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33 (); 124-130
doi:
10.1016/j.jor.2022.07.015

Selective bundle versus complete anterior-cruciate ligament reconstruction: A systematic review and meta-analysis

, , , ,
a Department of Orthopaedic Surgery, Singapore General Hospital, 1 Outram Road, Singapore
b Yong Loo Lin School of Medicine, National University of Singapore, 21 Lower Kent Ridge Road, Singapore
c Division of Musculoskeletal Science, Singapore General Hospital, 1 Outram Road, Singapore

∗Corresponding author: Denny Lie. denny.lie.t.t@singhealth.com.sg

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Selective bundle reconstruction (SLB) refers to preservation of the intact bundle and reconstruction of the ruptured bundle in a partial tear while complete ACL reconstruction involves the removal of all remnant tissue and reconstruction of one or both bundles. As the evidence for SLB versus complete ACL reconstruction remains unclear, this study aimed to compare the two techniques. This study's hypothesis was that SLB reconstruction allows better function and stability compared to complete ACL reconstruction.

A systematic search of PubMed, EMBASE, Scopus and Cochrane Library was conducted, identifying studies that compared SLB (‘selective’ group) versus complete (‘complete’ group) ACL reconstruction. Meta-analysis was conducted for post-operative functional scores, stability outcomes and complications as well as pre-operative to post-operative change.

Eleven studies were included in the meta-analysis, with 1107 patients and a pooled mean follow-up of 29.5 months. Post-operatively, the Selective group had significantly reduced anterior laxity, shown by a lower mean arthrometry side-to-side difference (p<0.01). Analysis of change results showed that the Selective group had a lower mean improvement in arthrometry side-to-side difference as well (p<0.01). No significant difference was shown for all other post-operative outcomes.

This study provides valuable insight to the management of partial tears. It has demonstrated that the preservation of the intact bundle offers stability and function that is as good as complete reconstruction and that SLB is a potentially viable option in the management of partial tears.

Meta-analysis; Level of evidence, 4.

Keywords

ACL
Selective bundle
Remnant bundle
Partial tear
Systematic review
Meta-analysis
1

1 Introduction

Anterior cruciate ligament (ACL) injury remains one of the most common injuries, with an annual incidence of approximately 1 in 3000.1 The extent of ACL injuries varies widely, from complete to partial tears. While the definition of partial tear remains controversial, certain literature has described partial tear as the rupture of either the anteromedial (AM) or posterolateral (PL) bundle while the other bundle remains intact.2 While factors relating to the reconstructed bundle such as graft configuration3 and single bundle (SB) versus double bundle (DB) reconstruction4–6 have been widely studied, selective bundle reconstruction (SLB) in partial tears remains controversial.7–10 SLB refers to the preservation of the residual non-injured bundle while performing selective reconstruction of the torn bundle in a partial tear, using autograft or allograft.11 Indications for this approach include MRI findings of a partial rupture with intact ACL that has continuity from femur to tibia and >50% thickness of the original ACL, as well as clinical findings of low-grade arthrometry measurement.7 This excludes any patient with a remnant stump which fails to meet the criteria of an intact bundle that can be preserved. Thus, it is important to highlight that SLB differs from the remnant preservation technique discussed by Wang et al.,12 which includes patients with a non-viable remnant ACL stump. Pre-operative MRI evaluation of anatomical structures, as described by Camarda et al.,13 is crucial in guiding surgeons on the suitability of SLB reconstruction.

Although complete replacement of the injured ACL has traditionally been preferred,14 there is increasing evidence supporting the SLB approach for partial tears. A study by Mifune et al. in 2013 provided evidence for the vascular and proprioceptive biological advantages of this technique.15 Moreover, a 2019 study by Perelli et al. found that SLB reconstruction offers viable functional outcomes and low failure rates at long-term follow-up.16 However, the evidence supporting its use remains limited as studies comparing SLB to traditional complete reconstruction have demonstrated varying results.7–10 Most importantly, as there is currently no gold standard treatment for partial tears,17 this study aimed to compare the outcomes of SLB versus complete ACL reconstruction to add greater insight into this topic. This study's hypothesis is that SLB reconstruction confers a possible biological and mechanical advantage promoting better recovery, thereby leading to greater functional outcomes compared to complete ACL reconstruction.

