Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis

Complex articular fractures of the distal radius in patients over 65 years old: A comparison of functional outcomes after locked anterior plate osteosynthesis versus orthopedic treatment, with an average follow-up of 40 months

INTRODUCTION

Distal radius fractures are among the most common traumatic injuries in patients over 65 years old, but there is no consensus on their management. Our aim was to compare the functional outcome between surgical treatment with an anterior locking plate and orthopedic treatment.

HYPOTHESIS

There was no difference in functional outcomes between orthopedic and surgical treatment by osteosynthesis with volar locking plates in patients older than 65 years old.

PATIENTS AND METHOD

A retrospective, non-randomized, multicenter study between 2017 and 2022 compared the functional outcome, after osteosynthesis with anterior locked plate versus orthopedic treatment of AO type C distal radius fractures in patients over 65 years old with a minimum follow-up of 6 months. One hundred and fourteen patients were included, 68 received surgical treatment and 46 had orthopedic treatment. The mean follow-up was 40 months (6-74 months). The main endpoint was to evaluate the PRWE score at the last follow. Secondary endpoints included: assessment of wrist motion, radiological parameters of the distal radius (radial inclination, radial shortening, ulnar variance, and radial tilt) at last follow-up, and complication rate.

RESULTS

The mean PRWE score was 14.3 (± 10.9) for the surgical group and 15.8 (± 8.6) for the orthopedic group, with no significant difference (p = 0.27). There was no clinical difference in wrist motion. Radiological parameters at final follow-up were better in terms of anatomical reduction after surgery (p < 0.01). The complication rate was 17% (n = 12) after surgery and 7% (n = 4) after orthopedic treatment (p = 0.03).

DISCUSSION

This study found no significant difference in the PRWE score at final follow-up between osteosynthesis by volar locking plate and orthopedic treatment after an AO type C distal radius fracture in patients aged over 65. Orthopedic treatment thus remained a valid and satisfactory treatment option for this population.

LEVEL OF EVIDENCE

III; Retrospective, comparative, non-randomized, multicenter study.

Empathy heals: patients' perception after an upper limb fracture and their experiences during and after the treatment discharge: a qualitative study

PURPOSE

To explore patients' experiences, identify barriers and facilitators to recovery, and analyze their perceptions of treatment following upper limb fractures.

MATERIALS AND METHODS

A qualitative study using semi-structured interviews was conducted with 25 patients (10 men, 15 women) at a tertiary referral hospital. A purposive sampling approach was used, and data analysis followed Braun and Clarke's thematic analysis method.

RESULTS

Four key themes emerged: the need for information to engage in treatment; the impact of physical and mental health on fracture patients; the role of physiotherapy in recovery; and the relationship with the healthcare team and treatment perception.

CONCLUSION

Although patients felt supported by the healthcare team, they expressed a need for a deeper understanding of the recovery process. Empathy and the patient-physiotherapist bond were crucial for treatment adherence and successful rehabilitation.

Sleep disturbances in elderly patients with distal radius fractures: a prospective observational study

PURPOSE

No previous studies have reported the presence of sleep disturbances or their association with baseline factors in elderly patients with distal radius fracture (DRF). This study aimed to describe the proportion of patients with sleep disturbances and analyze their association with baseline factors in patients older than 60 years with conservatively treated DRFs.

METHODS

This prospective observational study included 220 patients with extra-articular DRFs who completed the Pittsburgh Sleep Quality Index at two time points: two weeks after cast removal and at the one year follow-up. Sociodemographic, anthropometric, clinical, radiological, and patient-reported outcome measures were analyzed as baseline predictors, with measurements performed two weeks after cast removal.

