Systematic Review
Return to Preinjury Activity Levels After Surgical Management
of Femoroacetabular Impingement in Athletes
Hussain Alradwan, M.D., Marc J. Philippon, M.D., Forough Farrokhyar, M.Phil., Ph.D.,
Raymond Chu, B.H.Sc., Daniel Whelan, M.D., M.Sc., F.R.C.S.C.,
Mohit Bhandari, M.D., F.R.C.S.C., Ph.D., and Olufemi R. Ayeni, M.D., F.R.C.S.C.
Purpose: A systematic review was conducted to identify, assess, and summarize the available
evidence pertaining to surgical intervention for femoroacetabular impingement (FAI) in athletes.
Summary estimates of treatment effect (proportion with 95% confidence interval [CI]) were calculated specifically for the rate of return to sport. Methods: Electronic databases (Medline, Embase,
and Cochrane Library) were searched from inception to November 2011. The references of included
articles were reviewed for eligible studies. The inclusion criteria were clinical studies, studies
involving humans, minimum 6 months’ follow-up, exclusive FAI treatment, and focus on athletes.
Exclusion criteria were review articles, basic science investigations, radiologic studies, arthroplasty,
and nonathlete clinical studies. A quality assessment of the included articles was conducted by 2
reviewers using a quality assessment tool developed by Yang et al. We used a random-effects model
(DerSimonian-Laird method) to calculate weighted proportions. Percentages with 95% CIs are
reported. Results: Nine articles met the inclusion and exclusion criteria in this review. There was
72% agreement (95% CI, 0% to 94%) between the 2 independent reviewers for inclusion and quality
assessment of the studies. A total of 418 athletes were surgically treated for FAI and were available
for assessment. The rate of return to sport was 92% (95% CI, 87% to 96%), and the rate of return
to the previous level of competition was 88% (95% CI, 80% to 94%). Conclusions: Despite the
limitations of our systematic review, the findings suggest that surgical treatment for FAI resulted in
a high return to preinjury activity levels of sports. Level of Evidence: Level IV, systematic review
of Level IV studies (case series).
H
ip joint impingement was discussed in previous
historical reports, and the concept of morphologic mismatch between the femoral head and the
acetabulum with resultant impingement was described
as early as 1936 in the work of Smith-Petersen.1 He
described impingement of the femoral neck against
the acetabular rim with resultant pain, synovitis, and
chondral damage. In his early series, pain relief and
From the Division of Orthopaedic Surgery, Department of Surgery (H.A., F.F., R.C., M.B., O.R.A.), and Department of Clinical
Epidemiology and Biostatistics (F.F., M.B.), McMaster University, Hamilton, and Division of Orthopaedics, Department of Surgery, St.
Michael’s Hospital (D.W.), Toronto, Ontario, Canada; The Saudi Ministry of Higher Education (H.A.), Riyadh, Saudi Arabia; and Steadman
Philippon Research Institute (M.J.P.), Vail, Colorado, U.S.A.
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Received March 5, 2012; revised March 12, 2012.
Address correspondence to Olufemi R. Ayeni, M.D., F.R.C.S.C., Division of Orthopaedic Surgery, Department of Surgery, Faculty
of Health Sciences, McMaster University, 1200 Main St W, 4E17, Hamilton, Ontario, L8S 3Z5, Canada. E-mail: ayenif@
mcmaster.ca
© 2012 by the Arthroscopy Association of North America
0749-8063/12157/$36.00
http://dx.doi.org/10.1016/j.arthro.2012.03.016
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 10 (October), 2012: pp 1567-1576
1567
1568
H. ALRADWAN ET AL.
improvement of function were obtained by open surgical acetabuloplasty.1
More recently, femoroacetabular impingement (FAI)
has been formally defined by Ganz et al.2 and identified
as a cause of hip pain in the young adult. In FAI,
repeated collision between the femoral head and neck
and the acetabular rim leads to labral and cartilage
damage. Given the loss and dysfunction of these protective structures, eventually, osteoarthritis will develop in affected hips.2-4
In theory, if FAI is addressed early, one can halt the
progression or even prevent the development of osteoarthritis. This possibility has led to increased
interest about the disease and surgical options available.2,5,6
Specific subtypes of FAI have been described. Cam
impingement occurs when the primary morphologic
abnormality is a decrease in the femoral head-neck
offset. This subtype is more common in young male
patients. The pincer subtype occurs when the abnormality is related to focal or global acetabular overcoverage. This type is typically observed in middle-aged
women. However, most patients (86%) have a mixed
type of both cam and pincer subtypes.5-9 Several radiologic investigations have described these subtypes.10,11
The aim of the surgical intervention primarily is to
resect the impinging lesion and to address the associated pathologies: labral tears, chondral damage, and so
on. Several types of surgical technique have been
developed to address FAI. Open surgical procedures
performed with safe access to the hip were initially
described by Ganz et al.12 In recent times, hip arthroscopy as a minimally invasive option has gained popularity. Combined arthroscopic and mini-open procedures also have been described with success.12,13
Ayeni et al.14 prepared an educational video highlighting hip arthroscopy and cam decompression on a
21-year-old athlete with cam impingement and no
labral tear.
