therapy; NSAIDs, nonsteroidal anti-inflammatory
medication; PRP, platelet-rich plasma; ESWT, extracorporeal shock wave therapy.

point on the inferior patella.7 However, they can also Although many repair techniques have been reported,
occur at the mid-substance, which predisposes to a more repair with transosseous tunnels is the most popular.31,32
challenging repair because of poorer tissue quality.30 This technique typically includes two to four bone
Regardless of rupture location, repair is indicated for tunnels through which sutures are passed and tied
patients of all ages irrespective of the activity level. (Figures 4 and 5). Suture fixation into the tendon is
Furthermore, repair is recommended to be performed as critical for adequate repair, and various suture techni-
soon as possible after recognition of the injury to ques have been reported. The most reported suture
facilitate the healing and rehabilitation process.1 There techniques include the Mason Allen, Bunnel, and
are numerous fixation, augmentation, and technique Krackow suture techniques.33,34 The Krackow method
options when considering repair. is commonly reported and uses locking running suture

Figure 4

Images illustrating the surgical technique involving patellar bone tunnels and their locations.

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Journal of the AAOS Global Research & Reviews ® April 2024, Vol 8, No 4 © American Academy of Orthopaedic Surgeons
Acute Patellar Tendon Ruptures

Figure 5

Image illustrating the fixation technique using patellar bone tunnels plus Krackow suture fixation.

through the tendon. Despite its many throws, the tation can be performed with suture, cable wire, allog-
Krackow technique has been shown to not markedly rafts, or autografts. Reported benefits of augmentation
alter the vascularity of the tendon on advanced include decreased strain across the repair, which may
imaging.35 result in earlier knee motion and less tendon gapping.38
To avoid transosseous tunnels, repair can also be Augmentation with hamstring autograft is a commonly
performed using suture anchors in place. Capiola et al reported technique and involves a doubled hamstring
describe a technique using suture anchor fixation to the graft that is inserted into the distal patellar pole socket
inferior pole of the patella with tendon fixation using a 6- and sutured to the native tendon (Figure 6). In the
strand Krackow technique.36 Reported benefits of this revision setting or cases involving poor tendon quality, a
technique include less invasive exposure, decreased risk cerclage wire can be placed circumferentially around the
of penetrating patellar articular cartilage, shorter sur- patella and fixed to the tubercle to support repair.
gical time, and more accurate recreation of the patellar Transosseous repair with woven surgical mesh aug-
tendon footprint on the inferior patella.36 A modified mentation has also been reported to increase resistance
technique has also been reported using cortical buttons to gap formation after repair.39
instead of suture anchors to afford a stronger repair.37 Internal bracing treatment is another method for acute
In cases of frayed tendon edges or tendon gapping patellar tendon repair. This technique uses high strength
limiting the strength of the above techniques, augmen- suture tape and knotless anchors to provide

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Journal of the AAOS Global Research & Reviews ® April 2024, Vol 8, No 4 © American Academy of Orthopaedic Surgeons
 Joseph C. Brinkman, MD, et al

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Figure 6 rates of implant rupture and synovitis.48 To date, tissue
scaffolds and biomaterials remain unable to fulfill the
complex physical, mechanical, and morphological re-
quirements of native tendons.

