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56 (); 26-31
doi:
10.1016/j.jor.2024.05.008

The effect of fixation type on periprosthetic fractures in high-risk patients who have osteoporosis undergoing total joint arthroplasty

, , , , , , , ,
a LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
b Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA

⁎Corresponding author: Ronald E. Delanois. delanois@me.com

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

Minimizing the burden of periprosthetic fractures (PFF) following total joint arthroplasty (TJA) with regard to morbidity and mortality remains an outcome of interest. Patient and surgical risk factors, including osteoporosis and fixation type, have not truly been optimized in patients undergoing TJA as a means to reduce the risk of PFF. As such, we examined: (1) What percentage of patients who underwent THA and total knee arthroplasty (TKA) met the criteria for osteoporosis screening? (2) How did the 5-year rate of PFF and fragility fracture differ in the high-risk and low-risk groups for osteoporosis between the cemented and cementless cohorts? (3) What percentage of the aforementioned patients received a dual x-ray absorptiometry (DEXA) scan before THA or TKA?

We queried an all-payer, national database from April 1, 2016 to December 31, 2021, to identify high-risk and low-risk patients who underwent TJA with a cementless or cemented fixation. High-risk patients met at least one of the following criteria: men at least 70 years old, women at least 65 years old, or patients at least 60 years old who have the following: tobacco use, alcohol abuse, body mass index <18.5, prior fragility fracture, chronic systemic corticosteroids, or genetic condition affecting sex hormones or bone mineral density. Exclusion criteria were a diagnosis of malignancy, high-energy events (motor vehicle collision), those who underwent TJA indicated for fracture, patients less than 50 years old, those who had a prior diagnosis of or treatment for osteoporosis, and a minimum follow-up of less than 2 years.

There were 384,783 patients (67.1 %) who underwent cementless TKA and 67,774 patients (11.8 %) who underwent cementless TKA who were considered high risk. Additionally, there were 62,505 patients (10.9 %) who underwent cemented THA and 58,667 patients (10.2 %) who underwent cementless THA and were considered high risk. The cementless cohort had a 5-year periprosthetic fracture risk following TKA of 7.8 % (95 % CI, 5.56 to 10.98) in comparison to 4.30 % in the cemented cohort (85 % CI, 3.98 to 4.65), P < 0.0001. The high-risk cementless cohort had a 5-year periprosthetic fracture risk following THA of 7.9 % (95 % confidence interval (CI), 6.87 to 9.19) in comparison to 7.78 % in the cemented cohort (85 % CI, 6.77 to 8.94), P < 0.0001.

There is an increased risk of PFF at 5 years following TKA in patients at high risk for osteoporosis undergoing cementless fixation in comparison to cemented fixation. There is an increased risk of PFF at 5 years following THA in patients at high risk for osteoporosis for both cementless fixation and cemented fixation, but no clinically meaningful difference between the two groups. Addressing the shortcomings of the underutilization of bone density scans and better selecting appropriate patients for TJA based on bone quality and fracture risk can help expedite the process of improving the current state of practice.

1

1 Introduction

The consequences of periprosthetic femoral fractures (PFF) are substantial, including an 11 % increase in overall mortality risk within 12 months following total joint arthroplasty (TJA) and a four-fold increased likelihood of requiring postoperative readmission for surgical complications.1–3 Additionally, the rate of PFF is expected to increase by 4.6 % every decade over the next 30 years.4 Several interrelated patient factors, such as the presence of osteoporosis, increasing age, history of fragility fractures, vitamin D deficiency, renal disease, rheumatoid arthritis, and women, contribute to the risk of PPF. In addition, surgical factors, such as cementless stems and non-posterior-based approaches for THA, have been associated with the rising rates of PFF.5–8

Despite the known risks of PFF, patient optimization, surgical technique, and implant choices are not always ideally managed. For example, a recent systematic review comprised of 11 studies and 3462 patients who underwent TJA found the prevalence of osteoporosis and osteopenia in TJA patients was 64.0 %, while the treatment rate was only 32.9 %. The authors called for an improvement in the assessment of pre-operative bone mineral density in order to identify patients who are at high risk for osteoporosis.9 In a similar fashion, in the 2017 American Joint Replacement Registry Annual Report, cementless stem fixation was utilized in 99 % of patients aged 69 years and younger and 88 % in those aged 80–89 years, despite these age groups accounting for 95 % of total hip arthroplasty (THA) PFF.10,11 The challenge in optimization lies in surgeons’ decision-making when faced with balancing the needs of elderly patients who have compromised biological and physiological reserves with the current state of practice that may not be guided by evidence-based recommendations.12

