Does lateral extra-articular tenodesis affect knee stability in cases with isolated anterior cruciate ligament reconstruction?

Abstract

Objective

The purpose of this randomised controlled trial was to assess the effect on knee function and stabilising effectiveness of lateral extra-articular tenodesis (LET) in anterior cruciate ligament (ACL) restoration.

Methods

A prospective randomised clinical study that compared the functional outcomes of two groups—one undergoing anatomic single bundle ACL reconstruction (ASB-ACLR) with ilio-tibial band tenodesis (LET) for 20 patients, and the other undergoing ASB-ACLR—was carried out between February 2020 and August 2022.

Results

By combining Lateral Extra-articular Tenodesis (LET) with intra-articular Anterior Cruciate Ligament Reconstruction (ACLR), our study observed a significant reduction in the occurrence of high-grade pivot-shift phenomena. Prior to surgery, both Groups A and B exhibited graded (D) pivot-shift test results. However, post-surgery, the pivot-shift test yielded negative results in 60% of patients in Group A and 90% of patients in Group B. The statistical analysis revealed a notable difference between the two groups, as indicated by a P-value of 0.003. Upon conducting a brief follow-up, we evaluated the Lysholm score, and anterior knee stability of ACLR with LET, finding no statistically significant difference compared to those of single ACLR. The Lachman tests also revealed no significant disparity between the two groups (p = 0.106). Analyzing the Lysholm scores in Group A and Group B, we observed an increase to 90.70% and 91.10%, respectively.

Conclusion

Rotational stability is much improved when lateral extra-articular tenodesis (LET) utilizing the ilio-tibial band as an augmentation is used in ACL restoration. Especially useful for high-grade pivot-shift phenomena is this technique.

1. Introduction

The Anterior Cruciate Ligament (ACL) is critical in maintaining knee joint stability by actively resisting anterior tibial translation and rotational pressures. However, this crucial ligament is frequently susceptible to injury, especially during high-impact or sports-related activities, rendering it one of the most commonly affected structures.¹ Despite significant advancements in surgical techniques, primary ACL reconstruction carries a notable failure rate of 3–5%, a figure that escalates to a more concerning 15–20% for revision ACL procedures.² The aftermath of successful reconstruction introduces a new challenge in the form of persistent rotatory laxity, a factor that has gained substantial attention due to its impact on patient satisfaction.³ Post-standard intra-articular ACL reconstruction, addressing rotatory instability becomes paramount, propelling knee surgeons to explore innovative strategies for enhancing rotational stability. Among these strategies, there is a growing focus on the potential advantages of incorporating lateral extra-articular tenodesis (LET) into ACL procedures.^4,5 The theoretical basis of LET is its ability to more effectively restrain lateral tibial compartment displacement, producing a sturdy lever arm that aids in reducing rotational laxity within the knee joint.⁶ Along with the LET, recent focus has switched to the anterolateral ligament (ALL), a fascinating ligamentous structure located on the anterolateral portion of the knee.^7,8 Studies on the interaction of these structures have revealed that isolated ACL transection resulted in a pivot shift of no more than grade I. Additional ALL transection, on the other hand, results in a more problematic high-grade (grade II or III) pivot shift in all cases.⁹ This heightened instability across all specimens studied, reinforcing the intricate relationship between ALL lesions and the manifestation of high-grade pivot shifts. The anterolateral ligament's contribution to knee stability becomes apparent in these circumstances, highlighting its role as a key factor in preventing excessive joint movement. Understanding the nuances of this ligamentous interplay is crucial for clinicians and researchers alike, as it sheds light on the complexity of knee biomechanics and aids in developing more effective strategies for diagnosing, treating, and preventing injuries related to ACL and ALL pathology.¹⁰ Continued exploration of these ligaments and their interactions holds promise for advancing orthopedic knowledge and improving patient outcomes,¹¹ this study aims to contribute valuable insights to the evolving landscape of knee surgery. Building upon these compelling insights to explore the hypothesis that the combined approach of LET and ACL reconstruction holds the potential to effectively eliminate the high-grade pivot-shift phenomenon.

2. Methods

2.1. Study settings

From February 2020 to August 2022, a prospective randomised controlled clinical investigation was undertaken at Al Kasr El-Ainy University Hospital in Egypt. Approval for the study protocol was granted by the Research Ethical Committee at the Faculty of Medicine, Cairo University in Egypt, thereby ensuring adherence to ethical standards. Before inclusion in the study, participants offered written informed consent, signifying their voluntary involvement in the study.