RESULTS

At two weeks after cast removal, 166 (75.5%) patients had sleep disturbances. Sleep disturbances were associated with the affected dominant hand (β = 1.6; p = 0.04), high-energy injury (β = 3.8; p < 0.001), extra-articular comminuted metaphyseal DRFs (β = 2.3; p < 0.001), higher Tampa Scale of Kinesiophobia scores (β = 2.4; p < 0.001), higher Pain Catastrophizing Scale scores (β = 2.4; p < 0.001), higher Pain Anxiety Symptoms Scale-20 scores (β = 2.1; p < 0.001), and higher visual analogue scale scores (β = 4.1; p < 0.001). At the one year follow-up, 85 (38.6%) patients had sleep disturbances, which were associated with higher Tampa Scale of Kinesiophobia scores (β = 2.6; p < 0.001), higher Pain Catastrophizing Scale scores (β = 2.5; p < 0.001), and higher Pain Anxiety Symptoms Scale-20 scores (β = 1.8; p = 0.02).

CONCLUSIONS

A high proportion of elderly patients with DRF experienced sleep disturbances. Expanding our understanding of the interplay between sleep disturbances and baseline risk factors may lead to improved care and clinical outcomes for these patients. Future studies should incorporate the clinical management of sleep disturbances in patients with DRFs.

Distal radius fractures after 75 years of age: are six-month functional and radiological outcomes better with plate fixation than with conservative treatment?

BACKGROUND

Surgery and non-operative treatment produce similar 1-year functional outcomes in patients older than 65 years. Data are lacking for patients older than 75 years. The main objective of this study was to compare surgical vs. non-operative treatment regarding short-term outcomes in patients older than 75 years. In addition to an overall analysis, sub-group analyses were done in patients with displacement and severe displacement (>20 ° posterior tilt).

HYPOTHESIS

Surgery provides better clinical and radiological outcomes than does non-operative treatment.

PATIENTS AND METHODS

Patients older than 75 years at the time of a distal radius fracture were included prospectively over a 2-year period. A follow-up duration of at least 6 months was required. Treatment choices were based on displacement, Charlson's Co-morbidity Index, and patient autonomy. Surgery consisted in open fixation using an anterior locking plate and non-operative treatment in a short arm cast without reduction. The main assessment was based on clinical criteria: range of motion, strength, visual analogue scale (VAS) scores, the short version of the Disabilities of the Arm, Shoulder, and Hand tool (QuickDASH), the Patient Rated Wrist Evaluation (PRWE), and the 36-Item Short Form Health Survey (SF-36). The secondary assessment criteria were the radiological outcomes and the complications.

RESULTS

74 patients were included, among whom 24 were treated surgically and 50 non-operatively. At 1.5 months, surgery was associated with significantly better results for flexion, ulnar inclination, and supination, with range increases of at least 7 ° vs. non-operative treatment, and with greater dorsal angle and ulnar variance values (p < 0.05 for all comparisons). At 6 months, pronation and the radio-ulnar index were better with surgery (p < 0.05 for both comparisons). In the patients with displacement or severe displacement, surgery was associated with 10° gains vs. conservative treatment for flexion, ulnar inclination, and supination at 1.5 months (p < 0.05 for all comparisons).

DISCUSSION

In patients older than 75 years, surgery for distal radius fracture was associated with significantly better clinical and radiological outcomes within 6 months. Surgery is recommended for displaced and severely displaced distal radius fractures to expedite the recovery of joint motion ranges. Beyond 6 months, the outcomes are similar.

LEVEL OF EVIDENCE

III.

Hospital-Based Epidemiological Study of Distal Radius Fractures at a Hand and Microsurgery Unit in Malaysia

OBJECTIVE

Distal radius fractures (DRFs) are the most common upper limb fractures in clinical practice. Due to the absence of a formal national registry describing the characteristics of DRFs in Southeast Asia, this study aims to provide hospital-based epidemiological data to bridge this gap in the literature.

METHODS

We conducted a retrospective study in the Hand and Microsurgery Unit of Hospital Selayang, Batu Caves, Malaysia, which included all patients who sustained non-pathological DRFs over 24 months, from 01 January 2022 to 31 December 2023. Medical records were analyzed in terms of detailed demographic data, fracture characteristics, and mode of treatment.