A recent study attributed a higher rate of fragility and periprosthetic fractures at 5-years in those at high-risk for osteoporosis compared with those at low-risk to an occult diagnosis of osteoporosis, in which 50 % of patients undergoing TJA should be screened, but less than 20 % of these patients were screened.12 While these findings accentuate the need for patient optimization in those who have a high risk for osteoporosis undergoing TJA, they do not address the importance of surgeons’ decisions regarding fixation choices and the implications they may have on PFF and bone health-related complications. Additional studies examining the optimization of osteoporosis and fixation type have been limited by single-institutional data and a lack of comparison of the effect of fixation type on PFF at time points greater than 6 months.12–15

To our knowledge, no studies have evaluated the role of cementation in patients who are considered high-risk and low-risk for osteoporosis on PFF and fragility fractures at 5-year follow-up. As such, we examined: (1) What percentage of patients who underwent THA and total knee arthroplasty (TKA) met the criteria for osteoporosis screening? (2) How did the 5-year rate of PFF and fragility fracture differ in the high-risk and low-risk groups for osteoporosis between the cemented and cementless cohorts? (3) What percentage of the aforementioned patients received a dual x-ray absorptiometry (DEXA) scan before THA or TKA?

2

2 Methods

2.1

2.1 Database

We queried a national, all-payer database, the PearlDiver Mariner Patient Claims Database (PearlDiver Technologies, Colorado Springs, Colorado, USA), from April 1st, 2016 to December 31st, 2021. It is one of the largest aggregations of healthcare data that tracks patients longitudinally and includes over 120 million Health Insurance Portability and Accountability-compliant records across all states of the United States. This allows for more generalizable results for the United States population in comparison to a single-institution analysis. The identification of cohorts was obtained by using International Classification of Disease (ICD)-10 procedural and diagnostic codes and Current Procedure Terminology (CPT) codes. The study was exempt from the institutional review board because of the inclusion of patient-protected information and its retrospective status.

2.2

2.2 Patients

Our query identified 613,642 patients who underwent 480,654 TKA and 132,988 THA between April 2016 and December 2021, using ICD-10 and CPT codes. Due to a lack of follow-up or incomplete data, there were 573,729 patients included in this study and eligible for analysis. There were 384,783 patients (67.1 %) who underwent cementless TKA and 67,774 patients (11.8 %) who underwent cementless TKA who were considered high risk. Additionally, there were 62,505 patients (10.9 %) who underwent cemented THA and 58,667 patients (10.2 %) who underwent cementless THA and were considered high-risk. THA. In the TKA cohort, patients underwent full cementation of components. In the THA cohort, patients underwent cementation of the femoral component only, as fully cemented THA is rare. We excluded patients who have a diagnosis of malignancy, high-energy events (motor vehicle collision), those who underwent TJA indicated for fracture, patients less than 50 years old, those who had a prior diagnosis of or treatment for osteoporosis, and those who had a minimum follow-up of less than 2 years.

2.3

2.3 Study groups

The American Association of Clinical Endocrinologists and Endocrinology Society guidelines for men and postmenopausal women were used to risk stratify patients into: i) those considered to be at low risk of osteoporosis at the time of surgery; and ii) those considered to be at high risk of osteoporosis.16 High risk was determined if the patient met at least one of the following criteria: men at least 70 years old, women at least 65 years old, or patients at least 60 years of age who had at least one known risk factor, including tobacco use, alcohol abuse, body mass index (BMI) < 18.5, prior fragility fracture, chronic systemic corticosteroids, or a genetic condition affecting sex hormones or bone mineral density.

