Abstract
Purpose
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We conducted a systematic review of all proposed classifications of tibial plateau fractures (TPFs) to facilitate comparison and identify the most effective reduction methods.
Methods
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PubMed, Scopus, Embase, Web of Science and Cochrane Library databases were searched for all the articles involving the suggestion of a new method of TPF classification. The descriptions of classifications, along with their suggested management strategies, were recorded.
Results
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Out of the 2,712 identified records, 69 were included in the study. Schatzker’s and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classifications were the most frequently mentioned in the literature. The concept of a ‘column’ and posterior column fractures were introduced in 2010. Following this, posterior plateau fractures were further divided into posteromedial and posterolateral fractures. Proposed treatment approaches in most studies were based on the involved region and degree of displacement, while others considered fracture plane, deformity direction and type of fracture. The latest developments include the subclassification of the posterolateral column and consideration of associated injuries to the fibular head, eminentia, extensor mechanism and mechanical derangements along with the concept of the main deformity direction.
Conclusion
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The understanding of TPF patterns, associated injuries, surgical approaches and fixation methods has evolved in a compelling stepwise manner. Currently, there is no gold standard classification that addresses fracture configuration, soft-tissue injuries, principal direction of deformity, central eminence avulsions, extensor mechanism disruptions and mechanical derangements, while maintaining a simple and reliable categorization. Therefore, employing individualized classification systems remains the most logical approach at present. This study offers invaluable assistance in this regard.
Introduction
Tibial plateau fractures (TPFs) account for nearly 1% of fractures in adult population (1). The annual incidence of TPF is estimated to be 10.3–13.3 in 100,000 (2, 3). The decision whether to perform a surgical fixation and choosing the appropriate approach for TPF depends on a number of factors, namely, the presence of associated neurovascular and moderate-to-severe soft-tissue damage, the anatomic and morphologic characteristics of the fracture, the degree of displacement and the presence of instability (4, 5). Mismanagement of TPF might result in joint stiffness and contractures, post-traumatic osteoarthritis, malunion, nonunion, malalignment and possible residual neurovascular injuries (6, 7, 8). Therefore, a classification that can take a higher number of aspects of fractures into consideration with acceptable reliability seems to provide a more accurate guidance for the surgeons. For this purpose, it is important for a trauma/knee surgeon to be familiar with practical classification systems in order to decide the best treatment plan.
Earlier classifications, such as Schatzker (9), classified TPF based on two-dimensional plain radiography, providing a poor view of plateau in the transverse plane. This led to mostly viewing plateau in the coronal plane. In addition, the accurate identification of the fracture plane is crucial as most of the commonly used surgical approaches recommend placement of the plate parallel to the fracture plane (10, 11). Therefore, to fill this gap, newer classifications such as the one proposed by Luo et al. in 2010 (12), and almost all of the classifications that were introduced afterward, used CT for a more detailed classification. They might bear a higher reliability compared to the classifications that are based on plain radiography (13, 14). With addition of other imaging modalities such as three-dimensional CT and MRI, more information can be obtained. Therefore, we attempted to systematically review all the classifications suggested for TPF so far, and the management strategies that were developed based on them.
Methods
This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, and registered through International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42023479635.
Literature search and inclusion criteria
PubMed, Scopus, Embase, Web of science and Cochrane library databases were searched for articles proposing a new classification system for TPF by two reviewers (IMO and NR) for the following terms last updated in November 2023: ((‘tibial plateau’ OR ‘proximal tibia’ OR plateau) AND (Fracture* OR trauma) AND (classification* OR categor* OR taxonom*)) mentioned in article title, abstract or keywords. A new classification is defined as categorization of different patterns of TPF in a sample containing a number of patients in a way not similar to previous classifications. This could be an entirely new method of categorization, or alteration of the previously developed classifications (15).
Study selection
The EndNote version 20 (IBM, USA) software was used to import the extracted citations for reference list management and for the identification of duplicated references (16). The remaining references were screened based on the title and abstract. A senior reviewer (FV) was recalled in case of discrepancy between the two reviewers. The full-texts of the remaining articles were then retrieved and reviewed for existence of the inclusion criteria mentioned above for the final selection (17).