RESULTS

Over the two-year study period, we identified 446 patients with DRF, totaling 450 DRFs (four patients had bilateral injuries). Male patients outnumbered female patients 114 (64%) to 63 (36%) in 2022 and 145 (54%) to 124 (46%) in 2023. The mean age of patients was significantly higher in 2023 compared to 2022 (54.51 ± 22.20 vs. 45.25 ± 23.64 years, respectively; p < 0.0001). The most common fracture type was type A, based on the Orthopaedic Trauma Association(OTA) classification, accounting for 83.6% of cases in 2022 and 87.4% of cases in 2023. In terms of treatment, most DRFs were treated conservatively as opposed to operatively (77.4% vs. 71.3%), with plate fixation being the most common operative intervention, accounting for 57.5% of cases in 2022 and 73.3% of cases in 2023.

CONCLUSION

The incidence of DRF was higher among male patients than among female patients in our study population, with an increasing annual trend. Most cases were the result of low-impact trauma and were closed fractures that were conservatively managed.

The relationship between soong classification and fracture characteristics with implant removal for distal radius fractures: a comparative study of 795 cases

INTRODUCTION

Although there is no consensus in the literature, it is believed that the Soong classification system and fracture pattern are risk factors for plate removal in distal radius fractures.

HYPOTHESIS

The aim of this large-scale study was to evaluate the relationship between Soong classification, fracture pattern, and implant removal in distal radius fractures.

MATERIALS AND METHODS

We retrospectively evaluated 795 patients who underwent surgery using a volar locking plate for distal radius fractures at our clinic between 2005 and 2022. The patients were divided into two groups: implant removed, and implant retained. The groups were examined for demographic data, follow-up periods, fracture classifications, and radiological parameters. Additionally, the patients were divided into groups and compared according to the Soong classification, which was determined according to implant placement. Indications for implant removal were also included in this study, and their relationships with other parameters were evaluated.

RESULTS

A total of 123 and 672 patients were included in the implant removed and retained groups, respectively. The average age of the implant removed group was significantly lower (p = 0.005). There were no significant differences between the two groups in terms of fracture classification or other radiological parameters. In the implant removed group, the rate of grade 2, according to the Soong classification, was statistically higher than that in the other groups (p = 0.019). Flexor tenosynovitis was the most common reason for implant removal.

CONCLUSION

The Soong classification system is an important risk factor associated with implant removal. This risk may increase, particularly among young patients. Surgeons should consider placing the distal radius locking plate as proximally as possible to reduce the frequency of implant removal.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Risk factors for complications following volar locking plate fixation of distal radial fractures

INTRODUCTION

With the aging population comes an increase in the number of distal radial fractures and therefore in the number of cases requiring volar locking plate (VLP) fixation. The complication rates after VLP fixation vary greatly from one study to the next. Several authors have already focused on these complications and how to lower their rate. The aim of this study was to identify risk factors for complications after VLP fixation of distal radial fractures that lead to implant removal.

HYPOTHESIS

Implant removal (except systematic removal) after VLP fixation can be predicted by risk factors for complication.

MATERIALS AND METHODS

There were 2951 patients included in the study and divided into two groups: fixation without implant removal and fixation with implant removal. Then, intrinsic factors (age, sex, dominant side, tilt, type of fracture based on the AO classification (extra-articular - partial articular - complete articular - fracture); as well as one extrinsic factor (plate position according to the Soong classification compared to the watershed line) were identified. For all these factors, the relative risk (RR) was computed using univariate and multivariate models. The risk factors that reached statistical significance (p < 0.02) were used in the multivariate analysis.

RESULTS

The univariate and multivariate analyses identified three risk factors for complications, i.e. implant removal: being under 62 years of age (RR = 1.99; CI 1.56-2.54, p < 0.0001), type 2R3C fracture according to the AO classification (RR = 1.50; CI 1.17-1.93, p = 0.0050) and Soong grade 2 plate position (RR = 1.73; 1.32-2.26, p < 0.0001).

CONCLUSION

Our study showed that plate position recorded as grade 2 was a risk factor for complications and therefore implant removal. This is an extrinsic factor that is implant and surgeon dependent. Moreover, intrinsic factors were also identified such as age and type of fracture. Assessing these risk factors after VLP fixation of distal radial fractures may lead to early detection of these complications and an opportunity to propose implant removal as a preventive measure.

