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DiGiovanni PLC, Hoftiezer YAJ, van der Heijden BEPA, Eberlin KR, Lans J, Chen NC. Psychosocial and functional impact of successful digital replantation - A cohort study of 36 patients with a median follow-up of 6 years. HAND SURGERY & REHABILITATION 2024:101758. [PMID: 39103052 DOI: 10.1016/j.hansur.2024.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION This study aims to evaluate the long-term psychosocial and functional outcomes of successful digital replantation following traumatic amputation. METHODS Patients that underwent successful replantation (i.e. no secondary amputation following replantation) of one or more traumatically amputated digits between January 2009 and April 2019 were invited to participate in this study. In addition to a custom questionnaire on psychosocial and socioeconomic aspects of life, various Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires regarding global health, upper extremity function, and depressive symptoms were completed. Bivariate analyses were performed to identify significant associations between outcomes and explanatory variables. RESULTS Thirty-six patients were successfully enrolled and completed the questionnaires at a median follow-up of 6.1 years. The median PROMIS score for Upper Extremity Function (40.6) was considerably different from the score that is typically found in the general population (all PROMIS instruments are calibrated with a control group score of 50.0), but the median PROMIS scores for Global Health - Physical (49.0), Global Health - Mental (50.7), and Depression (45.6) were comparable to those among the general population. Dominant hand injury, a greater number of injured digits, higher age at the time of injury, and the need for neuropathic pain medication were associated with lower Upper Extremity Function scores (all p < 0.05). Additionally, the presence of neuroma was associated with negative changes in both household finances and mental well-being (p < 0.05). CONCLUSIONS At long-term follow-up, a majority of patients that underwent replantation of traumatically amputated digits seem to cope well based on psychosocial and functional outcomes. However, neuropathic pain and the presence of neuroma are strong negative factors. Specific attention to digital nerves at the time of surgery is crucial in the management of traumatic amputations.
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Affiliation(s)
- Peter Luca C DiGiovanni
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston MA, United States
| | - Yannick Albert J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston MA, United States; Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Brigitte E P A van der Heijden
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston MA, United States; Harvard Medical School, Boston MA, United States
| | - Jonathan Lans
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston MA, United States; Harvard Medical School, Boston MA, United States
| | - Neal C Chen
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston MA, United States; Harvard Medical School, Boston MA, United States.
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Raasveld FV, Mayrhofer-Schmid M, Johnston BR, Gomez-Eslava B, Hoftiezer YAJ, Liu WC, Valerio IL, Eberlin KR. Targeted muscle reinnervation at the time of amputation to prevent the development of neuropathic pain. J Plast Reconstr Aesthet Surg 2024; 97:13-22. [PMID: 39121547 DOI: 10.1016/j.bjps.2024.07.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 07/22/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Targeted muscle reinnervation (TMR) is an established modality for the surgical management of neuropathic pain. Although the preventive effect of primary (acute) TMR at the time of amputation has been demonstrated previously, it remains unclear how many and which patients benefit most. Therefore, this study investigated the proportion of patients achieving sustained pain prophylaxis following amputation, as well as factors associated with its efficacy. METHODS Primary patients who underwent TMR with a minimum follow-up of 6 months between 2018 and 2023 were enrolled. Pain outcomes (numeric rating scale [NRS], 0-10), comorbidities, and surgical factors were collected from chart review. Patients achieving sustained pain prophylaxis (NRS of ≤3 for ≥3 months until final follow-up) were identified. Multilevel mixed-effect models and multivariable regression were used to visualize pain courses and identify associated factors. RESULTS Seventy-five patients who underwent primary TMR were included (median follow-up: 2.0 years), of whom 57.3% achieved sustained pain prophylaxis whereas 26.7% reported pain disappearance. Distal amputation levels (p = 0.036), a lower Elixhauser Comorbidity Index (p = 0.001), and the absence of psychiatric comorbidities (p = 0.039) were associated with pain prophylaxis. CONCLUSION This study demonstrates that more than half of all patients undergoing primary TMR achieved sustained pain prophylaxis, and approximately a quarter of patients achieved sustained pain disappearance. Several factors associated with these favorable outcomes are described. These results will aid in preoperative counseling, managing patient expectations, and selecting patients who may benefit most from primary TMR surgery. LEVEL OF EVIDENCE IV - Therapeutic.
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Affiliation(s)
- Floris V Raasveld
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America; Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - Maximilian Mayrhofer-Schmid
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin R Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Barbara Gomez-Eslava
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; F.M. Kirby Neurobiology Center, Boston Children's Hospital and Department of Neurobiology, Harvard Medical School, Boston, MA, United States of America
| | - Yannick A J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Wen-Chih Liu
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Orthopaedic Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Department of General Surgery, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America.