Previous systematic reviews showed improved patient outcomes with all approaches, although the arthroscopic approach had lower rates of complications
and a faster rehabilitation course.13-17 Surgical interventions and related outcomes in the nonathletic population have been published in the literature.18,19 Most
of these reported clinical improvement and improved
functional scores with short-term follow-up. Some of
these individual studies have reported outcomes in
athletes.16 The athletic group is an important group
because a recent study showed a high prevalence of
radiologic signs of FAI in a group of football players.20
However, no consistent surgical technique or approach has been applied to the athlete. In addition, no
previous review has specifically assessed return to
sport in this subgroup, which requires a higher level of
performance compared with the general population.
This systematic review was conducted with the intention of arriving at summary estimates of the rate and
level of return to sport after FAI surgery in athletic
populations.
METHODS
For the systematic review, the research question and
eligibility criteria were defined a priori. Two independent reviewers performed searches in electronic databases and identified the eligible studies. Quality assessment of eligible studies and data extraction were
also completed in duplicate. All discrepancies were
reconciled by discussion and consensus.
Study Population
The study population was composed of athletes
with FAI.
Inclusion and Exclusion Criteria
The inclusion criteria were (1) clinical study with
reported minimum 6 months’ follow-up, (2) athletic
patient population diagnosed with FAI, and (3) patients treated surgically with open or arthroscopic
techniques. The exclusion criteria were (1) basic science or nonhuman studies, (2) review articles, (3)
technique articles, (4) radiographic studies, (5) arthroplasty studies, and (6) nonathlete clinical studies.
Outcomes
The primary outcome evaluated was the return to
sport and level of return to sport. The secondary
outcome was improvement in modified Harris Hip
Score.
Search Strategy
Electronic databases (MEDLINE, EMBASE, and
Cochrane Library) were searched for targeted studies
published before or in November 2011. The search
terms were FAI, femoroacetabular impingement, hip
impingement, cam impingement, pincer impingement,
surgical dislocation, mini-open, Hueter approach, hip
arthroscopy, osteoplasty, femoroplasty, acetabuloplasty,
FAI AND RETURN TO SPORT
rim trim, and return to sport. The search process was
conducted with the guidance of a librarian from our
institution. For the EMBASE and MEDLINE database
searches, these same keywords were used as both text
words and Medical Search Headings (MeSH terms)
and were combined by using Boolean operators as
follows: (femoroacetabular impingement.mp. or exp
femoroacetabular impingement/hip arthroscopy.mp.
or exp hip arthroscopy). The search was limited to
articles published in the English language.
Assessment of Methodologic Quality
All eligible studies as determined by the inclusion
and exclusion criteria were assessed for reporting
quality by 2 independent assessors (H.A. and R.C.).
An instrument developed and validated by Yang et
al.21 was used to assess the quality of the case series
studies included in the systematic review. This tool
has shown a high level of consistency and meets
content validity standards.
The tool of Yang et al.21 assesses the article for 4
factors: (1) study aims and design, (2) descriptions of
treatment protocol, (3) descriptions of methods and
therapeutic/side effects, and (4) conduct of the study.
The 4 factors were rated with 13 dichotomous criteria
in which each can be given a score of either 0 or 1. An
independent statistician then calculated the level of
agreement between the 2 independent assessors’ evaluations of the studies.
Data Abstraction
Data were independently collected and recorded
onto a spreadsheet by 2 reviewers. Abstracted data
included authors, date of publication, patient demographics, FAI subtypes, type of sport and level, type
of surgical intervention, return to sport and level, and
follow-up duration. The data were organized and
coded into a database (Microsoft Excel 2007; Microsoft, Redmond, WA).