LEVEL OF EVIDENCE

III.

Assessment of the Mechanical Properties and Fragment Characteristics of a 3D-Printed Forearm Orthosis

Distal radius fractures (DRF) are one of the most prevalent injuries a person may sustain. The current treatment of DRF involves the use of casts made from Plaster of Paris or fiberglass. The application of these materials is a serious endeavor that influences their intended use, and should be conducted by specially trained personnel. In this research, with the use of the full-body 3D scanner Vitus Smart, 3D modelling software Rhinoceros 3D, and 3D printer Creality CR-10 max, an easy, yet effective workflow of orthosis fabrication was developed. Furthermore, samples that represent segments of the orthosis were subjected to static loading. Lastly, fragments that occurred due to excessive force were characterized with the use of a digital microscope. It was observed that with the implementation of the designed workflow, a faster 3D printing process was present. Samples subjected to mechanical loading had values that exceeded those of conventional Plaster of Paris; the minimum recorded value was 681 N, while the highest was 914 N. Microscopic characterization enabled a clear insight into the occurrence of fragments, as well as their potential risk. Therefore, in this research, an insight into different stages of fabrication, characterization of undesirable events, as well as the risks they may pose were presented.

Health-economic evaluation of orthogeriatric co-management for patients with forearm or humerus fractures: an analysis of insurance claims data from Germany

Orthogeriatric co-management (OGCM) describes a collaboration of orthopedic surgeons and geriatricians for the treatment of fragility fractures in geriatric patients. While its cost-effectiveness for hip fractures has been widely investigated, research focusing on fractures of the upper extremities is lacking. Thus, we conducted a health economic evaluation of treatment in OGCM hospitals for forearm and humerus fractures.In a retrospective cohort study with nationwide health insurance claims data, we selected the first inpatient stay due to a forearm or humerus fracture in 2014-2018 either treated in hospitals that were able to offer OGCM (OGCM group) or not (non-OGCM group) and applied a 1-year follow-up. We included 31,557 cases with forearm (63.1% OGCM group) and 39,093 cases with humerus fractures (63.9% OGCM group) and balanced relevant covariates using entropy balancing. We investigated costs in different health sectors, length of stay, and cost-effectiveness regarding total cost per life year or fracture-free life year gained.In both fracture cohorts, initial hospital stay, inpatient stay, and total costs were higher in OGCM than in non-OGCM hospitals. For neither cohort nor effectiveness outcome, the probability that treatment in OGCM hospitals was cost-effective exceeded 95% for a willingness-to-pay of up to €150,000.We did not find distinct benefits of treatment in OGCM hospitals. Assigning cases to study groups on hospital-level and using life years and fracture-free life years, which might not adequately reflect the manifold ways these fractures affect the patients' health, as effectiveness outcomes, might have underestimated the effectiveness of treatment in OGCM hospitals.

Complex Regional Pain Syndrome after Distal Radius Fracture-Case Report and Mini Literature Review

This study explores the impact of the complex regional pain syndrome (CRPS) on the lives and mobility of patients, with a particular focus on its emergence as a late complication of distal radius fractures (DRFs), a common occurrence, especially among an aging population. The absence of a standardized treatment for the CRPS and the challenge of predicting its occurrence make it a complex medical issue. This research aims to shed light on the effects of treating the CRPS through a case study involving a 75-year-old woman with untreated osteoporosis who experienced a Colles fracture after a fall. The initial management involved repositioning and stabilizing the fractured forearm with a plaster cast, followed by an operation using percutaneous pinning via a Kirschner wire. Subsequently, the patient developed CRPS symptoms and was admitted to the rehabilitation department three months post-fracture. The affected forearm exhibited swelling, warmth, pain, and severely limited range of motion. Treatment involved a combination of medications, physiotherapy, and kinesiotherapy. Significantly, the patient experienced notable improvement following these interventions. This study underscores the absence of a definitive standard for CRPS treatment but suggests that proper rehabilitation and pharmaceutical interventions can contribute positively to patient outcomes. The case further highlights the potential association between DRF and CRPS development, emphasizing the need for continued research in this field.

Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures

PURPOSE OF REVIEW

The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities.

RECENT FINDINGS

There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.

Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures-An Updated Narrative Review

Distal radius fractures (DRFs) are the most common among all kinds of fractures with an increase in incidence due to the rapidly expanded size of the elderly population in the past decades. Both non-surgical and surgical treatments can be applied for this common injury. Nowadays, more and more elderly patients with DRFs undergo surgical treatments to restore pre-injury activity levels faster. However, optimal treatment for geriatric DRFs is still debated, and careful evaluation and selection of patients are warranted considering clinical and functional outcomes, and complications following surgical treatments. Furthermore, osteoporosis is a predominant factor in elderly DRFs mostly deriving from a low-energy trauma, so many treatment modalities are developed to enhance better bone healing. Among various options for bone augmentation, bone cement is one of the most widely used measures. Bone cement such as calcium phosphate theoretically improves fracture stability and healing, but whether the elderly patients with DRFs can significantly benefit from surgical fixation with bone cement augmentation (BCA) remains controversial. Hence, in the present review, the latest literature regarding current concepts of management and evidence about volar locking plate fixation (VLPF) with BCA for elderly DRFs was searched in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science; out of >1000 articles, full texts of 48 and 6 articles were then examined and analyzed separately for management and VLPF with BCA for elderly DRFs. We aim to provide the readers with updates concerning the above issues.

Supervised exercise therapy program vs non-supervised exercise therapy program after distal radius fracture: A systematic review and meta-analysis

BACKGROUND

It is an updated systematic review with meta-analysis that compared supervised exercise therapy (SET) vs non-supervised exercise therapy (NSET) programs for patients with distal radius fracture.

PURPOSE

The purpose of this systematic review is to appraise the current literature to determine if SET program is more effective than a NSET program for pain relief, improvement of range of movement, function and grip strength, both in the short or medium term for patients following distal radius fractures.

STUDY DESIGN

Systematic review.

METHODS

The following electronic databases were searched: Medline/Pubmed, PEDro, Cinahl, Embase, CENTRAL, and Lilacs. PICOT strategy was used for trial selection. The searches were conducted on August 22, 2021, and May 26, 2022. Two researchers performed an independent search for papers from the references of the chosen trials. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used for assessing the quality of evidence.

RESULTS

The search strategy identified 2786 potentially eligible studies and 15 studies met our inclusion criteria. The results did not show that the SET program was more effective than the NSET program for all outcomes, in both terms for patients after distal radius fractures. GRADE showed that all analyses presented very low-quality evidence.

CONCLUSIONS

Even the results showing there was no difference between the two programs analyzed, the available evidence for randomized controlled trials was insufficient to support these results.

Baseline predictors related to functional outcomes in patients older than sixty years with complex regional pain syndrome type 1 after distal radius fracture treated conservatively: a prospective observational study

PURPOSE

This study aimed to analyze baseline predictors of functional outcomes six weeks and at one year follow-up in patients older than 60 years with complex regional pain syndrome type 1 (CRPS I) after distal radius fracture (DRF).

METHODS

A total of 120 patients with CRPS I after DRF were prospectively recruited. Presumptive relevant factors were collected and analyzed as potential baseline predictors. Additionally, functional outcomes were assessed at the beginning of physiotherapy treatment, at six weeks after finishing physiotherapy treatment, and at one year follow-up. Patient-Rated Wrist Evaluation; Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; Jamar dynamometer; and visual analog scale (VAS) were assessed.

RESULTS

All participants completed the study. At 6 weeks, the main results showed an association of lower values of grip strength with female sex (p = 0.010), intra-articular DRFs (p = 0.030), longer immobilization time (p = 0.040), lower levels of physical activity (p < 0.001), higher levels of kinesiophobia (p = 0.010), and anxiety (p = 0.020). At 1-year follow-up, the results showed an association of lower values of DASH with higher BMI (p < 0.001) and longer immobilization time (p < 0.001); and higher values of VAS showed an association with older age (p = 0.010), higher BMI (p = 0.010), and lower levels of physical activity (p = 0.040).