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Finkelstein ER, Hui-Chou H, Fullerton N, Jose J. Experience with ultrasound neurography for postoperative evaluation of targeted muscle reinnervation. Skeletal Radiol 2024; 53:811-816. [PMID: 37665347 DOI: 10.1007/s00256-023-04441-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/09/2023] [Accepted: 08/26/2023] [Indexed: 09/05/2023]
Abstract
Targeted muscle reinnervation (TMR) was originally developed as a means for increasing intuitive prosthesis control, though later found to play a role in phantom limb pain and neuroma prevention. There is a paucity of literature describing the clinical course of patients with poor TMR surgical outcomes and the value of imaging in the postoperative recovery period. This report will illustrate the potential utility of ultrasound neurography to accurately differentiate TMR surgical outcomes in two patients that received upper extremity amputation and subsequent reconstruction with TMR. Ultrasound evaluation of TMR sites in patient 1 confirmed successful reinnervation, evident by nerve fascicle continuity and eventual integration of the transferred nerve into the target muscle. Conversely, the ultrasound of patient 2 showed discontinuity of the nerve fascicles, neuroma formation, and muscle atrophy in all three sites of nerve transfer, suggesting an unsuccessful procedure and poor functional recovery. Ultrasound neurography is uniquely able to capture the longitudinal trajectory of rerouted nerves to confirm continuity and eventual reinnervation into muscle. Therefore, the application of ultrasound in a postoperative setting can correctly identify instances of failed TMR before this information would become available through clinical evaluation. Early identification of poor TMR outcomes may benefit future patients by fostering the discovery of failure mechanisms and aiding in further surgical planning to improve functional outcomes.
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Affiliation(s)
- Emily R Finkelstein
- Dewitt Daughtry Family Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
- Division of Plastic Surgery, University of Miami Hospital, 1400 NW 12Th Ave, Miami, FL, 33136, USA.
| | - Helen Hui-Chou
- Department of Orthopedic Surgery, Divison of Hand, Peripheral Nervem and Upper Extremity Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Natalia Fullerton
- Dewitt Daughtry Family Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean Jose
- Department of Clinical Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
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Phair J, Choinski K, Inglesby DC, Diamond S, Sultan SM. Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations. Vascular 2024; 32:154-161. [PMID: 36062583 DOI: 10.1177/17085381221124982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease. METHODS Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation. RESULTS TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality. CONCLUSIONS TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.
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Affiliation(s)
- John Phair
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Krystina Choinski
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dani C Inglesby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawn Diamond
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Steven M Sultan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Le ELH, Iorio ML, Greyson MA. Targeted muscle reinnervation in upper extremity amputations. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03736-2. [PMID: 37814069 DOI: 10.1007/s00590-023-03736-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation.
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Affiliation(s)
- Elliot L H Le
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 East 17Th Ave, Room 6111, Aurora, CO, 80045, USA
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 East 17Th Ave, Room 6111, Aurora, CO, 80045, USA
| | - Mark A Greyson
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 East 17Th Ave, Room 6111, Aurora, CO, 80045, USA.
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Rask DMG, Adams MH, Liverneaux P, Plucknette BF, Wilson DJ, Alderete JF, Sabbag CM. Targeted muscle reinnervation in upper extremity amputation in military hand surgery: A systematic review. HAND SURGERY & REHABILITATION 2023; 42:392-399. [PMID: 37499798 DOI: 10.1016/j.hansur.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Targeted Muscle Reinnervation (TMR) is a surgical technique utilized to alleviate post-amputation neuroma pain, reduce reliance on narcotic pain medication, and enhance control of prosthetic devices. Motor targets for upper extremity TMR vary depending on injury patterns and amputation levels, with conventional transfer patterns serving as general guides. This study aims to summarize the common patterns of TMR in transradial and transhumeral amputations, focusing on anatomic and surgical considerations. METHODS A comprehensive systematic review of TMR literature was conducted by two independent physician reviewers (M.H.A. and D.M.G.R.) to identify the prevailing motor targets, while considering injury patterns and amputation levels. INCLUSION CRITERIA 1) TMR techniques, outcomes, or advancements; 2) Original research, systematic reviews, meta-analyses, or clinical trials; 3) Peer-reviewed journal articles or reputable conference proceedings. EXCLUSION CRITERIA non-English resources, editorials, opinion pieces, and case reports. The databases utilized include MEDLINE (PubMed), EMBASE (Scopus) and Cochrane CENTRAL, last searched 01APR2023. RESULTS The reviewed literature revealed multiple motor targets described for upper extremity TMR out of our included 51 studies. However, the selection of motor targets is influenced by the availability of viable options based on injury patterns and amputation levels. Conventional transfer patterns provide useful guidance for determining appropriate motor targets in transradial and transhumeral amputations. DISCUSSION TMR has played a significant role in military medicine, particularly in addressing the impact of blast-related injuries. The energy associated with such injuries often results in substantial soft tissue defects, higher amputation levels, and increased post-amputation pain. TMR, in conjunction with advancements in prosthetic technology and ongoing military research, offers improved outcomes to help achieve the goals of active-duty service members. The capabilities and applications of TMR continue to expand rapidly due to its high surgical success rate, technological innovations in prosthetic care, and favorable patient outcomes. As technology evolves to include implantable devices, osseointegration techniques, and bidirectional neuroprosthetic devices, the future of amputation surgery and TMR holds immense promise, offering innovative solutions to optimize patient outcomes. It is important to note, this review was limited to the data available in the included resources which was mostly qualitative; thus, it did not involve primary data analysis.