2

2 Methods

This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.18 It is registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021279301).

2.1

2.1 Search strategy

This study utilised MeSH terms “anterior cruciate ligament”, and “arthroscopy” as well as non-MeSH terms “remnant”, “selective”, “preserv*”, “reconstructive surgery”, and “reconstruction” (Supplementary Data 1), and performed a literature search in four bibliographic databases from inception to 16 June 2021: PubMed, EMBASE, Scopus, and The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library. References from primary and review articles were cross-referenced to identify additional articles.

2.2

2.2 Selection criteria

Studies were included based on the following criteria: (1) patients with ACL tear which required reconstruction surgery using single-, double-bundle (SB/DB) or SLB reconstruction; and (2) articles that directly compared SLB versus complete ACL reconstruction. All procedures were primary ligament reconstructions performed for acute or chronic ACL deficiencies. Studies fulfilling the above criteria were included regardless of autograft or allograft use.

The following articles were excluded: (i) Non-English; (ii) Literature or systematic reviews; (iii) No comparison between SLB and complete reconstruction; (iv) Absence of an intact bundle eligible for SLB reconstruction (v) No clinical outcomes; (vi) Mean/median follow-up duration less than 24 months; (vii) Recruitment period prior to 1995; (viii) Case reports/conference abstracts/editorials; and (ix) articles with overlapping cohorts. This study established a standardised duration of minimum 24 months follow-up to allow the evaluation of mid-term outcomes post-surgery. For studies with overlapping cohorts, the study with the longest follow-up or highest granularity was included.

Two independent reviewers (M.Y and S.S) filtered articles based on title/abstract followed by full-text screening. Web-based platform Rayyan QCRI19 was used to deconflict selected articles in a blinded manner. Disagreements were resolved via consensus with a senior author (D.L).

2.3

2.3 Data extraction and quality assessment

Two authors (M.Y and S.S) independently extracted data using a predefined spreadsheet (Microsoft Corporation, Washington, Virginia, United States). Conflicts with data collection were resolved after consensus with the senior author (D.L). The following data were extracted: Study characteristics (Supplementary Table 1); Pre-operative outcomes of patients (Supplementary Table 2); Post-operative outcomes (Supplementary Table 3).

Study characteristics included study design, country, recruitment period, follow-up duration, rupture pattern, type of reconstruction, patient details (sex, age, height/weight/BMI), injury details (number/type of combined injuries, injured side, mechanism of injury) and procedural details (type of graft, fixation method, femoral tunnel approach). For studies with outcomes at different follow-up durations, the longest duration of follow-up was selected to ensure the criteria for minimum duration of 24 months was met. Post-operative outcomes included were (1) Functional Scores, including Lysholm, subjective IKDC and objective IKDC grade; (2) Stability Tests, including Lachman and Pivot Shift grade; (3) Anterior laxity, including mean arthrometry side-to-side difference; and (4) Complications requiring second-look procedures. Anterior laxity is defined by an anterior knee displacement resulting from an applied force and measured with the affected knee as a reference using KT1000/2000 or Rolimeter arthrometry devices.20 Stability tests are physical examination techniques which can be used to diagnose and evaluate the extent of ACL-insufficiency.21 This study was unable to analyse failure rates due to the lack of sufficient data, as only Berruto et al. reported it.22 To account for selection bias, pre-operative outcomes were extracted as well for the calculation of pre-operative to post-operative change results where relevant (Supplementary Tables 2 and 3).

This study used the Newcastle-Ottawa Scale23 to evaluate the risk of bias within the included studies (Supplementary Table 4). Two independent reviewers (M.Y and S.S) graded a scale which included eight items using possible scores which ranged from zero to nine. Studies with a score of seven or more were considered high quality. The GRADE methodology was used to assess the quality of the retrieved evidence (GRADEpro Guideline Development Tool [Software], McMaster University and Evidence Prime, 2022).

2.4

2.4 Statistical analysis

All data analyses were performed using R 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria) via the dmetar 0.0.9, meta 4.19-2, and metafor 3.0-2 packages.