2.2. Participants selection

Participants were selected based on specific eligibility criteria, including the presence of an isolated anterior cruciate ligament (ACL) injury, whether acute or chronic, and the manifestation of both a grade 3 pivot shift and a grade 3 Lachman injury. Conversely, individuals with a prior history of knee ligament injury reconstruction, those undergoing additional ACL reconstruction with frontal plane deformity correction, having pivot shift grades 0, 1, and 2, exceeding the age of 45, or possessing a body mass index (BMI) greater than 29 were deliberately excluded from the study. This rigorous selection process aimed to ensure a homogeneous participant group for a focused investigation into the specific cohort meeting the defined criteria.

2.3. Study measures

The assessment was based on the International Knee Documentation Committee (IKDC) score, which consisted of seven criteria: Effusion, Ligament Examination, Harvest Site Pathology, X-ray Findings, Effusion, and Passive Motion Deficit. Prior to surgery and at the 9-month mark following the procedure, each patient was scored using these parameters. One of four grades—Grade A for normal, Grade B for almost normal, Grade C for abnormal, and Grade D for significantly abnormal conditions—was given to each group. Pat Using the sealed envelope technique, patients were randomly allocated into two groups: Group B received iliotibial band tenodesis in addition to ACLR, while Group An underwent ACL reconstruction (ACLR). Hamstring tendons were used as grafts for ACLR, and a standard knee arthroscopy was carried done. Using an antero-medial portal with knee flexion at 120°, the femoral tunnel was formed. Graft fixation was done using an interference screw or adjustable loop on the femoral side and a biodegradable interference screw on the tibial side. The supra-patellar gap and the graft wound were both treated with drains. To avoid interfering with the ACL femoral tunnel, Group B underwent a LET procedure that included tunnel drilling and iliotibial band graft preparation. Knee flexion was achieved by securing the iliotibial band with a bioabsorbable interference screw at 30°. Using the sealed envelope technique, patients were randomly allocated into two groups: Group B received iliotibial band tenodesis in addition to ACLR, while Group An underwent ACL reconstruction (ACLR). Hamstring tendons were used as grafts for ACLR, and a standard knee arthroscopy was carried done. Using an antero-medial portal with knee flexion at 120°, the femoral tunnel was formed. Graft fixation was done using an interference screw or adjustable loop on the femoral side and a biodegradable interference screw on the tibial side. The supra-patellar gap and the graft wound were both treated with drains. To avoid interfering with the ACL femoral tunnel, Group B underwent a LET procedure that included tunnel drilling and iliotibial band graft preparation. With the knee flexion at 30°, the iliotibial band was secured with a bioabsorbable interference screw. The iliotibial band was carefully closed, and the drain was positioned after that. Prior to surgery, both groups underwent evaluations for knee stability, range of motion, and translation while sedated. All patients had evaluations after surgery every two weeks until the second postoperative month, then once a month for the next six months, and lastly once a month at nine months.

2.4. Statistical analysis

The data was coded and inputted using IBM SPSS version 26, a statistical application for the social sciences. The metrics mean, standard deviation, median, minimum, and maximum were used to summarise the quantitative data; these metrics were counted and relative frequency (%) was used for the categorical data. The unpaired t-test was utilised to compare quantitative variables that were regularly distributed between groups, whereas the non-parametric Mann-Whitney test was employed for data that was not normally distributed. For regularly distributed quantitative variables, the paired t-test was used to compare serial measures within each group; for non-normally distributed quantitative variables, the non-parametric Wilcoxon signed rank test was employed. To compare categorical data, the Chi square (χ2) test was used. An exact test was used in its place when the expected frequency was less than five.