Postoperative Rehabilitation
Historical postoperative protocols after repair called for
long periods of immobilization. However, more recent
protocols have emphasized early range of motion to
avoid stiffness, patella baja, persistent pain, and weak-
ness associated with prolonged immobility.49 Further-
more, early joint range of motion is recognized to
stimulate tendon healing and perhaps shorten the
overall rehabilitation time. To achieve early range of
motion, augmentation strategies have been developed to
increase the strength of repair and limit gapping with
early stress to the repair.
Various early range of motion protocols have been
reported. Outcomes have demonstrated that early range
of motion is safe, feasible, and decreases the time to full
range of motion and strength.50 The optimal postoper-
Image illustrating patellar tendon repair using suture tendon ative protocol remains unknown, although West et al51
repair augmented by semitendinosus autograft.
report a protocol that was associated with device-free
ambulation at an average of 7.7 weeks in their series on
biomechanical stability of the repaired tendon.40 A 30 patients undergoing patellar tendon repair. In this
modified technique has also been described using bone series, patients kept their leg elevated for 48 hours after
tunnels in the patella and cortical buttons on the tibia surgery. A hinged knee brace was used for the following
with suture tape whipstitched through the tendon.41 5 to 7 days with daily wound checks. From this time
Enhanced fixation, immediate postoperative mobiliza- point until week 6, daily active range of motion between
tion, and early functional recovery are reported benefits 0 and 55 degrees of flexion was performed. During this
of internal bracing treatment techniques.40,41 time, patients were permitted to weightbear as tolerated
Platelet-rich plasma (PRP) and the application of with locked extension. At 6 weeks postoperatively,
engineered tissue are more recently evaluated techniques patients were allowed to perform full active knee flexion
to improve patellar tendon tissue regeneration and and ambulate without the brace.
functionality in the instance of tendon injury.42 In 2012,
Almeida et al43 showed that PRP had a beneficial effect Biomechanical Outcomes
on patellar tendon healing and pain postoperatively Several biomechanical studies have evaluated differences
after harvest for anterior cruciate ligament reconstruc- between repair techniques. In 2006, Bushnell compared
tion. Since this time there have been several studies and suture anchors and transosseous tunnels on 12 cadaveric
systematic reviews that have demonstrated mixed re- knees and found markedly less gap formation after 250
sults regarding the use of PRP for patellar tendinop- cycles in the suture anchor group.52 In a larger cohort of
athy.44-46 In the acute tear setting, it remains unknown if 30 knees, Ettinger et al reported markedly greater
PRP offers any benefit. However, a case in which rup- ultimate failure loads in addition to less gap formation
ture occurred after PRP use for chronic tendinopathy after cyclic loading in the absorbable as well as titanium
has been reported.47 Additional studies will contribute suture anchor cohorts when compared with trans-
to understanding the role and expectations of PRP in the osseous tunnels.53 The authors noted that failure was
management of acute patellar tendon tears. Collagen typically a result of failure of the eyelet in the absorbable
and fibrin gel scaffolds have also been reported as anchor group and suture rupture in the titanium group.
treatment options and have nearly replicated the native These findings were further corroborated by Lanzi
tendon tensile strength.42 However, long-term clinical et al54 in a study on 24 porcine specimens that found
outcomes of synthetic scaffolds have exhibited high markedly less gap formation and higher load to failure

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Acute Patellar Tendon Ruptures