Statistical Analysis
We calculated the intraclass correlation coefficient
with a 2-way mixed-effects model to determine the
level of agreement between the reviewers. We used a
random-effects model (DerSimonian-Laird method)
for the calculation of weighted proportions. We assumed that there is between-study heterogeneity due
to the limitations and biases inherent to case series.
Weighted means of preoperative and postoperative
modified Harris Hip Scores were calculated. Weighted
proportions with 95% confidence intervals (CIs) and
1569
weighted means with standard deviations are reported.
StatsDirect software (StatsDirect, Altrincham, England) was used for calculations.
RESULTS
Literature Search
The search is outlined diagrammatically in Fig 1. The
electronic searches through MEDLINE, EMBASE, and
the Cochrane Library yielded 3,662 titles. Duplicates
(1,299 titles) were identified and deleted. The remaining titles were screened for “nonrelated” hip conditions and treatments—including arthroplasty (1,870
titles)—that were subsequently excluded, resulting in
493 studies. Formal abstract review proceeded with
application of the inclusion/exclusion criteria to arrive
at 53 studies reporting outcomes in surgically treated
patients with FAI.
After the full-text review, 41 studies were excluded
because they focused on nonathletes. Two studies
were excluded because of incomplete reporting on the
return to sport after surgical intervention22,23 and another for treating athletes with mixed diagnoses (pubalgia and FAI).24
Nine studies met the inclusion criteria for this review.25-33 The references for each article included in
this review were hand searched for other eligible
studies.
The process of title screening and duplicate deletion
was performed using a Web-based bibliography and
database manager (RefWorks 2.0/2011; ProQuest,
Ann Arbor, MI) available through our university library Web site.
Quality Assessment of Included Studies
All 9 included studies were case series, which is
Level IV evidence.34 Quality assessment was completed according to Yang et al.21 The mean quality
assessment score for reviewer H.A. was 11.5 ⫾ 0.5,
and it was 11.0 ⫾ 0.9 for reviewer R.C. The intraclass
correlation coefficient, indicating the level of agreement between the 2 reviewers, was 72% (95% CI, 0%
to 94%) in the quality assessment.
Study Characteristics
All included studies were conducted between 2007
and 2011. All were case series. Of the studies, 5 were
from the United States,27,29-32 3 were from Switzerland,25,26,28 and 1 was from Australia.33
1570
H. ALRADWAN ET AL.
FIGURE 1. Schema of search
process. Electronic databases
(Medline, Embase, and Cochrane Library) were searched
for targeted studies published
before or in November 2011.
The initial search yielded 3,662
studies, of which 1,299 studies
were duplicates. Further exclusion of 1,870 studies was performed based on a title review,
followed by 440 studies excluded based on an abstract review. Fifty-three studies remained, of which 41 were
nonathlete related, thus leaving
12 studies. Two studies were
excluded because they did not
report the return to sport in athletes, and 1 study was excluded
because the diagnosis was not
an isolated FAI diagnosis. This
left 9 studies included in this
systematic review.
Two studies involved patients treated with open
surgical dislocation,25,28 and the other 7 studies used
the arthroscopic approach.26,27,29-33 A total of 440
patients were treated in all the studies. Of the hips
treated, 249 had cam impingement, 36 had pincer
impingement, and 138 had the mixed type. Most of the
studies used plain radiographs and magnetic resonance imaging to categorize the hips’ morphology
(Table 1). Some of the studies provided limited data
on the FAI subtypes.28,29
There were 309 male and 94 female patients. Two
studies did not specify the gender of their study populations.25,33 The mean age of the participants was
25.4 years, with a range from 11 to 66 years. Athletes
aged older than 50 years were included in 4 studies.26,27,29,30 One study had a pediatric population of
FAI AND RETURN TO SPORT
TABLE 1.
