Mid-term outcome of elbow hemiarthroplasty performed in a tertiary elbow hub

Abstract

Background

Elbow hemiarthroplasty (EHA) is a surgical option for managing acute, non-reconstructable distal humerus fractures in elderly and low-demand patients. In England, due to its low-volume nature, EHA is now centralised to designated regional hubs. This study evaluates medium-term clinical and radiological outcomes of EHA performed in a high-volume tertiary elbow hub.

Methods

A retrospective review of consecutive patients treated with EHA for acute distal humeral fracture between 2016 and 2024 was performed. Clinical and radiological outcomes were assessed, and all complications and re-operations were documented. Subgroup analysis compared outcomes for tertiary versus local referrals and for patients aged <80 versus ≥80 years.

Results

Fifty-five patients, including 50 (91%) females with a mean age of 75 (57–93), were included. Median time to surgery was 8 days (6–12). Thirty cases (55%) were external referrals. Clinical outcome data were available for 44 patients. Mean follow-up was 44 months (13–101). Median Oxford Elbow Score 44 (40–46) and visual analogue scale 1 (0–2), with a mean flexion arc of 123° (70°–140°). The overall complication rate was 16%, with a 4% re-operation rate (2 patients). No cases of implant loosening or instability were recorded, and no cases required revision surgery.

Discussion

Centralised EHA for acute distal humeral trauma demonstrates consistent, good clinical outcomes and a favourable complication profile when compared to the literature and national registry data. These findings support the centralisation of low-volume arthroplasty to hub units.

Keywords

Elbow hemiarthroplasty distal humeral hemiarthroplasty distal humerus fracture outcomes complications elbow hub

Introduction

Surgical management strategies for acute, intra-articular distal humeral fractures include open reduction and internal fixation (ORIF), total elbow arthroplasty (TEA) or elbow hemiarthroplasty (EHA).¹ While joint preservation with ORIF is considered the gold standard treatment option, its success can be limited in cases with osteoporotic bone stock or marked intra-articular comminution, when traditional fixation can be technically demanding and is associated with a higher risk of complications, including non-union or implant failure.^2,3 More recently, EHA has been increasingly accepted as an option for acute non-reconstructable distal humeral fractures, as it offers a more predictable option for joint reconstruction, while negating the complications associated with the ulna component in TEA – including bushing wear, osteolysis secondary to polyethylene wear and ulna component complications, including loosening and periprosthetic fracture.^2,4,5 However, concerns remain around the longer-term performance of EHA – particularly with regards to the incidence of instability, cartilage wear and arthritis affecting the native joint surfaces of the proximal ulna and radius. Previous case series reporting EHA outcomes suggest reliable functional outcomes; however, they largely consist of small series, often combining both acute and chronic indications, with variable follow-up durations.^6–8

Since 2012, the UK National Joint Registry (NJR) has been collating and publishing data on elbow arthroplasty activity. The 2025 NJR report indicated that 1056 primary elbow arthroplasty procedures had been performed in the preceding year (2024), of which 137 (13%) were EHA.⁹ This compares to over 116,000 primary hip replacements and over 134,000 primary knee replacements during the same period.⁹ The relatively low volumes of elbow arthroplasty being undertaken inherently limit the volume of cases managed by individual surgeons. It has been consistently demonstrated that high-volume practice in lower limb joint replacement is associated with better outcomes and lower complications, with similar findings also shown in elbow replacement surgery.^10–15 The NHS England Getting It Right First Time (GIRFT) initiative has therefore worked with the British Orthopaedic Association (BOA) and British Elbow and Shoulder Society (BESS) to implement a centralised model with a smaller number of designated elbow hubs now delivering the elbow arthroplasty service nationally.^16,17 It is intended that concentrating experience and case volumes within these designated centres will optimise surgical proficiency and enhance patient outcomes following elbow arthroplasty procedures.

This study aims to assess the medium-term outcomes of EHA performed in a designated regional tertiary elbow hub by reporting the clinical, radiological and patient-reported outcomes and presenting the incidence of complications and re-operation. We will consider our findings relative to the existing published literature and registry data for non-centralised models of care.