2.4

2.4 Outcomes of interest

Our main objective was to determine the 5-year cumulative incidence rates of fragility fractures and periprosthetic fractures between those at high-risk and those at low-risk of osteoporosis and by fixation type. Fragility fractures were defined using procedural codes for closed fractures of the hip, wrist, spine, pelvis, humerus, and other unspecified locations, excluding high-energy events.

Our secondary goals were to identify the percentage of patients who do not have a prior diagnosis of or treatment for osteoporosis undergoing TJA who were at high risk of osteoporosis and underwent preoperative bone health screening via DEXA (dual-energy x-ray absorptiometry) scan.

2.5

2.5 Data analyses

Descriptive analyses, including the number of patients in each category and respective percentages, were performed to identify the percentage of patients who had been screened via DEXA scan. We used Kaplan-Meier analysis to determine the 5-year cumulative incidence rates of fragility fracture and periprosthetic fractures between those at high-risk and those at low-risk of osteoporosis and by fixation type. All analyses were performed using R Studio (R Foundation for Statistical Computing, Vienna, Austria), with significance set at P < 0.05.

3

3 Results

3.1

3.1 Baseline parameters of high-risk categories undergoing TKA and THA by fixation type

The TKA cemented cohort had a higher percentage of patients in the following high-risk categories, including women (57 versus 52 %, P < 0.001), any high-risk (81 versus 77 %, P < 0.001), metabolic or genetic conditions (13 versus 12 %, P < 0.001), and prior fragility fractures (5 versus 5 %, P = 0.0009), in comparison to the cementless cohort, respectively (Table 1).

Table 1 Baseline parameters and high-risk categories of patients undergoing total knee arthroplasty.
Cemented (n = 384,783) Cementless (n = 67,774) P-value
Age group (years)
<60 22.3 (85,957) 25.1 (16,997) <0.0001
60-69 40.3 (155,088) 38.6 (26,170) <0.0001
70-74 18.3 (70,297) 16.5 (11,154) <0.0001
75+ 20.4 (78,561) 20.0 (13,537) 0.0171
Men 42.6 (163,736) 47.9 (32,477) <0.0001
Women 57.4 (221,047) 52.1 (35,297) <0.0001
Any High Risk 81.0 (311,574) 77.1 (52,276) <0.0001
Women 65 years and Older 33.7 (129,775) 30.6 (20,771) <0.0001
Men 70 years and Older 16.3 (62,667) 15.9 (10,807) 0.0092
Metabolic or Genetic Conditions 13.3 (51,103) 12.1 (8179) <0.0001
Prior Fragility Fracture 4.9 (18,663) 5.2 (3534) 0.0009
Underweight 1.4 (5507) 1.3 (850) 0.0400
Chronic Corticosteroid 2.1 (8142) 2.0 (1350) 0.0929
Tobacco Smoker 10.4 (40,189) 12.2 (8265) <0.0001
Alcohol Abuse or Dependence 1.1 (4111) 1.4 (980) <0.0001

The THA cemented cohort had a higher percentage of patients in the following high-risk categories, including women 65 years and older (32 versus 31 %, P < 0.008), prior fragility fracture (6 versus 5 %, P < 0.020), and any high-risk (78 versus 77 %, P < 0.01), compared to the cementless cohort, respectively (Table 2).

Table 2 Baseline parameters and high-risk categories of patients undergoing total hip arthroplasty.
Cemented (n = 62,505) Cementless (n = 58,667) P-value
Age group
<60 Years 24.0 (14,991) 24.5 (14,371) 0.0424
60–69 Years 37.4 (23,381) 38.0 (22,317) 0.0313
70–74 Years 16.7 (10,413) 16.6 (9755) 0.6404
75+ Years 22.1 (13,819) 21.0 (12,292) <0.0001
Men 47.5 (29,707) 48.1 (28,193) 0.0367
Women 52.5 (32,798) 51.9 (30,474) 0.0367
Any High Risk 78.0 (48,762) 77.4 (45,423) 0.0121
Women 65 years and Older 32.2 (20,144) 31.3 (18,389) 0.0008
Men 70 years and Older 16.5 (10,300) 16.3 (9556) 0.3474
Metabolic or Genetic Conditions 12.2 (7639) 12.1 (7096) 0.5944
Prior Fragility Fracture 5.7 (3539) 5.4 (3182) 0.0227
Underweight 1.3 (812) 1.3 (752) 0.7933
Chronic Corticosteroid 2.1 (1292) 2.0 (1197) 0.7130
Tobacco Product Use 12.3 (7659) 12.3 (7214) 0.7910
Alcohol Abuse or Dependence 1.5 (965) 1.5 (897) 0.8875
3.2