Study
History/Physical
Bizzini et al.25 (2007)
Nonspecific hip/groin pain,
reduced ROM in internal
rotation, and positive
impingement test result
Philippon et al.30
(2007)
Debilitating hip pain between
October 2000 and September
2005 and positive
impingement test or FABER
test
Persistent pain with
conservative treatment,
mechanical symptoms,
radiographic evidence of
FAI, and positive for anterior
impingement test and
FABER test
Debilitating hip pain between
March 2005 and December
2007 and positive anterior
impingement sign and/or
FABER test
Unilateral hip pain and positive
impingement test result
Philippon et al.32
(2008)
Philippon et al.31
(2010)
Brunner et al.26 (2009)
Singh and O’Donnell33
(2010)
Byrd and Jones27
(2011)
Naal et al.28 (2011)
Nho et al.29 (2011)
Intra-articular hip pathology as
underlying cause of groin
pain
Recalcitrant hip pain and
inability to partake in desired
athletic activity
Reduced flexion (usually ⬍95°)
and internal rotation (usually
⬍10°) and positive
impingement test result
Failure of nonsurgical treatment
between January 2007 and
November 2008; pain on
flexion, adduction, and
internal rotation; and
crossover sign and/or alpha
angle ⬎45°
1571
Medical Histories
Radiographic Investigation
Surgical Intervention
Mean Follow-up
Acetabuloplasty ⫹
femoroplasty ⫹
labral repair
2.7 yr
Arthroscopic
osteoplasty ⫹ labral
repair/others
1.6 yr
AP pelvis view with cross-table
lateral view of affected side
and MRI
Arthroscopic
osteoplasty ⫹ labral
repair
1.36 yr
Standard AP and cross-table
lateral plain radiographs and
MRI
Arthroscopic
osteoplasty ⫹ labral
repair/others
2 yr
Plain AP pelvis radiographs and
magnetic resonance
arthrography
Plain radiographs, MRI scans,
and Pritchard-O’Donnell
computed tomography scans
Not specified
Arthroscopic
osteoplasty ⫾ rim
trim
Arthroscopic
osteoplasty ⫹ labral
repair/others
Arthroscopic
osteoplasty ⫹ labral
repair/others
Acetabuloplasty ⫹
femoroplasty ⫹
labral repair
2.4 yr
Magnetic resonance arthrography
(with gadolinium contrast) and
plain radiography (2 planes:
AP and cross-table lateral
views)
Not specified
Conventional radiographs (AP
pelvis and cross-table lateral
views) and MRI (with intraarticular gadolinium contrast)
Standard AP radiographs for
pelvis and oblique lateral view
with patient in supine position
Arthroscopic
osteoplasty ⫹ labral
repair
1.8 yr
1.58 yr
3.76 yr
2.25 yr
Abbreviations: AP, anteroposterior; FABER, flexion–abduction– external rotation; MRI, magnetic resonance imaging; ROM, range of
motion.
athletes with ages ranging from 11 to 16 years32
(Table 2).
Outcomes
A total of 418 athletes were surgically treated
for FAI and were available for assessment during
follow-up visits. Of these, 379 returned to sport
after FAI surgery, for a rate of 92% (95% CI,
87% to 96%) (Fig 2). Of the total athletes, 88%
(95% CI, 80% to 94%) returned to preinjury activity levels at a minimum of 6 months’ follow-up
(Fig 3).
Assessment of the subgroups showed that among
the recreational athletes, the return-to-sport rate was
87% (95% CI, 78% to 94%) and the return to
pre-activity levels was 84% (95% CI, 68% to 95%).
On the other hand, for the subgroup of professional athletes, the rate of return to sport was 95%
1572
H. ALRADWAN ET AL.
TABLE 2.
Study
Bizzini et al.25 (2007)
Philippon et al.30 (2007)
Philippon et al.32 (2008)
Philippon et al.31 (2010)
Brunner et al.26 (2009)
Singh and O’Donnell33 (2010)
Byrd and Jones27 (2011)
Naal et al.28 (2011)
Nho et al.29 (2011)
Demographics and Sports Type
Demographics
Sports Type (No. of Patients)
5 young professional ice hockey players
Mean age, 21.4 yr
Range, 20-22 yr
Male-female, not specified
45 professional athletes
Mean age, 31 yr
Range, 17-61 yr
Male-female, 42:3
16 athletes
Mean age, 15 yr
Range, 11-16 yr
Male-female, 2:14
28 athletes
Mean age, 27 yr
Range, 18-37 yr
Male-female, 28:0
45 athletes and 8 nonathletes
Mean age, 42 yr
Range, 17-66 yr
Male-female, 41:12
24 athletes
Mean age, 22 yr
Range, 16-29 yr
Male-female, 24:0
200 athletes
Mean age, 28.6 yr
Range, 11-60 yr
Male-female, 148:52
22 athletes
Mean age, 19.7 yr
Range, 16-25 yr
Male-female, 22:0
47 athletes
Mean age, 22.8 yr
Range, 17-56 yr
Male-female, 34:13
(95% CI, 91% to 98%) and the rate of return to
preinjury activity levels was 92% (95% CI, 82% to
98%).