3. Results

3.1. Demographic and clinical data of enrolled patients

The study included 40 patients with ACL tear. 35 patients were males and 5 were females. Six patients were professional athletes. The average age in both groups is similar, with Group 1 having a mean age of 25.65 years (SD = 5.17) and Group 2 having a mean age of 25.45 years (SD = 5.58). In terms of ACL injuries, 60% of participants in each group had a right ACL injury, while 35% in Group 1 and 40% in Group 2 had a left ACL injury. Non-contact injuries were more prevalent than contact injuries in both groups. Most participants in both groups engaged in non-professional activity levels. Regarding associated injuries, medial meniscal injuries were more common than lateral meniscal injuries in both groups, and a small percentage had chondral lesions. The average time to surgery was around 11 months in Group 1 (SD = 12.13) and approximately 14 months in Group 2 (SD = 20.90). Table 1 Prior to surgery, the mean Lysholm score in group A was 58.40, which is a measure of knee function. This recovered to 90.70 after surgery. When comparing the preoperative and postoperative findings, there was a statistically significant difference that favoured the postoperative results (p < 0.001). In contrast, group B's average Lysholm score was 54.10. This recovered to 91.10 after surgery. When comparing the preoperative and postoperative findings, there was a statistically significant difference that favoured the postoperative results (p < 0.001). There was no discernible difference between the two groups when comparing the postoperative outcomes (p = 0.832). Fig. 1.

Table (1).

Demographic and clinical data of enrolled patients.

Variable		Group A		Group B
		Count	%	Count	%
Age (years)	Mean ± SD	25.65 ± 5.17		25.45 ± 5.58
Sex	Male	20	100	15	85
	Female	0	0	5	15
side affected	RT ACL	13	60	12	60
	LT ACL	7	35	8	40
type of trauma	Contact injury	3	15	1	5
	Non contact injury	17	85	19	95
level of activity	Professional	3	15	3	15
	Non-professional	17	85	17	5
Associated Injury	Medial meniscal injury	7	35	11	55
	Lateral meniscal injury	0	0	2	10
	Medial + lateral meniscal injury	1	10	0	0
	Chondral lesions	1	5	1	5
Time to surgery (months)	Mean ± SD	11.05 ± 12.13		13.96 ± 20.90

Figure (1).

Lysholm scores for both groups (pre and post-operative score).

3.2. Intraoperative assessment

In the group A, meniscus injuries were observed in 35%, predominantly involving the medial meniscus (MM) in 55%, lateral meniscus (LM) in 10%, and both in 5%. Partial meniscectomy was performed in 20%, primarily for MM (40%). Meniscal repair procedures were conducted in 15%, with 5% involving both MM and LM. Cartilage injuries were minimal, with 5% affecting the medial femoral condyle (FC) and an additional 5% undergoing microfracture. In the group B, meniscus injuries were present in 55%, with 40% involving MM and 10% LM. Partial meniscectomy was performed in 30%, predominantly for MM (40%). Meniscal repair was undertaken in 15%, all involving MM. Cartilage injuries were limited, affecting 5% of cases in both groups, with involvement of the medial femoral condyle and microfracture procedures. Table 2.

Table (2).

Intraoperative findings of studied patients.

Variable		Group A		Group B
		Count	%	Count	%
Meniscus injury	MM	7	35	11	55
	LM	0	0	2	10
	MM + LM	1	5	0	0
Partial meniscectomy	MM	4	20	8	40
	LM	0	0	2	10
	MM + LM	1	5	0	0
Meniscal repair	MM	3	15	3	15
	LM	0	0	0	0
	MM + LM	1	5	0	0
Cartilage injury	Medial FC	1	5	1	5
	Microfracture	1	5	1	5

In the group A, the majority exhibited favorable results in the Pivot Shift test, with 60% having a negative outcome, 25% showing a just detectable shift, 10% displaying an obvious shift, and 5% presenting a gross shift. Lachman tests were predominantly normal, with 80% in the normal category and 20% deemed nearly normal. The Lysholm score showed a median of 90.7%, reflecting high functional outcomes. In the group B, postoperative results were notably positive, with 90% achieving a negative Pivot Shift test, demonstrating improved stability compared to the group A. Lachman tests showed even more favorable outcomes, with 90% classified as normal and 10% nearly normal. The Lysholm score displayed a median of 91%, indicating excellent postoperative functional recovery. Table 3 When comparing the preoperative and postoperative data, there was no discernible change in group A with respect to the effusion level (p = 0.248). When comparing the preoperative and postoperative results in group B, there was a statistically significant difference that favoured the postoperative results (p = 0.001). There was no statistically significant difference between the two groups' postoperative outcomes when they were compared. Fig. 2.

Table (3).

Postoperative objective and subjective outcome of studied patients.