with suture anchor versus transosseous tunnels. In a early repair, with poorer outcomes in cases of delayed
systematic review and meta-analysis of seven studies repair.59 Belhaj et al60 report the longest-term follow-up
and a total of 128 cadaveric knees, Imbergamo et al32 of patellar tendon suture anchor repair in their series of
found markedly less gap formation in the suture anchor 25 patients. At a median of 75-month follow-up, pa-
cohort but did not reveal any notable difference in tients demonstrated markedly improved Knee Society
ultimate load to failure. In a separate meta-analysis, pain and function scores and decreased pain compared
suture anchors again demonstrated favorable biome- with preoperative scores. However, knee extension
chanical properties in terms of gap formation when strength was markedly lower on the surgical versus
compared with transosseous tunnels.55 The authors also nonsurgical side. There was no extension deficit, which
found most suture anchor failures were in cases of has also been shown in smaller retrospective series.50
titanium anchors. Reported risk factors for poorer outcomes after repair
Biomechanical studies have also been performed on include female sex, non-White race, and lower preop-
specific technique modifications. Ode et al37 compared erative function. Overall failure rates between techni-
cyclic gap formation and failure rate between trans- ques were compared in a systematic review that included
osseous, suture anchor, and cortical button fixation in 503 patients across 41 manuscripts.61 They found that
23 cadaveric knees. The cortical button group demon- in the acute setting, primary repair with augmentation
strated markedly less gap formation than the suture with either cables or suture resulted in the best clinical
anchor and suture repair groups, up to 20 cycles and results with an overall failure rate of 2%. In the chronic
250 cycles, respectively. In addition, the cortical button setting, autograft reconstruction markedly out-
knees demonstrated markedly higher loads to failure. performed primary repair.61
The authors conclude that there is a clear biomechanical Fredericks et al15 report on a large series of 504 pa-
advantage of cortical button fixation although inves- tients who underwent primary patellar tendon repairs in
tigations have not yet proven any clinical benefit. the military population. Fixation method was 81%
A number of biomechanical studies have evaluated the bone tunnels, 7% suture anchors, and 12% were
impact of augmentation strategies. In an investigation of unknown. Overall return to previous activity occurred
60 porcine models, Schliemann et al56 noted markedly in 76% of patients, with 15% returning on a limited
higher maximal loads and less tendon elongation of basis. Rerupture occurred in 3% of the series, with
both polydioxanone suture and cable wire augmenta- identified risk factors of Black race and age between 35
tion strategies when compared with suture anchor to 44 years. Not surprisingly, return to work is reported
repair alone. Black et el found a 68% increase in gap to be higher in the nonmilitary population with a review
formation in the standard repair group compared with of 757 patellar tendon repairs noting an overall return
figure-of-eight suture augmentation on transosseous to work rate of 95.8%.62
fixation at 250 cycles.38 The suture augmentation group Clinical outcomes and return to sport have specifically
also demonstrated a markedly higher mean load to been evaluated in a number of studies in the athletic
failure. Similarly, Gould et al57 reported markedly less population. A systematic review of athletes who under-
displacement in suture tape augmentation up to 1,000 went patellar tendon repair of any surgical method found
cycles compared with standard transosseous repair, an overall return to recreational activity of 88.9%.62
although there were no difference in load to failure. A However, only 70.9% of professional athletes were able
notable increase in yield load has been noted with to return to preinjury level of sport in this series. Boublik
supplemental fixation using suture anchor internal and colleagues63 evaluated the outcomes of 24 patellar
brace with suture tape.58 In this series of 32 cadaveric tendon tears in National Football League athletes. In
knees, the augmented group demonstrated comparable 79.2% of cases, the athlete was able to return to at least
strength to augmentation with an 18-gauge wire. one game. The authors note that although the injury is
Additional study is needed to determine benefit of these typically season ending, acute surgical repair generally
augmentation strategies, although it is hypothesized that results in good functional outcomes. Nguyen et al per-
a stronger repair can prevent loss of reduction, reduce formed a separate analysis of 103 professional baseball,
failure, and allow for earlier postoperative mobilization. basketball, American football, and soccer athletes.64
They found that football athletes had the lowest return
Clinical Outcomes to sport rate overall, had the worst postoperative out-
Outcomes after primary repair are generally favorable. come, and demonstrated the greatest decrease in career
Specifically, excellent outcomes can be expected with lengths. Basketball athletes played less games the

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Journal of the AAOS Global Research & Reviews ® April 2024, Vol 8, No 4 © American Academy of Orthopaedic Surgeons
 Joseph C. Brinkman, MD, et al

Review Article
subsequent season after injury, and soccer athletes 5. Almekinders LC, Vellema JH, Weinhold PS: Strain patterns in the patellar
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normalized by postoperative season two.
6. Haraldsson BT, Aagaard P, Krogsgaard M, Alkjaer T, Kjaer M,
Clinical studies comparing patellar repair techniques Magnusson SP: Region-specific mechanical properties of the human
are somewhat limited. O’Dowd et al17 performed a patella tendon. J Appl Physiol 2005;98:1006-1012.
retrospective review of 374 knees that underwent pri- 7. Woo S, Maynard J, Butler D, et al: Ligament, tendon, and joint capsule
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between the cohorts. The authors conclude that their 10. Zhang J, Keenan C, Wang JH-C: The effects of dexamethasone on
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that suture anchors may be a preferred technique owing
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2916-2923.
the mainstay of treatment of complete ruptures and can
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Acute Patellar Tendon Ruptures

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Journal of the AAOS Global Research & Reviews ® April 2024, Vol 8, No 4 © American Academy of Orthopaedic Surgeons