Definitions for data extraction
Data sheet contained the name of the first author, year of publication, number of patients in the study, male-to-female ratio, age, imaging modality used to develop the classification, number of classes and subclasses, the detailed description of the classification and the suggested surgical approach based on the classification (18).
Results
A total of 2,451 studies were identified through database searches. After removing duplicates, 1,739 studies remained. Subsequently, 1,320 studies were excluded following the screening of titles and abstracts. Of the 419 studies remaining, full-text screening identified 57 relevant studies for inclusion in this systematic review. In addition, 152 studies were identified through citation tracing, among which 12 were deemed relevant for inclusion (Fig. 1).
Classifications
A total of 69 classifications were recognized (Supplementary Table 1 (see section on Supplementary materials given at the end of the article)). Seventeen of these introduced subclassifications, modifications or revisions to the prior classifications. The most commonly mentioned classifications in the literature were the ones by Schatzker (9) and AO/OTA (19, 20).
Imaging techniques and described morphologies
Earlier classifications were described based on plain radiography and two-dimensional imaging. Brophy et al. (21) were the first to use MRI; Elstrom et al. (22) the first to use tomography; and Dias et al. (23), who modified Duparc and Ficat’s (24) X-ray based classification, were the first to use CT. The most recent classifications insist on using three-dimensional CT as a complementory method.
Most of the classifications described so far are based on morphologic features of the fractures, namely split or wedge-shaped, depression and bicondylar types referred to as Y- or T-shaped fractures. The classification described by Moore (25), and its modifications by Hohl & Moore (26) and Brophy et al. (21), and the classifications by Khan et al. (27) and Yao et al. (28) included the rim avulsion fractures as well.
Luo et al. (12) were the first to suggest the concept of columns of medial, lateral and posterior based on CT. Chen et al. (29) divided the posterior column into posteromedial (PM) and posterolateral (PL) columns with different fracture morphologies (Table 1). Hoekstra et al. (30) isolated the part of posterior column between the anterior and posterior borders of the fibula, namely PL column, to modify the surgical approaches suggested by Luo et al. (12) for posterior column fractures. Zhang et al. (31) also suggested the subclassification of posterior TPF due to their different prognoses and surgical approaches.
Practical guide to individualized use of TPF classifications.
| Specific feature | References, n | Study | Year* |
|---|---|---|---|
| Rim avulsion | 5 | Moore (25) | 1981 |
| Hohl & Moore (26) | 1990 | ||
| Brophy et al. (54) | 1996 | ||
| Khan et al. (27) | 2000 | ||
| Yao et al. (28) | 2018 | ||
| Tibial tuberosity | 5 | Duparc & Cavagna (78) | 1987 |
| Ruggieri et al. (45) | 1991 | ||
| Chang et al. (36) | 2018 | ||
| Yao et al. (28) | 2018 | ||
| Wang et al. (46) | 2020 | ||
| Mechanism | 6 | Hayes et al. (38) | 2000 |
| Hua et al. (39) | 2019 | ||
| Zhang et al. (41) | 2019 | ||
| Xie et al. (40) | 2020 | ||
| Wang et al. (43) | 2021 | ||
| Hu et al. (42) | 2022 | ||
| Fibula and subtype of fibula | 1 | Yao et al. (28) | 2018 |
| Proximal tibiofibular joint instability | 1 | Yao et al. (28) | 2018 |
| Posterolateral as a separate column | 21 | Chang et al. (79) | 2012 |
| Chang et al. (80) | 2014 | ||
| Sun et al. (81) | 2015 | ||
| Chen et al. (29) | 2015 | ||
| Krause et al. (50) | 2016 | ||
| Hoekstra et al. (30) | 2017 | ||
| Martinez-Rondanelli et al. (82) | 2017 | ||
| Meinberg et al. (83) | 2018 | ||
| Gebel et al. (35) | 2018 | ||
| Kfuri & Schatzker (32) | 2018 | ||
| Yao et al. (28) | 2018 | ||