Pooled data was calculated for study characteristics, which included patient demographics, follow-up, injury details and procedural details (Supplementary Table 1). For categorical outcomes, non-weighted combined proportions were calculated using simple arithmetic methods. For continuous outcomes, pooled means with confidence intervals were computed with the inverse variance method.

Pairwise meta-analysis was conducted, comparing outcomes in SLB reconstruction (‘Selective’ group) versus Complete reconstruction (‘Complete’ group). Outcomes with ≥2 studies were included. For continuous outcomes with multiple subgroups, means of relevant subgroups were combined using a validated formula from Cochrane.24 Median and range were converted to mean and SD using a validated formula described by Hozo et al.25 To account for between-study heterogeneity, fixed- and random-effects models were used to create forest plots which included Cochrane heterogeneity statistic and Higgins I2 coefficient.26 Two-tailed statistical significance was set at p-value≤0.05 while I2>50% represented substantial statistical heterogeneity.27 When I2>50%, random-effects model was adopted, otherwise a fixed-effects model was used. Subgroup analysis was conducted to compare studies with DB reconstruction only (‘DB only’) versus those with SB only or mix of SB/DB cases (‘SB only/Mixed’) in the Complete group.

Meta-analysis of pre-operative to post-operative change was conducted for post-operative outcomes with significant difference between the two groups. For continuous outcomes, SD change was calculated using a validated method by Cochrane.28

3

3 Results

3.1

3.1 Literature search and study selection

The search strategy yielded 2913 articles while 3 additional articles were identified through citation searching. Following de-duplication, a total of 1341 title/abstracts were screened and 113 full-text articles were sought for retrieval and assessed for eligibility, of which 11 articles were included (Fig. 1).7–10,22,29–34 Notably, Adachi et al.35 was excluded due to its recruitment period (1992–1997), as this would predispose to significant differences in characteristics such as graft fixation method.36 Pujol et al.37 was also excluded as its duration of follow-up (1 year) did not meet this study's criteria of minimum 24 months follow-up. All included studies achieved a score of at least 7 out of 9 on the Newcastle-Ottawa Scale (Supplementary Table 4).

PRISMA 2020 flowchart.
Fig. 1 PRISMA 2020 flowchart.
3.2

3.2 Study characteristics

All study characteristics were summarised in Supplementary Table 1. This meta-analysis consisted of one randomised controlled trial (RCT)29 and ten non-RCT studies (nine retrospective and one prospective).7–10,22,30–34

3.2.1

3.2.1 Patient demographics and follow-up

Across all eleven studies, total cohort size was 1107 with 405 (36.6%) patients in the Selective group and 702 (63.4%) patients in the Complete group.7–10,22,29–34 The pooled mean follow-up across eight studies was 29.5 months (95%CI: 27.9–31.1) across both groups, and 30.3 months (95%CI: 28.0–32.5) and 29.0 months (95%CI: 26.5–31.4) for the selective and complete group respectively.7,10,22,30–34 All studies reported mean/median follow-up duration of at least 24 months or later. The pooled mean age and number of males were 29.7 years (95%CI: 27.7–31.8) and 261 (67.8%) in the selective group respectively, compared to 29.2 years (95%CI: 26.6–31.8) and 461 (69.2%) in the complete group.7–10,29–34 Across two studies, the selective group had a mean height and weight of 174.6 cm (95%CI: 169.1–180.1) and 75.2 kg (95%CI: 56.3–94.1) while the complete group had a height and weight of 175.7 cm (95%CI: 157.0–194.5) and 75.3 (95%CI: 43.6–107.0).30,34 None of the patient demographics was significantly different between the two groups.

3.2.2

3.2.2 Type of reconstruction, graft type and injury details

All except for three studies8,10,22 specified the type of reconstruction in each group. In the Selective group, 50.8% and 49.2% of patients had the PL and AM bundle reconstructed respectively. In the complete group, 61.2% and 38.8% of patients received DB and SB reconstruction respectively.

Seven studies reported mean injury-to-surgery interval.7,9,29–31,33,34 The pooled injury-to-surgery interval was 19.7 weeks (95%CI: 0.1–39.3) in the selective group and 38.7 weeks (95%CI: −2.3 to 79.8) in the complete group. However, the mean difference was not statistically significant. Across seven studies, meniscal injury (MM/LM) was the most common combined injury with 75.7% and 79% of such injuries found in the selective and complete groups respectively.7,9,31,33,34

The most common type of graft for both selective and complete groups was autograft hamstring (HT) only, which was used in eight studies,7–10,29,30,32,33 while the rest used either allograft only or a mix of autograft and allograft.