The modified Harris Hip Score was reported in 5
studies.27,29,31-33 The weighted mean preoperative
Harris Hip Score was 71.3 (95% CI, 69.0 to 74.0) with
an SD of 10.4, and the weighted mean postoperative
Harris Hip Score was 91.6 (95% CI, 89.3 to 94.0) with
an SD of 10.1 (with a maximum score of 100). The
mean improvement was 20.4 (95% CI, 18.0 to 22.6)
(Table 3).
Table 4 provides non-weighted data for return to
sport.
Professional ice hockey in Switzerland league (5)
Hockey (24), golf (6), football (5), soccer (3), dance (2),
baseball (2), martial arts (1), tennis (1), and jockey (1)
Dance (5), volleyball (3), skating (2), baseball (2),
skiing (2), hockey (1), and horseback riding (1)
Professional ice hockey in National Hockey League (28)
Preoperative sports: biking, swimming, soccer, aerobics/
fitness, and jogging
Postoperative sports: biking, swimming, soccer,
aerobics/fitness, jogging, hiking, hockey, and skiing
Football in Australian Football League (24)
Running, football, soccer, baseball, basketball, golf,
softball, ice hockey, workouts, track/cross country,
martial arts, tennis, swimming, lacrosse, dance,
hiking, volleyball, wrestling, field hockey, equestrian,
cycling, racquetball, walking, bull riding, water skiing,
gymnastics, snow skiing, snowboarding, and
weightlifting
Professional ice hockey (14), soccer (3), table tennis (1),
and floor hockey (4)
Ice hockey (11), soccer (7), baseball (6), swimming (4),
lacrosse (4), field hockey (4), football (4), track (3),
tennis (2), crew (1), and equestrian (1)
DISCUSSION
FAI is increasingly being recognized in the literature by many medical and surgical disciplines (orthopaedics, radiology, and physical therapy). Moreover,
Ganz et al.2 provided an elegant description that has
enhanced the awareness, recognition, and understanding of FAI. It follows that treatment strategies are
currently being refined and improved.
With increasing frequency, the literature documents
favorable outcomes of case series and cohort studies
in patients with surgically treated FAI.16,17 The abnormal morphology of FAI is being recognized in athletes
FAI AND RETURN TO SPORT
1573
FIGURE 2. Weighted proportion of athletes
who returned to sports after FAI surgery. The
squares represent the best estimate of the
proportion of athletes who returned to sports
after FAI surgery. The horizontal lines extending out of the squares and diamond represent the 95% CI surrounding the best estimate, with the size of the blocks representing
the sample size of the respective study. The
diamond represents the weighted pool.
more frequently because it can present with decreased
range of motion and impaired performance.35
The results of this review show a 92% rate return to
activity, observed in athletic populations across a variety of sports. Furthermore, 88% of athletes returned
to preinjury activity levels of participation. Although
the studies included had methodologic limitations
(Level IV),34 they were of high quality as assessed by
the tool of Yang et al.21
Our review is the first to specifically evaluate return to participation in an athletic population. The
strengths of this review include the expansive search
of the literature, which was aided by a search strategy
devised in consultation with a librarian. In addition,
the search of databases and processes of the review
were completed in duplicate.
There were several limitations in this review. All
articles included were case series (Level IV evidence).34 The studies were also limited by the relatively short period of follow-up (ranging from 1.36 to
3.76 years). The modified Harris Hip Score and its
variation were not reported in all studies, and wei-
FIGURE 3. Weighted proportion of athletes
who returned to preinjury activity level of
sport. The squares represent the best estimate
of the proportion of athletes who returned to
their preinjury activity level of sport after FAI
surgery. The horizontal lines extending out of
the squares and diamond represent the 95%
CI surrounding the best estimate, with the
size of the blocks representing the sample
size of the respective study. The diamond
represents the weighted pool.
1574
H. ALRADWAN ET AL.
TABLE 3.