| Anwar et al. (84) | 2019 | ||
| Hua et al. (39) | 2019 | ||
| Zhang et al. (41) | 2019 | ||
| Bernholt et al. (85) | 2020 | ||
| Saragaglia et al. (37) | 2021 | ||
| Sim et al. (68) | 2021 | ||
| Wu et al. (48) | 2021 | ||
| Zhang et al. (86) | 2021 | ||
| Zhu et al. (62) | 2022 | ||
| Zhu et al. (53) | 2023 | ||
| Subtype for posterolateral column fracture | 7 | Chen et al. (29) | 2015 |
| Krause et al. (50) | 2016 | ||
| Krause et al. (34) | 2016 | ||
| Menzdorf et al. (49) | 2020 | ||
| Saragaglia et al. (37) | 2021 | ||
| Sim et al. (68) | 2021 | ||
| Zhu et al. (53) | 2023 | ||
| Cartilage degeneration | 1 | Zhang et al. (31) | 2018 |
| MRI-based | 5 | Brophy et al. (54) | 1996 |
| Hayes et al. (38) | 2000 | ||
| Bernholt et al. (85) | 2020 | ||
| Menzdorf et al. (49) | 2020 | ||
| Tunçez et al. (47) | 2022 | ||
| Tibial spine | 4 | Chang et al. (36) | 2018 |
| Gebel et al. (35) | 2018 | ||
| Yao et al. (28) | 2018 | ||
| Wang et al. (46) | 2020 | ||
| MCL injury | 1 | Yao et al. (28) | 2018 |
| LCL/ACL/PCL/PLC tear | 2 | Yao et al. (28) | 2018 |
| Tunçez et al. (47) | 2022 | ||
| MDD | 1 | Boluda-Mengod et al. (65) | 2021 |
| Meniscus | 1 | Tunçez et al. (47) | 2022 |
| Posterocentral as a separate area | 6 | Krause et al. (50) | 2016 |
| Krause et al. (34) | 2016 | ||
| Meinberg et al. (83) | 2018 | ||
| Boluda-Mengod et al. (65) | 2021 | ||
| Saragaglia et al. (37) | 2021 | ||
| Zhu et al. (62) | 2022 | ||
| Extensor mechanism injury (quadriceps and patellar tendon, patella) | 2 | Hayes et al. (38) | 2000 |
| Wang et al. (46) | 2020 | ||
| Considered skin/subcutaneous (soft tissue) injury | 0 | NONE |
First year is presented in bold.
MDD, main deformity direction; LCL, lateral collateral ligament; PLC, posterolateral corner; ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; MCL, medial collateral ligament; TPF, tibial plateau fracture.
The two most popular classifications by Schatzker (9) and AO/OTA (19, 20) were both revised in 2018, changing their imaging modality from plain radiography to CT scan. Therefore, the revision by Kfuri & Schatzker in 2018 (32) added posterior and anterior divisions, resulting in four quadrants. They also introduced the concept of ‘main fracture plane’ based on the exit points of the wedge fragment from the articular and metaphyseal cortex to help with the acknowledgment of most optimal direction of plate and screw placement. Other authors tried to further classify the Schatzker’s (9) classification, mostly by categorizing different morphologies of medial plateau fractures. Wahlquist et al. (33) divided medial TPF based on the location of fracture lines relative to intercondylar spines, and stated that the importance of doing so lies in their different prognoses and severities. Krause et al. (34), Gebel et al. (35), Chang et al. (36), Saragaglia et al. (37) and Yao et al. (28) incorporated the bare-area or the non-weight bearing area of the plateau, unlike the other ones.
Mechanism-based classifications
Hayes et al. (38), the first to describe a mechanism-based classification in 2000, included ten types of injury mechanism including two entities of patellar dislocation and direct trauma that are only described in their classification. Hua et al. (39) and Xie et al. (40) included six types based on injury mechanism. Zhang et al. (41) included nine types mainly based on posterior tibial slope angle (PTSA) and tibial plateau angle, with inclusion of axial-loading forces causing bicondylar fractures, in addition to the types described by Xie et al. (40) and Hua et al. (39). Hu et al. (42) divided flexion-type TPF into five subtypes and rotary forces. Wang et al. (43) analyzed the injury mechanisms causing each type of medial TPF described by Wahlquist et al. (44). Hua et al. (39) divided Schatzker (9) type IV fractures based on their main mechanism, which is varus, subcategorized into flexion, extension and hyperextension forces.