3.2 The five-year fracture risk between patients at high-risk and low-risk for osteoporosis by fixation type

For periprosthetic fracture, the cementless cohort had a 5-year fracture risk following TKA of 7.81 (95 % confidence interval (CI), 5.56 to 10.98) in comparison to 4.30 in the cemented cohort 4.30 (95 % CI, 3.98 to 4.65), P < 0.0001). By comparison, the cementless TKA cohort had a 4.16 % (95 % CI, 3.95 to 4.37) 5-year fragility fracture risk following TKA in comparison to a rate of 3.6 % (95 % CI, 3.50 to 3.70), P < 0.0001, in the cemented cohort.

The 5-year periprosthetic fracture risk following cementless THA was 7.94 % (95 % CI, 6.87 to 9.19) in comparison to a rate of 7.78 % (85 % CI, 6.77 to 8.94), P < 0.0001in the cemented cohort, P < 0.0001. Similarly, for fragility fracture, the cementless cohort had a 5-year fragility fracture risk following THA of 4.05 % (95 % CI, 3.84 to 4.27) in comparison to a rate of 4.18 % (95 % CI, 3.96 to 4.41), P < 0.0001 in the cemented cohort.

3.3

3.3 Prevalence of DEXA scan within 3 years before TKA and THA in high-risk for osteoporosis by fixation type

The prevalence of DEXA scans within 3 years prior to TKA ranged from 2 % for men 70 years of age and older to 24 % for patients on chronic corticosteroids in the cementless cohort. The prevalence of DEXA scans within 3 years prior to TKA ranged from 2 % for men 70 years of age and older to 24 % for chronic corticosteroids in the cemented cohort (Table 3).

Table 3 Prevalence of Dual-energy X-ray absorptiometry scan within 3 years before total knee arthroplasty in patients at high risk for osteoporosis.
Cemented (n = 311,574) Cementless (n = 52,276) P-value
Any High Risk 11 (35,476 of 311,574) 11 (5690 of 52,276) 0.0008
Women 65 years and Older 18 (23,707 of 129,775) 18 (3640 of 20,771) 0.0099
Men 70 years and Older 2 (1050 of 62,667) 2 (198 of 10,807) 0.2446
Metabolic or Genetic Conditions 23 (11,547 of 51,103) 21 (1730 of 8179) 0.0036
Prior Fragility Fracture 22 (4092 of 18,663) 21 (727 of 3534) 0.0734
Underweight 19 (1037 of 5507) 19 (159 of 850) 0.931
Chronic Corticosteroid 24 (1987 of 8142) 24 (319 of 1350) 0.5388
Tobacco Smoker 12 (4982 of 40,189) 12 (990 of 8265) 0.2922
Alcohol Abuse or Dependence 9 (351 of 4111) 8 (76 of 980) 0.4269

The prevalence of DEXA scans within 3 years prior to THA ranged from 2 % for men 70 years of age and older to 23 % for chronic corticosteroids in the cementless cohort. The prevalence of DEXA scans within 3 years prior to THA ranged from 2 % for men 70 years of age and older to 23 % for chronic corticosteroids in the cemented cohort (Table 4) (see Table 5).