Study
Functional Score Type and Scores
Functional Score Type
Bizzini et al.25 (2007)
Philippon et al.30 (2007)
Philippon et al.32 (2008)
Return to sport
Return to sport
Modified Harris Hip Score
Hip Outcome Score: sport
Hip Outcome Score: activities of daily
living
Modified Harris Hip Score
Philippon et al.31 (2010)
Sports frequency score (OA stage I)
Brunner et al.26 (2009)
VAS (OA stage I)
NAHS: OA stage I
NAHS: OA stage II
Sports frequency score (OA stage II)
VAS (OA stage II)
Singh and O’Donnell33 (2010) Modified Harris Hip Score
Byrd and Jones27 (2011)
Naal et al.28 (2011)
Nho et al.29 (2011)
Preoperative
Scores
Postoperative Scores
NA
NA
55 (33-70)
33 (0-78)
58 (37-75)
3/5 patients returned to Swiss National Team,
2/5 patients competed in second division
42/42 returned to preoperative level of sport
90 (70-100)
89 (58-100)
94 (74-100)
70 (57-100)
0.74
5.84
57.3
48.1
0.86
5.29
86
Modified Harris Hip Score
Satisfied patient Hip Outcome Score:
sport
Dissatisfied patient Hip Outcome Score:
sport
Satisfied patient Hip Outcome Score:
activities of daily living
Dissatisfied patient Hip Outcome Score:
activities of daily living
Satisfied patient SF-12: physical
Dissatisfied patient SF-12: physical
Satisfied patient SF-12: mental
Dissatisfied patient SF-12: mental
Modified Harris Hip Score
Hip Outcome Score
Alpha angle
72
NA
95 (74-100)
1.71
1.44
86.7
83.5
2.14
1.54
80 (2 wk), 73 (6 wk), 94 (1 yr), 97 (2 yr),
96 (4 yr)
96
94.3 (89.1 ⫾ 16; range, 41-100)
61.7
NA
98.6 (94.5 ⫾ 9.3; range, 62-100)
NA
NA
79
54.4 (51.1 ⫾ 8.0; range, 32.9-57.3)
40.8
NA
54.3 ⫾ 7.1; range, 29.7-60.9
68.6 ⫾ 12.8
88.5 ⫾ 17.7
78.8 ⫾ 11.3
91.4 ⫾ 14.0
76.4° ⫾ 14.5°
51.4° ⫾ 11.7°
Abbreviations: NA, not applicable; NAHS, Nonarthritic Hip Score; OA, osteoarthritis; SF-12, Short Form 12; VAS, visual analog scale.
ghted means and their variation were calculated based
on the available data. This may further limit the sample size and its generalizability to the population at
large.
The data were limited to identify any significant
differences between the open approach and the arthroscopic approach.
Finally, the athletes included in this review participated in a wide range of sports with correspondingly
wide ranges of levels of participation. Thus this review cannot assess successful return to sport based on
type of sport or level of participation. Likewise, inferences to longer-term results are indeterminate.
When we compared the reported outcomes in athletes with those reported in nonathletic populations,
we found similar clinical outcomes. In the review by
Botser et al.,17 a mean improvement of 24.55 in the
modified Harris Hip Score was observed. In our re-
view the modified Harris Hip Score was reported in 5
studies,27,29,31-33 with a mean improvement of 20.4.
This finding suggests that the results in the athletic
population may be applicable to the nonathletic population. In the future, well-designed prospective cohort trials can help delineate longer-term outcomes in
athletes and further clarify whether athletic individuals derive specific benefit from FAI surgery.
CONCLUSIONS
A high rate of return to preinjury activity level is
observed from this systematic review of available
Level IV evidence. Longer follow-up studies are required to observe the long-term effect and ability to
maintain active participation in sports.
FAI AND RETURN TO SPORT
TABLE 4.
1575
Return to Sport (Non-Weighted Data)
Return
Study
Yes
No
Return at Same Level
Return at Lower Level
Bizzini et al.25 (2007)
Philippon et al.30 (2007)
Philippon et al.32 (2008)
Philippon et al.31 (2010)
Brunner et al.26 (2009)
Singh and O’Donnell33 (2010)
Byrd and Jones27 (2011)
Naal et al.28 (2011)
Nho et al.29 (2011)
5/5
42/45
16/16
28/28
37/45
23/24
181/200
21/22
26/33
0/5
3/45
0/16
0/28
8/45
1/24
19/200
1/22
7/33
3/5
42/45
16/16
28/28
31/45
23/24
181/200
19/22
24/33
2/5
0/45
0/16
0/28
6/45
0/24
0/200
2/22
2/33
Acknowledgment: The authors thank the staff of the
McMaster University Health Sciences Library.
13.
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