Methods

Study population

A consecutive series of patients who underwent EHA for acute distal humeral fracture, at a single tertiary elbow hub, between July 2016 and August 2024 were retrospectively reviewed. This included patients who presented to our hospital and those referred from neighbouring trusts. Patients were referred from regional centres via a standardised electronic referral system. Referrals were reviewed by trauma coordinators and escalated to the on-call upper limb consultant, allowing treatment planning within 24 h and facilitating timely transfer for definitive management.

Eligible patients presented with acute, comminuted intra-articular distal humeral fractures that were determined to be unreconstructible based on radiological and/or intra-operative assessment, with the decision to proceed with EHA guided by both patient factors and fracture morphology. This included fractures with limited distal bone stock or fracture configurations at high risk of fixation failure. Elbow hemiarthroplasty was considered in selected extra-articular fractures where fixation was unlikely due to poor bone stock with a risk of secondary displacement. TEA was preferentially performed for patients with pre-existing elbow arthritis or fracture patterns involving the coronoid. Exclusion criteria included salvage EHA for those presenting with established non-union or failed fixation of the distal humerus.

Surgical technique and rehabilitation

All operations were performed by two senior authors with subspecialist experience in elbow arthroplasty or under their direct supervision. Surgery was conducted with the patient in either the lateral decubitus or supine position using the triceps-on lateral para-olecranon approach, originally described in the literature by Studer et al.,¹⁸ and modified by Phadnis et al.¹⁹ Two patients with a concurrent olecranon fracture at presentation had surgery using the fracture for exposure. The ulna nerve was routinely decompressed and anteriorly transposed intraoperatively. The Latitude EV implant system (Wright Medical, Stryker, Kalamazoo, MI, USA) was used in all cases. Column fractures were stabilised using either K-wires or plates, while epicondylar fragments were secured with sutures using a previously described technique.^3,19 Postoperatively, a bulky bandage and sling was applied for the first 2 weeks. Shoulder, hand and wrist exercises were commenced immediately. Elbow flexion and extension were permitted from postoperative day 1 within the limitations of the bandage, unless wound concerns necessitated a delay of up to 2 weeks until a formal wound assessment. At 2 weeks, following bandage removal and wound review, rehabilitation was progressed with full active flexion and extension permitted in the supine position, including overhead exercises where tolerable. These exercises are illustrated in rehabilitation resources provided by BESS.²⁰ Patients were advised to perform exercises five times daily, with the use of a sling for comfort when not exercising for up to 4–6 weeks. To protect the collateral ligament reconstruction, varus and valgus stresses were restricted in the early postoperative period. Varus loading was minimised by avoiding unsupported shoulder abduction beyond 45°, while valgus stress was reduced through sling use and avoidance of combined shoulder abduction and external rotation. Rehabilitation was preferentially undertaken in the supine or overhead position to reduce distractive forces across the joint.

Weight-bearing through the operated limb was avoided for 6 weeks; however, assisted ambulation using a forearm gutter crutch was permitted where required. No strict long-term lifting limits were imposed; however, patients were educated on long-term joint protection strategies and advised to avoid excessive or repetitive loading to optimise prosthesis longevity.

Radiological assessment

Preoperative X-rays and CT scans were independently assessed, and injuries classified according to the AO/OTA system.²¹ Coronal shear fractures were additionally graded using the Modified Dubberly classification.^21,22 Radiographic assessment was performed by two authors (JP and FA), with any discrepancy in classification resolved through consensus. CT scans demonstrating the characteristic fracture patterns for each classification system are shown in Figure 1 and Figure 2. Postoperative anterior–posterior (AP) and lateral plain radiographs (Figure 3) were obtained at each postoperative visit. Radiographs were available for comparison at each time point, allowing for temporal changes in joint architecture and implant positioning to be appreciated. The serial images were evaluated for signs of implant loosening, wear of the retained native proximal radius and ulna, condylar union, the development of secondary osteoarthritis, including joint space narrowing, osteophyte formation and other degenerative changes, and presence of heterotopic ossification (HO).²³

Figure 1.

Preoperative radiographs (lateral and anterior–posterior [AP]) demonstrating ao/OTA Type 13-C3 distal humeral fracture in an 80-year-old patient.

Figure 2.

Preoperative CT demonstrating a modified Dubberly type 3B distal humeral fracture in a 72-year-old patient. (A) Coronal slice highlighting comminution (B) axial slice (C) Sagittal slice demonstrating fractured capitellum (D) sagittal slice demonstrating fractured trochlea.²²

Figure 3.