Table 4 Prevalence of Dual-energy X-ray absorptiometry scan within 3 years before total hip arthroplasty in patients at high risk for osteoporosis.
Cemented (n = 48,762) Cementless (n = 45,423) P-value
Any High Risk 11 (5357 of 48,762) 11 (4992 of 45,423) 0.9843
Women 65 years and Older 17 (3517 of 20,144) 18 (3226 of 18,389) 0.8288
Men 70 years and Older 2 (201 of 10,300) 2 (182 of 9556) 0.8103
Metabolic or Genetic Conditions 21 (1633 of 7639) 21 (1504 of 7096) 0.7873
Prior Fragility Fracture 20 (704 of 3539) 20 (644 of 3182) 0.7234
Underweight 19 (152 of 812) 19 (143 of 752) 0.9332
Chronic Corticosteroid 23 (300 of 1292) 23 (276 of 1197) 0.9237
Tobacco Smoker 12 (937 of 7659) 12 (879 of 7214) 0.9268
Alcohol Abuse or Dependence 8 (78 of 965) 8 (72 of 897) 0.9645
Table 5 The 5-year fracture risk between patients at high risk versus low risk for osteoporosis.
HR (95 % CI) p-value
Cemented Cementless
THA
Periprosthetic Fracture 7.78 (6.77–8.94) 7.94 (6.87–9.19) <0.0001
Fragility Fracture 4.18 (3.96–4.41) 4.05 (3.84–4.27) <0.0001
TKA
Periprosthetic Fracture 4.30 (3.98–4.65) 7.81 (5.56–10.98) <0.0001
Fragility Fracture 3.60 (3.50–3.70) 4.16 (3.95–4.37) <0.0001
4

4 Discussion

Our main finding was that the cementless cohort had a two-times greater 5-year PPF risk following TKA and a marginally greater 5-year PPF risk following THA. Our secondary finding showed an underutilization of the DEXA scan in high-risk patients before both TKA and THA.

Since approximately one-quarter of patients who have osteoarthritis awaiting lower extremity arthroplasty have concomitant osteoporosis,17,18 perioperative optimization of bone health in patients undergoing TJA may help reduce the risk of PPF and subsequent fragility fractures. Preoperative screening of high-risk osteoporotic patients could influence fixation choice. Longitudinal data, such as our findings, may serve as support for evidence-based recommendations.

The strengths of this study include a large sample size and nationwide data, which can have statistical power and a degree of generalizability, at least for the United States. At the same time, we acknowledge the limitations of our study, including those inherent in a retrospective review using a large administrative claims database for data abstraction, including billing or coding errors that could have altered our findings. However, the United States Department of Human and Health Services reports a 1.0 % billing or coding error nationwide, which may be mitigated by the third-party source review of all patients’ records.19 Several ICD codes may be underutilized in the study, which may lead to an underrepresentation in the population overall. While the high-risk categories encompass the recent Endocrinology Society guidelines, additional criteria, such as radiographic osteopenia, loss of kyphosis, vitamin D levels, and family history of osteoporosis, may warrant patient screening for osteoporosis. The lack of matching may contribute to a selection bias, but it also accentuates the increase in PFFs in the high-risk cohort. We were unable to distinguish PPF due to fragility fractures or due to other causes as a limitation of the database. We are unable to detect differences in implant designs between and within the cohorts, but the inclusion of only modern implant designs after 2016 reduces this risk. In addition, our study does not include radiographic, functional, or patient-reported outcome measures due to the limitations of the database. The strength of our study lies in the novel investigation of PFF between cemented and cementless fixation in high-versus low-risk patients undergoing TJA as a means to optimize patient and surgical factors alike.

The literature shows consistent support for the use of cemented femoral fixation in THA in osteoporotic patients to minimize PFF. In a recent study, Chammount et al. stopped a prospective, randomized study early because the total number of early hip-related complications, including PFF and dislocation, was substantially higher in the cementless cohort compared to the cemented cohort as treatment for the osteoporotic elderly who have displaced femoral neck fractures.20 Despite the fact that several national joint registries have shown a lower risk of PPF in patients older than 75 years old who receive cemented femoral components, and the American Academy of Orthopaedic Surgeons (AAOS) recommendation in 2021, which cited strong evidence for cemented femoral fixation for hip fractures, there remains an increasing frequency of the use of cementless femoral components worldwide.21–24.25 However, the decision to perform cemented or cementless fixation during THA often depends on the surgeon's preference, age of the patient, intraoperative impression of bone quality, and region-specific sstandards rather than guidelines based on bone quality.26