Soft-tissue extensions of classifications
Most of the classifications did not include associated soft-tissue injuries. Brophy et al. (21), Moore (25), Yao et al. (28) and Duparc and Ficat (24) described avulsion fractures of ligamentous insertion sites. Ruggieri et al. (45) mentioned collateral ligament injuries; Wang et al. (46) included the avulsion of posterior cruciate ligament (PCL), anterior cruciate ligament (ACL) and tibial tuberosity as the insertion site of patellar tendon. Tuncez et al. (47) modified Schatzker’s (9) classification by the addition of letters to the main fracture types for demonstration of associated ligamentous/meniscus injury; and Yao et al. (28) added two extensions of ligamentous tear or avulsion of their insertion site to a number of the subtypes. Yao et al. (28) described the most precise subclassifications regarding ligamentous disruptions. Yao et al. (28) and Wu et al. (48) included fibular fracture morphologies as well. The most comprehensive classification so far is the one by Yao et al. (28), with 28 separate entities including fracture and associated injury descriptions.
Treatment approaches based on classifications
A total of 34 studies were found to introduce a classification and a treatment approach based on the classification simultaneously. Fifteen of these studies also reported the patient outcomes based on their suggested managements with different tools, radiographic or clinical.
The earliest studies suggested conservative management. Soft-tissue and ligamentous injuries were not acknowledged very well and were usually dealt with immobilization. Moore et al. (25), who described fracture-dislocations, emphasized on the importance of ligamentous injuries, and highlighted the need for a surgical approach according to the involved ligaments. Brophy et al. (21) considered intra-articular soft-tissue injuries as an indication for operative treatment based on MR studies. However, in the absence of MRI, ligamentous injuries were diagnosed by stress examination in other studies. In the next step of evolution, nonoperative managements were only advised for fractures with minimal displacement and instability. Different indications for surgery have been described ever since: articular displacements >2 mm (39, 49, 50), 3 mm (51, 52, 53) and 5 mm (54, 55), or widening >5 mm (39, 56), 4 mm (26, 57) and 5–10 mm (56), and varus or valgus deformity >10° in full extension (58). However, application of rafting screws and plates to provide extra support only became popular in the more recent literature.
Luo et al. (12) were one of the first to consider the surgical management of TPFs based on their locations on the articular surface, described as columns, and suggested different approaches and incisions for involvement of each column.
The reported incidence of posterior TPF ranges from 28.8 to 61.9% (59, 60, 61). Recognizing posterior column fractures, Luo et al. (12) recommended a PM approach using an inverted L-incision for these fractures. Subsequent classifications have consistently divided the posterior column into PM and PL parts, a division deemed necessary due to the challenging access to PL areas of the tibial plateau.
Hoekstra et al. (30) recommended a single lateral approach for lateral column fractures extending into the posterolateral column (PLC). In contrast, Luo et al. (12) categorized this type of fracture as a ‘two-column’ fracture, involving both the lateral and posterior columns, and suggested using anterior and inverted L-shaped posteromedial (PM) incisions. Several authors following Luo et al. (12) also recommended fixing PLC fractures through a PM approach. Reduction of PL fractures through a PM approach can be difficult and often insufficient, with a risk of screw misplacement due to interference from the gastrocnemius and popliteus muscles, which obstruct the surgeon’s view (62). Chen et al. (29) recommended an inverse L-shaped incision in a PL direction for these fractures. However, fixing isolated PLC fractures through a PL approach also presents challenges because of the proximity of the fibular head and key soft-tissue structures behind the knee, such as the peroneal nerve, popliteal artery and popliteus tendon (63). Chang et al. (36) suggested the use of direct PL approach without osteotomy (64) or with osteotomies of the fibular neck or lateral femoral epicondyle for fixing isolated PL column fractures. They also recommended an inverted L-shaped incision for simultaneous PM and PL fractures, similar to other authors. However, Boluda et al. (65) suggested modified Lobenhoffer’s approach (66) for simultaneous access to the PL and PM columns instead of the inverse L-shaped incision. For isolated PL column fractures, they used either the direct PL approach proposed by Yu et al. (64) or an extended AL approach. In the extended AL approach, the incision can be lengthened to access the PL column, allowing direct PL buttress plating through the PL window, as described by Frosch et al. (67). This technique minimizes soft-tissue injury and preserves the anterior tibial artery, avoiding the need for fibular head osteotomy (Fig. 2).