3.3

3.3 Post-operative outcomes

Post-operative outcomes between the selective and complete groups were analysed and results were summarised in Table 1.

Table 1 Forest plot summary for post-operative outcomes.
Outcome S/C Mean difference (S–C) Odds Ratio (S:C) 95% CI I2 P value Favours
Functional Scores Mean Lysholm score 323/521 1.25 – −1.57 to 4.07 92% 0.34 Selective
Mean subjective IKDC score 111/135 0.26 – −1.10 to 1.61 0% 0.71 Selective
Objective IKDC grade A or B 105/142 – 1.18 0.57 to 2.43 0% 0.66 Selective
Mean Tegner score 121/227 0.33 – −0.41 to 1.08 85% 0.25 Selective
Stability Tests Lachman grade “0” 176/193 – 1.71 0.98 to 3.00 0% 0.06 Selective
Pivot shift grade “0” 304/409 – 1.52 0.99 to 2.34 0% 0.06 Selective
Mean arthrometry side-to-side difference (mm) 305/443 −0.33 – −0.47 to −0.18 21% <0.01 Selective
Complications requiring second-look/revision procedures 187/272 – 1.33 0.46 to 3.90 17% 0.60 Complete
3.3.1

3.3.1 Post-operative functional scores

Ten studies compared Lysholm scores between 323 patients from the selective group and 521 patients from the complete group.7–10,22,29,31–34 There was no significant difference between both groups (MD=1.25, 95%CI: -1.57–4.07, p=0.34, I2=92%) (Supplementary Fig. 1A).

Four studies compared subjective IKDC scores between 111 patients in the selective group and 135 patients in the complete group.22,29,31,32 There was no significant difference between both groups (MD=0.26, 95%CI: -1.10–1.61, p=0.71, I2=0%) (Supplementary Fig. 1B).

Three studies compared the rates of objective IKDC Grade A and B between 105 patients in the selective group and 142 patients in the complete group.8,32,34 There was no significant difference between both groups (OR=1.18, 95%CI: 0.57–2.43, p=0.66, I2=0%) (Supplementary Fig. 1C).

3.3.2

3.3.2 Post-operative stability tests

Five studies compared the rates of Lachman grade ‘0’ between 176 patients in the selective group and 193 patients in the complete group.7,29,31,32,34 There was no significant difference between both groups (OR=1.71, 95%CI: 0.98–3.00, p=0.06, I2=0%) (Supplementary Fig. 1D).

Eight studies compared the rates of Pivot shift grade ‘0’ between 304 patients in the selective group and 409 patients in the complete group.7,10,29–34 There was no significant difference between both groups as well (OR=1.52, 95%CI: 0.99–2.34, p=0.06, I2=0%) (Supplementary Fig. 1E).

Eight studies compared arthrometry side-to-side difference between 305 patients in the selective group and 443 patients in the complete group.8–10,22,30,31,33,34 The mean difference between both groups was statistically significant, favouring the selective group (MD=−0.33, 95%CI: (−0.47)–(-0.18), p<0.01, I2=21%) (Fig. 2).

Forest plot showing mean difference of post-operative arthrometry side-to-side difference.
Fig. 2 Forest plot showing mean difference of post-operative arthrometry side-to-side difference.
3.3.3

3.3.3 Complications requiring second-look/revision procedures

Seven studies were included in the analysis of complications requiring second-look or revision procedures, with the rates of such complications compared between 187 and 272 patients in the selective and complete group respectively.7,22,29–33 There was no significant difference between both groups (OR=1.33, 95%CI: 0.46–3.90, p=0.60, I2=17%) (Supplementary Fig. 1F).