CONCLUSION

At six weeks, factors such as BMI, immobilization time, physical activity, and kinesiophobia are associated with lower functional outcomes. Additionally, at one year follow-up, BMI, immobilization time, and physical activity continue to be associated with lower functional outcomes in patients with CRPS I after DRF treated conservatively.

Is Capitate Shift Reliable as a Single Indicator for Failure of Non-operative Management in Distal Radius Fractures?

Background Distal radius fractures (DRFs) are the most commonly treated fracture; however, their treatment remains controversial. There is significant variation in the rate of surgical intervention related to a lack of consensus regarding the displacement threshold for surgery. Although studies have advocated that carpal malalignment is the most important radiographic parameter for surgical correction, it is rarely considered in general clinical practice and remains poorly studied. Recently, capitate shift was identified as the most useful measure of carpal malalignment, and a capitate shift threshold of -5.98 mm was proposed to indicate surgical intervention. This study aimed to investigate if this threshold is associated with the failure of non-operatively managed DRFs and should be used as a threshold for primary surgical intervention. Methodology A retrospective analysis was performed of all adult patients who underwent closed manipulation and cast immobilisation for DRFs in a UK district general hospital between September 2021 and February 2022. Capitate shift was measured on initial post-casting radiographs using the validated capitate-to-axis-of-radius distance (CARD) by a junior surgeon. The outcome measure was the failure of conservative management, which was defined as the need for repeat intervention (i.e., cast reapplication or surgical fixation) following closed reduction and cast immobilisation. Results A total of 64 patients with 65 DRFs (16 (25%) male, 49 (75%) female) were included in the study. The mean age was 66.6 years (SD = 17.9, 95% CI = 62.2 to 70.9). The mean capitate shift was -1.51 mm (SD = 5.05, 95% CI = -0.28 to -2.73) in all cases (n = 65). The failure rate of DRFs with an 'unacceptable' capitate shift (i.e., equal or less than -5.98 mm) compared to those with an 'acceptable' capitate shift (i.e., greater than -5.98 mm) was 16.7% versus 3.8% (p = 0.09). Conclusions The study concluded that there was no significant association between a capitate shift threshold of -5.98 mm and failure of non-operatively managed DRFs. Given the ease of use and reliability of capitate shift, we advocate for multicentre large cohort studies to identify a threshold for surgical intervention and establish its association with functional outcomes.

Effectiveness and Safety of Different Treatment Modalities for Patients Older Than 60 Years with Distal Radius Fracture: A Network Meta-Analysis of Clinical Trials

The aim of this study was to compare the clinical effectiveness and complications of different treatment modalities for elderly patients with distal radius fracture (DRF).

METHODS

We performed a network meta-analysis (NMA) of randomized clinical trials (RCTs). Eight databases were searched. The eligibility criteria for selecting studies were RCTs that compared different treatment modalities (surgical or nonoperative) in patients older than 60 years with displaced or unstable intra-articular and/or extra-articular DRFs.

RESULTS

Twenty-three RCTs met the eligibility criteria (2020 patients). For indirect comparisons, the main findings of the NMA were in volar locking plate (VLP) versus cast immobilization, with the mean differences for the patient-rated wrist evaluation (PRWE) questionnaire at -4.45 points (p < 0.05) and grip strength at 6.11% (p < 0.05). Additionally, VLP showed a lower risk ratio (RR) of minor complications than dorsal plate fixation (RR: 0.02) and bridging external fixation (RR: 0.25). Conversely, VLP and dorsal plate fixation showed higher rates of major complications.

CONCLUSIONS

Compared with other treatment modalities, VLP showed statistically significant differences for some functional outcomes; however, most differences were not clinically relevant. For complications, although most differences were not statistically significant, VLP was the treatment modality that reported the lowest rate of minor and overall complications but also showed one of the highest rates of major complications in these patients. PROSPERO Registration: CRD42022315562.