Example of a posterolateral + anterolateral right TPF in a 28-year-old male, who underwent surgery through an extended anterolateral approach. (A, B, C, D) Preoperative radiograph and CT images. (E) Intraoperative view of posterolateral window, star: common peroneal nerve and biceps tendon (retracted anteriorly), arrowhead: direct posterolateral (frosh) interval, asterisk: lateral head of the gastrocnemius and soleus muscles (retracted posteriorly). (F and G) Postoperative radiographs after 6 months follow-up. (H and I) Final knee range of motion after 6 months from surgery.
Citation: EFORT Open Reviews 10, 5; 10.1530/EOR-2024-0184
Zhu et al. (53) suggested that isolated depression fractures of the PL column without cortical involvement can be fixed through the lateral window. If the cortex is involved (uncontained defect), simultaneous use of PL and lateral windows is necessary to provide direct buttress. Kfuri & Schatzker (32) compared the direct lateral and PM approaches for PLC fractures based on their ‘main fracture plane’ concept, which advocates using a buttress plate parallel to the plane in split fractures. They noted that the direct posterolateral approach provides limited distal access and allows only short plates due to neurovascular structures, whereas the extended PM approach supports longer plates, although with limited visibility. Sim et al. (68) argued that different regions of the PLC should be approached based on their subtypes. They recommended an extended AL incision for the anterior regions of PLC and a PM incision for the medial regions of PLC. For PLC areas obstructed by the fibula, a fibular head osteotomy was still advised.
In addition, Luo et al.’s (12) three-column classification defines compression fractures as ‘zero-column’ fractures but does not specifically address their management. This may be due to the ability of surgeons to reduce compression fractures through metaphyseal windows using various approaches that are not necessarily column-specific. Similarly, in the updated three-column concept by Wang et al. (61), minimally invasive techniques and metaphyseal windows are recommended for reducing compression fractures. However, an open surgical approach with a subchondral rafting screw is advised for rim compression fractures to prevent instability (32). Therefore, a column-specific surgical approach appears essential for articular rim compression fractures (non-contained depression).
Dhillon et al. (69) used the concept of compression and tension sides to determine the surgical approach. Boluda et al. (65) were one of the first to consider all the possible combinations of regional involvements (including four-column TPF) and suggested special surgical approaches according to the concept of ‘main deformity direction’ (MDD) (65, 70).
Discussion
The findings of this study demonstrate that the challenge of classifying TPF not only remains unresolved but has also become increasingly complex, reaching a peak in the recent decade. The number of TPF classification systems proposed over the past decade is comparable to those introduced in the preceding 50 years. This reflects a significant evolution in our understanding of TPFs, their treatment and associated injuries (Fig. 3).
Historical bar chart demonstrating the number of TPF classifications proposed in the past century.
Citation: EFORT Open Reviews 10, 5; 10.1530/EOR-2024-0184
Historically, management of TPF has undergone a remarkable stepwise progression (Fig. 4). This began with a shift from nonoperative management to more advanced operative interventions. Imaging techniques have also evolved from the use of simple plain radiographs to more sophisticated modalities such as CT scans and MRI, allowing for a more detailed understanding of fracture characteristics. Initially, TPF was analyzed predominantly in the coronal plane, but the approach has expanded to treat these fractures as three-dimensional entities, considering the axial, sagittal and coronal planes. In addition, the recognition of the posterolateral and posteromedial columns as distinct anatomical regions was a key development.
Suggested diagram for stepwise evolution of TPF journey.
Citation: EFORT Open Reviews 10, 5; 10.1530/EOR-2024-0184
These represent the primary and intermediate phases of our evolving understanding of TPF. More recent developments introduced an even more nuanced view. Emphasis is now placed on the mechanism of injury, and on the significance of soft-tissue damage and associated injuries, factors that were often overlooked in earlier classifications. The incorporation of the concept of MDD into treatment protocols marks another critical advancement, allowing for more tailored and comprehensive management strategies for TPF (65).