Similar findings are found in the literature for cemented fixation in TKA and THA. One large database study of 203,574 patients showed the cementless cohort had a greater risk of PFF at 1 year and 2-years (1 year OR 2.19, 2 years OR 1.89, P < 0.05) in comparison to the cemented cohort.27 Several factors, such as preoperative angular deformity, specifically neutral or valgus mechanical alignment, and evidence of osteopenia, may contribute to an increased risk of PFF that may not be minimized in the cemented TKA cohort.28 Interestingly, the AAOS guidelines cite strong evidence for similar rates of functional outcomes, complications, and reoperations between cemented and cementless fixation methods. The rationale does mention an increased rate of PFF in two studies, but does not mention the role of cementation in the treatment of osteoporotic patients and instead focuses on the surgical management of osteoarthritis of the knee.29–31 Geographically, differences can be found in many European countries using cement fixation for THA, while in the United States and Australia, cementless fixation dominates.32 Additionally, cementation may come at the expense of aseptic loosening, osteolysis, and bone resorption in the area of the bone-cement interface, which is more of a concern in younger and obese patients.33,34 Further, there is a risk of other complications, like bone cement implantation syndrome (BCIS). Screening and treatment may be even more important in these patients because of the relationship between bone metabolism and aseptic loosening.35 In both the THA and TKA literature, few studies compare PFF rates at time points greater than 6 months, even though the risk of post-operative PFF is 3.5 % at 20 years.15,36 Our findings suggest that in high-risk osteoporotic patients, the two-fold increase in PFF following TKA at 5-years in the cementless cohort may lead surgeons to consider cementation in these patients.

Though bone density scans are not routinely obtained prior to TJA, studies suggest that objectively quantified data on bone density might influence the surgeon's selection of cemented or cementless fixation.37 A published survey of 435 orthopaedic surgeons reported that while 60 % of respondents reported that low bone mineral density is a reason to reconsider operation strategies, only 4 % performed bone mineral density measurements preoperatively.38 Bone mineral density may differ in patients of advanced age, as demonstrated by a registry study of over 15,000 patients that showed an earlier risk of failure in patients greater than 75 years who had cementless stems compared to cemented stems, while they found similar results in patients less than 75 years.39 This is crucial to optimally select patients of older age with higher risks of falling for cemented fixation, which has shown an increased load-to-failure force of 25 % that may be underestimated in osteoporotic patients.40

Investigating patients at high risk of osteoporosis as opposed to patients who have a diagnosis of osteoporosis maximizes the inclusivity of patients who should be screened. A prior single-institution study found that 59 % of patients undergoing TJAs met at least one criterion for screening, while another study showed that 25 % of patients who had not undergone screening had an occult diagnosis of osteoporosis. Considered together, patients at high risk for osteoporosis should undergo preoperative screening not solely by radiologists or bone specialists, but by orthoapedic-driven initiatives in the elective TJA setting that already exist for patients who have already sustained a fracture.13 Agarwal et al. supported this notion in their recommendation that surgeon-initiated screening would have a high national impact in potentially narrowing the gap between patients that should undergo screening for osteoporosis and those that actually undergo the screening.13 While our findings demonstrate a similar sentiment, the lens of our recommendation is based on the risk of PFF at 5-years in the high-risk cohort of 7.81 in the cementless cohort in comparison to the low-risk cohort, which highlights the need for further intervention, especially in the setting of elective TJA.

There was an increased risk of PFF at 5 years following TKA in patients at high risk for osteoporosis undergoing cementless fixation in comparison to cemented fixation. There is an increased risk of PFF at 5 years following THA in patients at high risk for osteoporosis for both cementless fixation and cemented fixation, but there is no clinically meaningful difference between the two groups. Improving our understanding of how patient and surgical risk factors, including age, bone density, and fixation type, influence the risk of PFF can guide us towards further evidence-based recommendations. Addressing the shortcomings of the underutilization of bone density scans and better selecting appropriate fixation for TJA based on bone quality and fracture risk can help expedite this process.

Funding

None.

Patient consent

No patient consent needed due to retrospective nature and public database.

Ethical approval

IRB exemption due to retrospective nature and public database Authors’ contribution.

Credit

JD- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

DH- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

JN-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

GG- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing. MM- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

RM- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

MM- Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

CS-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

SB-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

PM-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

JN-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

RD-Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Roles/Writing - original draft; and Writing - review & editing.

Use of AI tool

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