Variable		Group A		Group B
		Count	%	Count	%
Pivot shift test	Negative (−ve)	1	60	18	90
	Just detectable (+)	5	25	1	5
	Obvious (++)	2	10	1	5
	Gross (+++)	1	5	0	0
Lachman test	Normal	16	80	18	90
	Nearly normal	4	20	2	10
	Abnormal	0	0	0	0
	Severely abnormal	0	0	0	0
Lysholm score	Median (IQR)	90 (85–100)		91 (72–100)

Figure (2).

Postoperative effusion level in group A and group B.

Four patients (20%) in group A and three patients (15%) in group B experienced postoperative problems, including persistent hemarthrosis lasting up to six weeks after surgery. Depending on the extent of the effusion, this was treated with aspiration performed in an entirely aseptic environment in addition to anti-inflammatory and anti-edematous medications. When the tenth week after surgery arrived, there was no more effusion. Eight patients in group B experienced pain and irritation, which persisted for two months in three of them, five months in three others, and six months in two patients before becoming better. Within group (A), a singular patient experienced a superficial infection at the site of graft harvest wound. This issue was effectively addressed through a regimen of repeated dressing changes and the administration of broad-spectrum oral antibiotics for a duration of one week, ultimately resulting in the complete resolution of the infection. In group (B), two patients had infection, the first one had infection one and half month after surgery as the physiotherapist injected steroid inside his knee to alleviate pain and improve ROM, but the patient suffered severe infection after injection, infection was managed with three times arthroscopic lavage with preservation of the ACL stump and fortunately the patient improved from infection. The other one had superficial infection at tenodesis site, we take care of wound at clinic by dressing it daily and gave him appropriate antibiotic after culture and sensitivity testing. After multiple clinic visits, the wound improved without affecting the fixation method of tenodesis.

A bilateral weightbearing anteroposterior (AP) X-ray with both lower limbs elevated is employed to evaluate the degree of medial and lateral joint space narrowing. In addition, patellofemoral constriction is documented using a 45-degree Merchant view. A modest grade is characterized by slight alterations such as small osteophytes, mild sclerosis or flattening of the femoral condyle, and minimal joint space restriction. In cases with a moderate grade, these changes may be followed with joint space narrowing (e.g., a joint space measuring 2–4 mm on either side or displaying up to 50% joint space narrowing). Conversely, severe alterations are characterized by less than 2 mm of joint space or more than 50% joint space narrowing. This classification system helps in assessing the severity of changes in the joint space and associated structural modifications. X-ray of severly infected case of ACLR with ilio tibial band tenodesis, the one who injected cortisone and had multiple arthroscopic lavages. The x-ray after lavage show the severe OA changes in the knee. Fig. 3.

Figure (3).

X-ray of severly infected case of ACLR with ilio tibial band tenodesis, the one who injected cortisone and had multiple arthroscopic lavages. The x-ray after lavage show the severe OA changes in the knee.