Postoperative (lateral and anterior–posterior [AP]) radiographs of elbow hemiarthroplasty.

Implant loosening was assessed by identification of radiolucent lines, classified according to the Gruen-type zones outlined by Goldberg et al.²⁴ Wear of the greater sigmoid notch of the proximal ulna and radial head wear was evaluated via assessment of ulnohumeral and radiocapitellar joint spaces in both AP and lateral planes. Changes in the observed joint space were graded as: none; mild – narrow but visible joint space; moderate – loss of joint space without bone erosion; and severe – loss of joint space (>50%) with bone erosion demonstrated in Figure 4. The presence and anatomical location of osteophytes or other degenerative changes around the proximal ulna and radius were also recorded. Heterotopic ossification was assessed according to its anatomic location (anterior, posterior, lateral or medial) and classified using the Hastings classification: type I – HO with no functional deficit; type II – non-bridging HO with decreased range of motion; type III – bridging HO with ankylosis.²⁵

Figure 4.

Postoperative anterior–posterior (AP) radiographs demonstrating (A) None, (B) Mild – narrow joint space, (C) Moderate – loss of joint space with no erosion.

Clinical assessment

Patients were seen postoperatively at 2 weeks for wound assessment and subsequently followed up at 3 and 12 months. Annual follow-ups were offered thereafter. Any complications or re-operations were documented. Patient-reported outcome measures were assessed using the Oxford Elbow Score (OES),²⁶ and pain was evaluated using a visual analogue scale (VAS).²⁷ Range of motion, including flexion–extension and pronation–supination arcs, was recorded at each clinic review and later self-reported by patients using a standardised visual aid.²⁸

Statistical analysis

Categorical variables and baseline demographic data were described with frequencies and percentages. Continuous variables are expressed as means with ranges and standard deviations (SDs). Surgical delay, OES and VAS scores were presented as median values with corresponding interquartile ranges (IQRs). Subgroup analyses were performed using the Shapiro–Wilk test for normality and Mann–Whitney U test to assess the impact on time to surgery between internal and external referrals, and the outcomes observed between patients aged ≥80 years and those aged <80 years at the time of surgery. Statistical analyses were performed using Excel (Microsoft, Redmond, Washington) and R Statistical Software version 4.3.2 (R Core Team, Vienna, Austria).

Results

A total of 55 patients underwent EHA for acute distal humeral fractures in our institution between 2016 and 2024. This included 50 females (91%) with an average age of 75 (57–93) at the time of presentation. Thirty cases (55%) were tertiary referrals from neighbouring trusts, and nine (16%) were open fractures (all grade 3a). A summary of the cohort's characteristics is provided in Table 1.

Table 1.

Characteristics of preliminary cohort at the time of surgery.

EHA (n)	55
Sex, n (%)
Female	50 (91%)
Male	5 (9%)
Age, years (range, SD)	75 (57–93, 8.9)
Laterality, n (%)
Left	40 (73%)
Right	15 (27%)
Time to surgery (IQR)	8 days (6–12)
Internal	7 days (5–9)
External	10 days (7–13)

Fracture types were identified from preoperative X-rays and CT scans according to the AO/OTA classification for all 55 patients who had undergone EHA. Those with a coronal sheer pattern of injury have been further assessed according to the Modified Dubberly classification. Two patients with an AO/OTA A3 fracture underwent EHA. These were extra-articular, low oblique fractures with limited lateral column bone stock, where stable fixation to permit early mobilisation was deemed unreliable, with a high risk of secondary displacement. The distribution of fracture patterns is summarised in Table 2 and Table 3, respectively.

Table 2.

Frequency of distal humeral fractures according to the AO/OTA classification.²⁰

AO/OTA type	Number of cases (n)
13-C3	36
13-B3	15
13-A3	2
13-C2	1
13-C1	1

Table 3.

Frequency of distal humeral fractures classified according to the modified Dubberley classification.²¹

Modified Dubberly type	Number of cases (n)
4B	16
3B	14
3A	4

The median time to surgery across the whole cohort was 8 days (6–12). When stratified by referral source, the median time to surgery was 7 days (5–9) for internal referrals and 10 days (7–13) for external referrals (p = 0.035).