Fibular head fractures are frequently associated with medial condylar TPF and can result from avulsion or the ‘push–pull’ mechanism (arcuate sign) (39). Few classifications have considered simultaneous tibial plateau and fibular head fractures. Yao et al. (28) included the fibula as a distinct segment in their classification, with additional extensions to describe injuries to the lateral collateral ligament (LCL) or avulsion of its insertion at the lateral femoral epicondyle. They characterized the hyperextension complex TPF as involving compression of the bare area, alteration or reversal of the PTSA, tension fractures of the posterior cortex, fibular head avulsion fractures or disruption of the PCL or posterolateral corner (PLC). Furthermore, fibular head fractures can lead to valgus instability in cases of lateral plateau fractures, while an intact fibular head in bicondylar fractures may cause varus deformity (71, 72).
The role of soft-tissue injuries in TPF prognosis is discussed in several studies. Schatzker (9) noted that type IV medial condylar fractures have the worst prognosis, likely due to the associated soft-tissue damage. Wahlquist et al. (44) observed worsening outcomes in medial condylar fractures as the fracture line extends laterally toward the intercondylar spines, with an increased risk of soft-tissue complications, including neurovascular injuries and compartment syndrome. Brophy et al. (21) emphasized the importance of MRI for detecting meniscal entrapment in the fracture line, which may lead to failed closed reductions, although this technique is less commonly used today. Wu et al. (48), similar to Yao et al. (28), is among the few studies to highlight avulsion fractures of the intercondylar eminence and associated ACL and PCL avulsion.
TPFs were historically referred to as ‘fender’ or ‘bump’ fractures, primarily involving lateral condylar fractures caused by car accidents. However, earlier studies introduced other mechanisms, including falls or vehicular accidents involving varus, valgus and axial forces. Recent mechanism-based classifications (38, 39, 40, 41, 73) have identified hyperextension and flexion injuries leading to anterior and posterior compression of the tibial plateau, respectively. These classifications aid in predicting concomitant soft-tissue injuries on the tension side and the force direction required for reduction (41, 74, 75). For instance, detecting hyperextension injuries alerts surgeons to potential soft-tissue injuries in the PLC, along with the risk of future fracture collapse causing recurvatum deformity and instability. Recent studies have shown a relatively high rate of PLC injuries in hyperextension varus TPFs, especially in cases without fracture of the posterior column cortex with a small anteromedial fracture area. (76).
Although all of the published TPF classifications were included in this study, the reliability of the classifications was not reported or compared. This information is detailed in a separate study (77). It seems that in the most comprehensive classification systems, reduced reliability is inevitable. Therefore, a gold standard classification with high reliability along with comprehensive consideration of all TPF features does not exist, and individualized use based on the patients TPF configuration and associated injuries is the logical approach (Table 1). The authors’ preferred algorithm for deciding the surgical approach based on fracture configuration is provided in Fig. 5.
Authors’ preferred algorithm for deciding surgical approach in TPF treatment.
Citation: EFORT Open Reviews 10, 5; 10.1530/EOR-2024-0184
Conclusion
The understanding of plateau fracture patterns, associated injuries, surgical approaches and fixation methods has evolved in a compelling stepwise manner. Currently, no gold standard classification addresses fracture configuration, soft-tissue injuries, principal direction of deformity, central eminence avulsions, extensor mechanism disruptions and mechanical derangements, all while maintaining a simple and reliable categorization. Therefore, employing individualized classification systems remains the most logical approach at present. This study offers invaluable assistance in this regard.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-2024-0184.
ICMJE Statement of Interest
The authors declare that they have no conflicts of interest that are relevant to the content of this work.
Funding Statement
This study did not receive any funds for conducting or publication.
Author contribution statement
F Vosoughi helped in conceptualization, validation, writing of the review, editing and supervision. I M Oskouie helped with methodology, conceptualization and writing of the original draft. N Rahimdoost helped in conceptualization, investigation and writing of the original draft. R Pesantez helped with editing the manuscript and preparation of the final draft.
Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Consent for publication
The authors all agree for the submission and publication of the manuscript.
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