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Affiliation(s)
- Dawn M G Rask
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Mason H Adams
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA.
| | - Philippe Liverneaux
- ICube, University of Strasbourg, CNRS, 2-4 rue Boussingault, 67000 Strasbourg, France; Department of Hand Surgery, Strasbourg University Hospitals, FMTS, 1 avenue Molière, 67200 Strasbourg, France
| | | | - David J Wilson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Joseph F Alderete
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
| | - Casey M Sabbag
- Brooke Army Medical Center, 3551 Roger Brooke Drive, San Antonio, TX 78234, USA
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Diagnosis and Management of Traumatic Hemipelvectomy. J Am Acad Orthop Surg 2022; 30:888-895. [PMID: 36166384 DOI: 10.5435/jaaos-d-21-01018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/10/2022] [Indexed: 02/01/2023] Open
Abstract
Traumatic hemipelvectomy (THP) is a catastrophic injury associated with high-energy trauma and high mortality. THP has been defined as a complete dislocation of the hemipelvis, often with disruption through the symphysis pubis and sacroiliac joint with concurrent traumatic rupture of the iliac vessels. Despite recent advances in prehospital resuscitative techniques, the true incidence of THP is difficult to ascertain because many patients die before hospital arrival. The leading causes of death associated with THP include blood loss, infection, and multiple system organ failure. Recognition and immediate intervention for these injuries is imperative for survival. The initial assessment includes a thorough physical examination assessing for signs of arterial damage and other associated injuries. Hemorrhage control and vigorous resuscitation should be prioritized to combat impending exsanguination. Emergent amputation has been found to be a lifesaving operation in these patients. The basis of this approach is rooted in achieving complete hemostasis while reducing complication rates. Understanding the nature of these massive pelvic injuries, the role of early amputation, and the importance of subspecialty communication can improve survivability and optimize patient outcomes.
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Cantwell SR, Nelson AW, Sampson BP, Spinner RJ, Bishop AT, Pulos N, Shin AY. The Role of Amputation and Myoelectric Prosthetic Fitting in Patients with Traumatic Brachial Plexus Injuries. J Bone Joint Surg Am 2022; 104:1475-1482. [PMID: 35976186 DOI: 10.2106/jbjs.21.01261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A cohort of patients with traumatic brachial plexus injuries (BPIs) underwent elective amputation following unsuccessful surgical reconstruction or delayed presentation. The results of amputation with and without a myoelectric prosthesis (MEP) using nonintuitive controls were compared. We sought to determine the benefits of amputation, and whether fitting with an MEP was feasible and functional. METHODS We conducted a retrospective review of patients with BPI who underwent elective upper-extremity amputation at a single institution. Medical records were reviewed for demographics, injury and reconstruction details, amputation characteristics, outcomes, and complications. Prosthesis use and MEP function were assessed. The minimum follow-up for clinical outcomes was 12 months. RESULTS Thirty-two patients with BPI and an average follow-up of 53 months underwent elective amputation between June 2000 and June 2020. Among the cases were 18 transhumeral amputations, 12 transradial amputations, and 2 wrist disarticulations. There were 29 pan-plexus injuries, 1 partial C5-sparing pan-plexus injury, 1 lower-trunk with lateral cord injury, and 1 lower-trunk injury. Amputation occurred, on average, at 48.9 months following BPI and 36.5 months following final reconstruction. Ten patients were fitted for an MEP with electromyographic signal control from muscles not normally associated with the intended function (nonintuitive control). Average visual analog scale pain scores decreased post-amputation: from 4.8 pre-amputation to 3.3 for the MEP group and from 5.4 to 4.4 for the non-MEP group. Average scores on the Disabilities of the Arm, Shoulder and Hand questionnaire decreased post-amputation, but not significantly: from 35 to 30 for the MEP group and from 43 to 40 for the non-MEP group. Patients were more likely to be employed following amputation than they were before amputation. No patient expressed regret about undergoing amputation. All patients in the MEP group reported regular use of their prosthesis compared with 29% of patients with a traditional prosthesis. All patients in the MEP group demonstrated functional terminal grasp/release that they considered useful. CONCLUSIONS Amputation is an effective treatment for select patients with BPI for whom surgical reconstruction is unsuccessful. Patients who underwent amputation reported decreased mechanical pain, increased employment rates, and a high rate of satisfaction following surgery. In amputees with sufficient nonintuitive electromyographic signals, MEPs allow for terminal grasp/release and are associated with high rates of prosthesis use. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sean R Cantwell
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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[Amputation techniques]. Unfallchirurg 2022; 125:257-259. [PMID: 35318517 DOI: 10.1007/s00113-022-01157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 10/18/2022]
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