Seven patients died during the follow-up period, three of whom had incomplete 12-month follow-up and were therefore excluded from functional outcome collection. None of the deaths were related to their elbow surgery. A further eight patients had incomplete clinical or radiographic follow-up and were not included in the outcome study. Consequently, 44 patients were available for functional outcome review at a mean follow-up of 41 months (12–101, SD = 25). Complications, reoperations and radiographic follow-up were reported for all patients, including deceased patients, to ensure no early or major complications were missed.

Clinical outcomes

Median (IQR) OES was 44 (40–46) and VAS 1 (0–2). Thirty-six patients (83%) reported excellent OES >38, six patients (15%) reported good OES of between 30 and 38, and a two patients reported moderate outcomes with OES of 28 and 21.¹⁹ Mean flexion arc was 123° (70°–140°, SD = 19°); mean pronation–supination arc 178° (160°–180°, SD = 6.8°).

Subgroup analysis exploring the significance of patient age on outcomes from surgery compared those patients aged ≥80 years with those <80 years is summarised in Table 4.

Table 4.

Subgroup analysis of functional and clinical outcomes by age group.

Age	≥80 (n = 12)	<80 (n = 32)	Significance
OES	43 (41–45)	44 (40–47)	0.552
VAS	2 (1–3)	1 (0–2)	0.100
Flexion–extension arc	124° ± 12° (100°–140°)	122° ± 21° (70°–140°)	0.559
Pronation–supination arc	175° ± 11° (140°–180°)	179° ± 3° (160–180°)	0.030

Further subgroup analysis explored the significance of a delay to surgery on outcomes. Table 5 compares those who waited over 10 days for surgery to those waiting 10 days or less. There were no significant observed differences in patient-reported outcomes or functional outcomes.

Table 5.

Subgroup analysis of time to surgery on function and clinical outcomes.

Surgical delay	≤10 days (n = 29)	>10 days (n = 15)	Significance
OES	44 (40–47)	44 (41–46)	0.610
VAS	1 (0–2)	1 (0–2)	0.899
Flexion–extension arc	122° ± 18° (70°–140°)	124° ± 19° (80°–140°)	0.144
Pronation–supination arc	178° ± 8.2° (140°–180°)	179° ± 2.5° (170°–180°)	0.669

Radiographic outcomes

Postoperative radiographs were available for 44 patients. Assessment identified 22 patients (54%) with changes consistent with secondary arthritis. Osteophytes were present in 13 patients on the medial aspect of the proximal ulna (as demonstrated in Figure 5), and three had osteophytes on the radial head. Loss of joint space at the radiocapitellar joint was present in three patients; all changes were mild; ulnohumeral joint space was reduced in four patients – three mild and one moderate.

Figure 5.

Anterior–posterior radiograph demonstrating medial osteophyte (red arrow).

Epicondyle non-union was present in 12 cases (27%). Seven cases involved the lateral epicondyle, two involved the medial epicondyle, and three cases involved both medial and lateral epicondyles. One case had radiological evidence of asymptomatic lateral epicondyle anterior malunion, with no evidence of epicondyle migration in any other cases. Some degree of HO was observed in 19 patients (43%), localised anteriorly in 16 cases, posteriorly in two, medially in five and laterally in five. All cases with HO were Hastings Grade I, and all remained clinically asymptomatic. There were no incidences of aseptic loosening, joint instability or symptomatic arthritic change observed in this cohort.

Complications and re-operations

Minor complications were reported in six cases (11%): two patients developed superficial wound infections, both of which were successfully managed with oral antibiotics; postoperative ulnar nerve sensory neuropraxia was reported in four patients, all of whom resolved spontaneously without intervention.

Three major complications were observed (5%): one patient with persistent mixed motor and sensory ulnar neuropathy underwent ulna nerve exploration, following which symptoms improved, and no further intervention was indicated. One patient had a delayed presentation with a periprosthetic olecranon fracture following a fall. Due to late presentation, absence of significant functional impairment and the presence of multiple medical comorbidities, this fracture was managed conservatively with no deterioration in outcome. A single case of superficial wound dehiscence required early surgical debridement and primary closure due to a subcutaneous haematoma, with no further intervention necessary. We have observed no cases of postoperative instability and no cases of implant revision.