4. Discussion

In patients with high grade pivot-shift instability, the primary goal of this study was to evaluate the impact of unilateral ACLR against ACLR + lateral extra-articular tenodesis. Over the previous fifty years, there has been a considerable advancement in ACLR..⁴ For the majority of patients, the current intra articular ACLR has yielded good to exceptional results; yet, rotational instability still presents a problem for some patients.^4,5 Up to 25% of patients may experience recurrent ACL injury following single bundle ACLR (10). This condition is assumed to be caused by residual rotational instability, which is subjectively evaluated as positive pivot shift. ACLR techniques have been continuously improved. Particularly, isolated single-bundle intraarticular ACLR methods were unable to completely control rotational knee instability and failed to return the knee joint to its normal biomechanics and kinematics. The absence of rotational laxity control has drawn renewed attention since the invention of doublebundle ACLR.¹² Clinical results and the likelihood of graft failure are comparable between single and double bundle ACLR, according to a meta-analysis by Mascarenhas et al.¹³ A thorough meta-analysis was carried out by Chen et al. to investigate changes in osteoarthritis (OA) throughout mid-to long-term follow-ups, as well as knee stability, clinical function, and graft failure rate. According to their research, the Double-Bundle (DB) approach for autologous ACL repair did not outperform the Single-Bundle (SB) procedure across these parameters.¹⁴ In group (A), the average period from injury to surgery was 11 months, while in group (B), it was 14 months. Persistent ACL rupture affects the knee's other ligamentous components, causing the anterolateral ligaments to elongate and become more slack, which increases rotational instability.¹⁵ One of the most recent meta-analysis and systematic review done on the time from injury to surgery by Devitt et al., stated that time from injury to surgery is crucial to do LET with ACLR to be effective in reducing pivot shift post operatively. The meta-analysis of 5 studies done within 12 months did not significantly reduce pivot shift, but when same meta-analysis done on 3 studies in which ACLR was delayed for more than 12 months, adding LET did significantly reduce postoperative pivot shift.¹⁵ The subjective Lysholm score was applied to the outcomes for each group. After contrasting the two groups' postoperative Lysholm scores. Between the two groups, there was no statistically significant difference. Hewison et al., Sonnery Cottet et al., and Devitt et al. These reviews and meta-analyses contrast the outcomes of intra-articular ACLR performed alone with ACLR that includes LET, and they conclude that the two surgical approaches are statistically equivalent in terms of lysholm score.15, 16, 17 Lachman test measures anteroposterior instability. Upon comparing the post operative results, no significant difference was found between the two groups as regard lachman test because lachman test measure A-P translational instability only which can be controlled by ASB ACLR only and in this study, we measure both A-P translational and rotational instability by pivot shift test. Pivot shift test measures rotational laxity, all patients in the study were grade D (gross) pre-operatively. In group A, post-operatively 12 patients were grade A (no pivoting), 5 patients were B (glide), 2 patients were C (clunk) and one patient D (gross). In group B,18 patients are A,1patients is B and 1 patient is C. Upon comparing the results postoperatively, there was statistically significant difference between the 2 groups (p = 0.003). Similar findings were made by Hewison et al. in their systematic review, which also contrasts the outcomes between ACLR alone and ACLR enhanced by LET. The study found no differences in the two groups' KT1000/-2000 and Lachman test measurements, indicating that intra-articular ACLR alone controls anterior translation. Wilson came to the same conclusion as us, combining ACLR and LET to provide both translational and rotational control. However, he did not find that this led to better clinical outcomes, as evidenced by the objective IKDC ratings, which did not indicate a statistically significant difference between groups.¹⁶

It should be noted that the extra LET treatment may provide protection throughout the ligamentizing phase of the hamstring ACL transplant. When combined with intra-articular ACLR, the extra LET decreased the stress on the hamstring graft by roughly 43%, according to an in vitro research by Engebretsen et al.¹⁸ Moreover, in contrast to individuals who underwent isolated intra-ACLR utilizing solely a hamstring graft, a notably greater proportion of patients who received a combined LET alongside ACLR achieved functional scores categorized as normal or very normal, as demonstrated in the study by Zaffagnini et al. The incorporation of LET in the treatment protocol appears to offer potential advantages, potentially mitigating the susceptibility of the hamstring graft to issues such as distortion, elongation, and rupture during the ligamentization process. This additional intervention may contribute to enhanced overall outcomes in comparison to the traditional solo intra-articular ACLR approach with a hamstring graft.¹⁹ X-ray changes after surgery is for evaluation of medial and lateral joint space narrowing and patellofemoral changes. In group A, 15 patients had normal x-rays, 3 patients had mild changes may be due to meniscal injury and 2 patients had moderate changes (one of them had infection and bucket handle tear of medial meniscus and the other one had an ulcer of MFC and varus knee). In group B, 13 patients had normal x-rays, 4 patients had mild changes, 2 patients had moderate changes due to infection, meniscal injury, ulcer and theoretically may be due to over constraint made by lateral tenodesis and 1 patient have severe changes, he had severe infection. Due to short term follow up of this study, arthritic changes were not reliable to assess. Pernin et al., performed a long term follow up (24.5 years) for cases with combined ACLR plus LET. They found that the onset of osteoarthritis was correlated with medial meniscal status and femoral chondral defects at time of surgery and not correlated to EAT.²⁰