3.4

3.4 Changes in arthrometry side-to-side difference

There was significant difference in post-operative arthrometry side-to-side difference. Thus, pre- to post-operative change was analysed. Seven studies reported pre-operative and post-operative mean arthrometry side-to-side difference, involving 285 patients in the selective group and 403 patients in the complete group.8–10,22,30,31,33,34 The complete group showed significantly greater improvements in mean arthrometry side difference from pre-operative to post-operative phases (MD=−1.53, 95%CI: (−2.36)–(-0.69), p<0.01, I2=92%) (Fig. 3).

Forest plot showing mean difference of pre-operative to post-operative change in arthrometry side-to-side difference.
Fig. 3 Forest plot showing mean difference of pre-operative to post-operative change in arthrometry side-to-side difference.
3.5

3.5 Subgroup analysis

For studies which reported the type of reconstruction in the Complete group, subgroup analysis of Lysholm Score demonstrated no significant difference between the ‘DB only’ and ‘SB only/Mixed’ subgroups (p=0.59) (Supplementary Fig. 2).

3.6

3.6 Publication bias

Egger's test for publication bias did not yield statistically significant results, indicating that the presence of publication bias was unlikely.38,39

3.7

3.7 GRADE

Quality of evidence was evaluated by the GRADE assessment tool (Supplementary Table 5). Overall, evidence on post-operative function, stability and complication rates (Complete versus Selective) was rated low quality. However, this was largely due to most studies being cross-sectional in nature, with only one being a randomised controlled trial. It is important to highlight there was no severe issue in the evidence that warrants a downgrade.

4

4 Discussion

ACL reconstruction is indicated for ‘non-copers’, which are ACL-ruptured patients who demonstrate dynamic instability or poor knee function on screening tests.40 In the realm of ACL reconstruction, various techniques have been applied. This meta-analysis aimed to compare SLB versus traditional complete ACL reconstruction in the context of partial tears. Given that SLB is a form of remnant preservation, which is a very broad topic with varying indications and definitions, this study has narrowed down the definition of SLB to the following: preservation of the intact non-injured bundle while performing selective reconstruction of the torn bundle in a partial tear, regardless of autograft or allograft.11 In concordance, the criteria for SLB requires the presence of a functionally viable intact bundle which fulfils MRI findings of continuity from femur to tibia and thickness >50% of the original ACL as well as low-grade arthrometry difference. Overall, this meta-analysis found that SLB offers comparable functional outcomes, stability as well as complications rates to complete ACL reconstruction. Although the results did not support the study's initial hypothesis, it has shown that SLB can at least produce similar results as complete reconstruction and thus is a potential surgical option for partial tears. However, this must be taken with caution since it is in the context of different surgical indications between the two groups, with SLB patients having lower-grade tears than those in the complete group, which is further discussed below.

In terms of stability and anterior laxity, this study shows that SLB offers comparable, and possibly superior, results compared to complete ACL reconstruction. There was no significant difference between both groups for Lachman and Pivot Shift, although both trended towards statistical significance (p=0.06) in favour of SLB. Moreover, there was significantly lower post-operative arthrometry side-to-side difference in SLB. Sonnery-Cottet et al. previously reported significant improvement in stability following SLB while several studies reported reduced anterior laxity when PL bundles are conserved.34,37,41 Reduced anterior laxity in SLB is expected, as by definition patients would have to have a low-grade arthrometry measurement to be eligible for SLB. In concordance, this study found greater pre- to post-operative improvement for arthrometry difference in the Complete group. However, there are several biomechanical and anatomical advantages of SLB reconstruction which can explain benefits to stability. Firstly, the intact bundle provides greater mechanical strength and stability during the early post-operative period when graft strength is reliant on the fixation device.8,42 Secondly, it has been hypothesised that there is greater revascularisation in remnant tissue, due to the presence of a vascularised synovial envelope around intact ACL fibres, and this promotes the healing response after a tear.43 Moreover, the intact bundle can improve arthroscopic orientation and bone tunnel placement, allowing for a more anatomic reconstruction.42 However, it is important to note that SLB reconstruction can be technically demanding as failure to ascertain the precise footprint of the torn bundle can potentially result in damage to the intact bundle, and this poses a risk to stability both in the short and long-term.34