Discussion

Elbow hemiarthroplasty is a technically demanding procedure primarily indicated for acute, complex intra-articular distal humeral fractures in patients with poor bone stock or comminuted intra-articular fractures where ORIF is not feasible. This study presents the largest single cohort of clinical and radiological EHA outcomes performed for acute fracture at a single high-volume UK tertiary elbow hub, providing some early insights into the efficacy of centralising low-volume procedures as recommended and recently implemented by the GIRFT initiative with support from the BOA and BESS.¹⁶ Although the elbow network has only formally been implemented in 2024, the South-East of England had informally adopted the hub model and centralised all trauma elbow arthroplasty procedures to a nominated hub since 2016.

In 2025, the NJR reported an EHA revision rate at 12 months of 3.0%, and a 4.1% overall revision rate (26 cases) across all 637 registered EHA procedures – including 15 revisions due to failed arthroplasties, 10 due to instability and 5 for infection.⁹ The Australian National Joint Replacement Registry reports a higher revision rate of 6.8% (20 revision procedures from 293 recorded EHAs) – predominantly attributed to instability, loosening and infection.²⁹ In the published literature, Piggott et al.³⁰ calculate an average revision rate of 3% and re-operation rate of 17% in their systematic review of outcomes from primary EHA for acute distal humeral fracture, Wilfred et al.³¹ observed revision rates of up to 15% and reoperation rates as high as 88% in their review of outcomes for EHA for both acute and chronic indications.

In our series, no patient has required implant revision, we have a 4% re-operation rate, and a major complication rate of 5%, but none of our complications have been related to the prosthesis or joint thus far. It is important to consider that some of these variations in reported revision rates may reflect the indication for EHA procedures, which are being reported: registry data reports outcomes of all EHA procedures undertaken regardless of indication and includes salvage hemiarthroplasty procedures for failed fixation within its cohort of primary procedures. Similarly, some published series present their outcomes from a combined cohort of both primary acute and salvage hemiarthroplasty procedures.^7,32–34 Salvage hemiarthroplasty has been demonstrated to have inferior outcomes when compared to those cases undertaken as an index procedure for acute trauma.³⁵ In contrast, our study and some others report experience with distal humeral hemiarthroplasty for cases of acute fracture only.^{7,8,19,36–38}

Centralisation of low-volume, technically demanding procedures such as EHA has been advocated to mitigate risks associated with fragmented care. The creation of relatively high-volume centres allows for the concentration of surgical experience, expertise and resources in order to improve outcomes in these low-volume and complex arthroplasty procedures.³⁹ Although the mean number of cases over the study period is around 8 per year, the volume is skewed to more recent years as the national hub model has gathered momentum. In addition, EHA is a small part of the overall elbow arthroplasty practice, with all regional primary and revision TEA also performed in the hub. This has had huge benefits for efficiency, cost, education and research that are harder to quantify. A recent systematic review by Prkic et al.⁴⁰ supports the association between higher surgeon volume and lower incidence of complications and revision surgery in elbow arthroplasty. Our results support these findings as they compare favourably with both registry data and some published case series.^6,7,9,29,36

A common feeling, extrapolated perhaps from the shoulder, is that hemiarthroplasty is for younger patients as it preserves revision options and total arthroplasty is favoured for older patients as it will outlive the patient before revision is necessary. In our hub, there has been a tendency towards the use of EHA; however, there remains uncertainty regarding the decision between EHA and TEA in this setting. Jonsson et al.⁴¹ in their RCT demonstrate no superiority in clinical and functional outcomes between EHA and TEA for unreconstructable distal humeral fractures in the elderly. With an increasingly ageing and active population, it is not clear what constitutes ‘older’. Furthermore, it is known that total elbow complications accelerate beyond 5 years when done for trauma, and it is clear that a total elbow revision is a more substantial revision than an EHA. We hence used our data to compare the outcome of the older cohort (>80 years) with younger patients. This comparison demonstrated equally good OES, VAS and range of motion in patients older than 80 years with no increase in complications. This is similar to the findings of Heifner et al.⁴² who observed a better range of motion in patients aged over 65 (mean flexion/extension arc of 110° vs. mean of 97°) in those aged under 65. Hence, we would suggest that the decision for TEA or EHA should not be strongly influenced by age.