Because extra-articular repair may cause the compartment to become very tight, there are worries about the possibility of developing secondary osteoarthritis (OA). In a recent investigation conducted by Ferretti et al., findings revealed that individuals who underwent extra-articular repair did not exhibit an increased risk of osteoarthritis (OA) during a follow-up period of at least 10 years. In contrast to the extra-articular reconstruction group, where only 14% (6 out of 42) of patients were identified in Kellgren-Lawrence grades II, III, and IV, the control group showed a statistically higher proportion at 51% (25 out of 49). These results align with the conclusions drawn by other researchers who similarly found no evidence supporting the notion that extra-articular tenodesis heightened the incidence of osteoarthritis.²¹ According to Ferretti et al., it is unlikely that the earlier theory that lateral overtightening causes degenerative alterations in the lateral compartment is accurate. They hypothesised that the conservative post-operative regimen, which includes immobilisation for up to two months postoperatively, may have contributed to the previously documented higher incidence of OA. Unusually anatomic ACL restoration combined with a non-anatomic extra-articular lateral tenodesis that is locked in flexion and frequently rotates the tibia externally are additional possible contributing causes.²¹ In our study, group B had two main issues that were statistically more closely related to them than group A. They included two cases of infection, one patient intra-articular, one patient at the site of the tenodesis, and eight cases of post-operative lateral compartment pain. Septic knee arthritis has been observed to be associated with ACL reconstruction surgery or concomitant surgical operations because of longer operating times, more or larger incisions, prolonged tourniquet inflation, or the use of suture material serving as a foreign body.²² It can be difficult to prevent infection when microorganisms grow biofilms on hardware and weakened tissue, like an avascular transplant. Although most surgeons are hesitant to utilise radical debridement with graft and hardware removal since it destabilises the knee joint and requires a second reconstructive procedure, it can help manage chronic infection.²² Positive results are expected when treating early infections arthroscopically, as stated by Schulz et al. In cases of severe or persistent illnesses, a more drastic approach seems advantageous; nevertheless, the authors were unable to present any comparable data to support their claim statistically.²³

4.1. Strengths

Our method has the benefit of having a control group because it is a randomised prospective control study. It is also very precise and easy to use; the middle third of the ilio tibial band was taken out to preserve the Kaplan fibres and the capsuleosseous layer, both of which are important for rotational stability. When fixed at all examined flexion degrees (0, 30, and 60), the LET treatment in conjunction with ACLR recovered all knee characteristics. In contrast to the ALL reconstruction, which involves a lengthy operation, numerous tunnels, numerous grafts, and fixation performed in extension, we fix the tenodesis site in flexion and neutral rotation, which limits over the constraint lateral compartment. Only when the combined ACL and ALL repair was fixed in full extent were normal parameters restored. The improvement in postoperative pivot shift demonstrated that LET had stabilised the anterolateral-rotatory instability, preventing graft rupture and allowing a safe return to sport for elite athletics patients.

4.2. Limitations

The present study has few limitations. First, because the two procedures differed in how they made the incision, blinding—which is crucial when evaluating patient-reported outcomes—was not achievable. It was not possible to assess the rates of meniscal re-injury, graft re-rupture, and OA in both groups during the extremely brief (9-month) follow-up. Subjective manual pivot-shift grading is used to determine which patients have the high-grade pivotshift phenomena. To evaluate pathologic knee joint rotational laxity following ACL injury, however, the pivot shift is the most accurate and widely used clinical test, there may be bias in our results if the pivot-shift grading is done differently during the usual clinical follow-up appointment or while the patient is sedated.

5. Conclusions

In the initial postoperative assessment, no discernible distinctions emerged between patients undergoing LET in conjunction with ACLR and those opting for solitary ACLR. The evaluation encompassing anterior knee stability, objective IKDC scores, and Lysholm scores at short-term follow-up revealed comparable outcomes for both approaches. Additionally, the integration of LET and intra-articular ACLR effectively eliminated the high-grade pivot-shift syndrome. Remarkably, the utilization of LET involving the ITB as a supplement to ACL rehabilitation resulted in an augmentation of rotational stability. Based on these findings, we recommend the incorporation of LET in high school settings, particularly for enhancing rotational stability, as evidenced by its positive impact on the pivot shift examination.

Ethical statement

Ethical approval was obtained from the Ethical Research Committee of Cairo University, Egypt.

Funding statement

No funds were received.

Guardian/patient's consent

Informed consent was obtained from all participants before their inclusion in the study, ensuring confidentiality and privacy of their information.

CRediT authorship contribution statement

Ahmed Nabil: Conceptualization, Methodology, Software. Khaled Abd Halim Hafez: Data curation, Writing – original draft. Ahmed Rizk: Visualization, Investigation. Ahmed Abu Taleb: Writing – review & editing. Ramy Emad: Supervision.