In terms of function, this study showed that SLB is at least as effective as complete ACL reconstruction, highlighted by similar results in both groups. This is supported by several studies that have shown no difference in clinical outcomes such as Lysholm score.9,10 However, others such as Ahn et al. and Chia et al. have found significantly better clinical outcome scores in SLB compared to complete reconstruction.7,8 It has been hypothesised that SLB reconstruction allows for improved proprioception due to the increased mechanoreceptors in preserved remnant tissue.44 This optimises the rehabilitation process and improves recovery of function.8,42

In terms of complications, one potential disadvantage is that the presence of an intact bundle predisposes to medial-lateral graft impingement and potentially cyclops lesion in the long-term.45 Despite this, this study's results showed no significant difference in the complication rates requiring second-look procedure between SLB and complete reconstruction. However, this could be due to the relatively short follow-up duration of the included studies (29.5 months) whereas cyclops lesions have been reported as late as 10 years.46 Another disadvantage is that there is an association between injury-to-surgery time and decline in the viability of the remnant bundle.30,47 According to Maestro et al., the critical period is four months, after which swelling and cell apoptosis may render the residual bundle impossible to preserve.30 Interestingly, the complete group had a mean injury-to-surgery time of 38.7 weeks, which was twice that of the selective group (19.7 weeks). This could be explained by the hypothesis that many undiagnosed partial ACL tears progress to symptomatic complete tears requiring surgery.48 However, failure rates were not analysed due to the paucity of studies that reported it. Nonetheless, Berruto et al. reported that out of all its patients, only one failure was recorded in the selective group, due to new trauma to the reconstructed bundle.

This study has important implications. Even though partial tears comprise a significant 10%–27% of ACL tears,49 the guidelines for diagnosing a partial tear and indications for SLB remain controversial2,45,50 Reported rates for partial tears indicated for SLB reconstruction ranged from 10% to 34.6% across three different studies.34,51,52 However, this study has shown that MRI findings of an intact bundle fulfilling criterion such as femur to tibia continuity and thickness >50% are reasonable indications for SLB reconstruction with the potential to offer comparable or greater stability and function to complete ACL reconstruction, with no increase in mid-term complications. It also joins a growing body of evidence supporting the use of this technique.16,37,41,53

There are several limitations to this study. Firstly, most studies included were retrospective in nature and there is the issue of selection bias owing to different surgical indications for SLB and complete reconstruction. To our knowledge, only two RCTs have been conducted, of which one was excluded due to insufficient follow-up duration (<24 months). Secondly, we were unable to analyse failure rates and other important function scores (e.g. Knee Society Score), due to paucity of studies which reported them. Moreover, this study was unable to conduct more extensive subgroup analysis, including other important variables and outcomes, due to limited studies in each subgroup.

Nonetheless, this study is to the best of our knowledge the first systematic review and meta-analysis comparing SLB and complete reconstruction and showing that SLB confers advantages that may produce comparable stability and functional outcomes to a patient with complete ACL reconstruction. This is further strengthened by similar baseline characteristics between the two groups. In this study, the complete ACL reconstruction group comprised of both SB and DB as both techniques are commonly employed by surgeons and high-quality studies have shown no difference in terms of patient-reported and objective outcome measures between the two.5,6 Our subgroup analysis did not highlight any difference as well. Therefore, both SB and DB cases were included as conventional methods of complete ACL reconstruction to be compared with SLB.

5

5 Conclusion

In conclusion, this study has shown that SLB reconstruction of a partial ACL tear offers post-operative stability and function that is comparable to complete reconstruction, with no difference in complication rates. This study adds valuable insight into SLB reconstruction and can serve as a reference point for future RCTs comparing SLB versus complete reconstruction. This is essential given the limitations in existing evidence and lack of a gold standard in the management of partial tears.

Funding/sponsorship

This Research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent

N/A.

Institutional ethical committee approval

N/A (no individual patient data/details required as this is a systematic review/meta analysis).

Authors' contribution

Conceptualization: D.L, M.Y, S.S.

Data Curation: M.Y, S.S.

Formal Analysis: M.Y, S.S.

Funding Acquisition: NIL.

Investigation, Methodology, Project Administration, Resources, Software: M.Y, S.S, D.L.

Supervision, Validation, Visualisation: D.L, A.Y, C.G.

Writing – original draft: M.Y, S.S.

Writing – review & editing: D.L, M.Y, S.S, A.Y, C.G.

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