Despite the results of this study, concerns remain regarding the long-term incidence of progressive symptomatic wear and arthritis of the native joint surfaces. This was the most frequently observed complication in the 2018 systematic review by Kwak et al.,⁴³ seen in 39% of their studies’ population and accounting for 53% of all observed complications. Phadnis et al.¹⁹ reported an incidence of 63% for ulna wear in an earlier review of hemiarthroplasty outcomes. Our radiographic surveillance has so far demonstrated osteophyte formation or joint space narrowing consistent with native joint surface wear in 22 patients (40%). A new finding not reported previously was the incidence of medial olecranon osteophyte formation (Figure 5). We speculate that this could be due to the relatively sharp medial edge of the prosthetic spool, which is not truly anatomic and is often narrower medially than the native trochlea. This may cause point loading and subsequent bone remodelling.

While there is a definite incidence of native joint wear, this does not appear to be correlated with symptoms. We have not observed patient's functional outcome or pain scores deteriorating with time, and to date, no implant revisions have been required, although there are two patients in the series with less good Oxford scores. Neither patient has adverse features on their X-rays.

A limitation with all EHA studies is the challenge of quantifying joint wear due to variations in limb positioning and X-ray projections between serial radiographs. Indeed, some patients in this series with ‘joint space narrowing’ categorised by our radiological observations may reflect positional discrepancies rather than true osteoarthritic progression. Hence, it remains important that radiographic findings are correlated with clinical outcomes and are vital that there is robust provision for long-term surveillance, which should be facilitated by the elbow hub network.

In this study, 55% of cases were referred from neighbouring units in line with the centralisation model now introduced for the delivery of elbow arthroplasty services nationally. This was associated with a median time to surgery of 10 days (7–13), compared to 7 days (5–9) in those presenting to our own centres. Despite there being a statistically significant difference, we did not identify any evidence of adverse clinical or functional outcomes associated with longer time to surgery, while referral to the hub may allow patients to benefit from lower revision and re-operation rates reported from our centre. Schwartz et al.⁴⁴ previously reported that more significant delays in TEA – described as surgery performed between 2 weeks and 6 months post-injury – were associated with an increased incidence of deep prosthetic infection but no increased risk of revision. We hence continue to recommend surgery be performed in as an expedient manner as possible, but are reassured that a delay up to 2 weeks is not harmful. Efficient referral pathways remain crucial in ensuring patients have timely access to specialist surgical care.

A key strength of this study is the inclusion of a large cohort managed consistently through an established regional network, allowing for assessment of clinical and radiological outcomes in a centralised setting. The medium-term follow-up provides additional insights into the durability of EHA and its complication profile.

This study is not without limitations; inherently, the retrospective design introduces potential selection bias. In addition, a number of patients had incomplete follow-up data, with some limitations to the generalisability of the findings as a consequence. This was in part due to the disruption of routine clinical services during the COVID-19 pandemic. Reassuringly, we were able to contact half of the patients lost to our follow-up, and these patients declined follow-up due to geographical and logistical challenges but did not report any adverse clinical issues with their elbows. Despite not being validated against NJR data, we believe the likelihood of revision surgery being performed elsewhere is low. Revision EHA is a relatively low-volume procedure performed in a limited number of specialist centres, and within the regional hub network, these cases are routinely referred to our tertiary unit. Therefore, the probability of revision surgery occurring without our knowledge is low, although this cannot be completely excluded and remains a limitation of the study.

These limitations highlight the need for future prospective multicentre studies with standardised follow-up protocols and outcome measures. Such studies would help establish and validate evidence-based guidelines for patient selection, optimal surgical timing and long-term functional outcomes. In addition, it would be desirable to compare outcomes prior to and after hub formation, although this will pose a challenge due to poor historical data collection.

Conclusion

Evaluation of the clinical and radiological outcomes of EHA for acute, complex intra-articular distal humeral fractures within a single high-volume tertiary elbow hub demonstrates favourable mid-term functional outcomes – regardless of age or time to surgery. The observed complication, reoperation and revision rate is superior to those currently reported in several national registries, and therefore, supports the recent introduction of centralised model of care for elbow arthroplasty procedures. Regional collaboration, national data collection and pathway optimisation remain priorities going forward.

Footnotes

ORCID iDs

Akram Hagos

Fiona Ashton

Richard Murphy

Joideep Phadnis

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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