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The proportion of high school sports-related injuries requiring surgery, which pose monetary and time loss burdens, has significantly increased during the last decade. The objective was to investigate the epidemiology of high school athletic injuries requiring surgery.High school sports-related injury data were collected for nine sports from 2005 to 2010 from 100 nationally representative US high schools.Athletes sustained 1,380 injuries requiring surgery for a rate of 1.45 injuries per 10,000 athlete exposures. Boys' football had the highest injury rate (2.52) followed by boys' wrestling (1.64). Among gender comparable sports, girls' sports has a higher injury rate (1.20) than boys' (0.94) (rate ratio, 1.28; 95% confidence interval, 1.08–1.51; p = 0.004). The rate of injuries was higher in competition (3.23) than practice (0.79) (rate ratio, 4.08; 95% confidence interval, 3.67–4.55; p < 0.001) overall and in each sport. Commonly injured body sites were the knee (49.4%), head/face/mouth (9.7%), and shoulder (8.7%). Common diagnoses were complete ligament strain (32.1%) and fracture (26.4%). Nearly half (48.0%) resulted in medical disqualification for the season.Rates and patterns of injuries requiring surgery differ by sport, type of exposure, and gender. Future studies should identify sport-specific risk factors to drive effective interventions to decrease the incidence and severity of such injuries.