Abstract
Introduction
Osteomyelitis presents with heterogeneous clinical, etiological, and microbiological characteristics depending on anatomical location. While foot osteomyelitis is commonly associated with diabetic foot infections and contiguous spread, non-foot osteomyelitis often arises from post-traumatic, hematogenous, or postoperative causes. However, direct comparative analyses between these two entities remain limited.
Materials and methods
A retrospective analysis was conducted on 202 adult patients who underwent surgical treatment for osteomyelitis between 2011 and 2026. Patients were divided into foot (n = 89) and non-foot (n = 113) osteomyelitis groups. Clinical, etiological, microbiological, and treatment-related variables were compared. Only intraoperatively obtained deep tissue and/or bone cultures were included.
Results
Patients with foot osteomyelitis were older and had a significantly higher prevalence of diabetes mellitus (49.4% vs. 5.3%, p < 0.001), which was identified as an independent predictor of foot osteomyelitis (OR 14.15, 95% CI 4.32–46.42; p < 0.001). Infections in foot osteomyelitis predominantly developed via contiguous spread (73.0%), whereas non-foot osteomyelitis showed more heterogeneous etiologies, including post-traumatic and hematogenous causes (p < 0.001). Microbiologically, Staphylococcus aureus was the most common pathogen in non-foot osteomyelitis, while foot osteomyelitis demonstrated a more diverse distribution with higher rates of polymicrobial infections. Amputation was significantly more frequent in the foot group (50.6% vs. 15.9%, p < 0.001), whereas antibiotic-loaded cement use was more common in non-foot osteomyelitis (p < 0.001).
Conclusions
Foot and non-foot osteomyelitis differ significantly in clinical, etiological, and microbiological characteristics. These findings suggest that foot and non-foot osteomyelitis differ in their clinical, etiological, and microbiological characteristics and may require different diagnostic and therapeutic approaches.
Keywords: Diabetic foot, Polymicrobial infection, Contiguous spread, Post-traumatic infection
Introduction
Osteomyelitis is an inflammatory process caused by pathogenic microorganisms and characterized by progressive bone destruction. Despite advances in diagnosis and treatment, it remains a significant clinical challenge. Clinical presentation, causative microorganisms, and routes of spread vary widely depending on factors such as anatomical location and patient comorbidities, making optimized management strategies essential [1].
The diagnosis of osteomyelitis remains challenging due to its variable clinical presentation and the absence of a single definitive diagnostic modality. Clinical findings are often non-specific, although the presence of a sinus tract is a key indicator. Laboratory markers such as erythrocyte sedimentation rate and C-reactive protein may support the diagnosis but lack specificity. Radiographic findings may include lytic lesions, sequestrum, and involucrum. Magnetic resonance imaging has high sensitivity; however, its specificity is limited in distinguishing infection from other inflammatory or traumatic conditions, and its use may be restricted in the presence of ferromagnetic implants. Microbiological confirmation through deep tissue or bone biopsy remains the gold standard, although obtaining adequate samples may not always be feasible, particularly in patients previously treated with antibiotics or undergoing amputation [2–4].
Management of osteomyelitis requires a multidisciplinary approach involving both medical and surgical strategies. Treatment decisions are influenced by infection location, etiology, host factors, and microbiological profile. In diabetic foot osteomyelitis, treatment typically involves targeted antibiotic therapy combined with surgical interventions ranging from debridement to amputation in advanced cases [3, 5]. In contrast, non-foot osteomyelitis, particularly those related to trauma or surgical procedures, is more frequently managed with aggressive debridement and limb-salvage strategies, including the use of antibiotic-loaded materials such as cement spacers. Despite advances in surgical techniques and antimicrobial therapy, recurrence and treatment failure remain significant concerns [6].
Foot osteomyelitis, especially when associated with diabetic foot ulcers, demonstrates a distinct clinical profile. These infections commonly arise from contiguous spread of soft tissue infections and are frequently polymicrobial. Their management is often complex, with a high risk of complications, including amputation. The presence of peripheral vascular disease further complicates treatment in this patient population [1].
In contrast, non-foot osteomyelitis typically arises from different etiological mechanisms, including post-traumatic, hematogenous, or postoperative spread. These infections generally exhibit a different microbiological profile, with Staphylococcus aureus being the most commonly identified pathogen. Compared to foot osteomyelitis, non-foot long bone osteomyelitis is more often managed with limb-salvage approaches, including extensive debridement and antibiotic-loaded cement application [7].
To our knowledge, there is a lack of studies directly comparing foot osteomyelitis—most commonly associated with diabetic foot infections—with non-foot osteomyelitis arising from post-traumatic, hematogenous, or postoperative causes. Therefore, this study aimed to compare these two groups in terms of patient characteristics, etiology, microbiological profiles, and treatment strategies.
Materials and methods
In this retrospective observational study, patients aged 18 years and older who underwent surgical treatment for osteomyelitis between January 2011 and January 2026 were evaluated. Patients were retrospectively identified from the institutional surgical database, and only those who were operated on for osteomyelitis were included. The study was approved by the Ethics Committee and was conducted in accordance with the Declaration of Helsinki. Due to the retrospective design, the requirement for informed consent was waived.
Patient selection and diagnostic criteria
Osteomyelitis was diagnosed based on the presence of a sinus tract communicating with bone or the detection of lytic bone cavities consistent with osteomyelitis on plain radiographs. Microbiological culture was performed for pathogen identification and was not used as a prerequisite for diagnosis. Implant-related infections without radiographic evidence of osteomyelitic bone destruction were excluded. Prosthetic joint infections were not included. Additionally, diabetic foot ulcers without radiographic evidence of osteomyelitis and predominantly soft tissue involvement, as well as Charcot foot cases without draining sinus tracts, were excluded.
Microbiological evaluation
Intraoperative microbiological sampling was routinely performed whenever feasible. When cultures were obtained, at least two separate deep tissue and/or bone specimens were collected. Superficial cultures were excluded from analysis. Cases in which no intraoperative culture was obtained were classified as “culture not obtained.” Microbiological data were categorized as Staphylococcus aureus, Gram-negative bacteria, other Gram-positive bacteria, polymicrobial infections, culture-negative cases, and cases with no culture obtained.
Data collection
Clinical and demographic data, including age, sex, presence of diabetes mellitus, infection etiology, affected bone location, foot involvement, microbiological culture results, use of antibiotic-loaded cement, and amputation status, were collected from electronic medical records.
Grouping and comparison
Patients were divided into two groups based on infection location: foot osteomyelitis and non-foot osteomyelitis. Foot osteomyelitis was defined as osteomyelitis involving the phalanges, metatarsals, tarsal bones (including the talus, navicular, cuboid, and cuneiform bones), and calcaneus. These groups were compared in terms of clinical characteristics, etiology, microbiological distribution, and treatment strategies.
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation and compared between groups using the Student’s t-test after assessment of normality. Categorical variables were presented as frequencies and percentages, and comparisons were performed using the chi-square test or Fisher’s exact test, as appropriate.
To identify factors independently associated with foot osteomyelitis, a multivariable logistic regression analysis was performed. Clinically relevant variables, including age, sex, diabetes mellitus, and etiology, were entered into the model. Treatment-related variables were excluded because they occur after disease classification and could introduce reverse causality. Multicollinearity was assessed using variance inflation factors (VIF), and model calibration was evaluated using the Hosmer–Lemeshow goodness-of-fit test. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs).
Additionally, a subgroup analysis was performed to evaluate microbiological differences after excluding cases classified as “culture not obtained,” in order to minimize potential bias related to the lack of microbiological sampling. Pathogen distributions between foot and non-foot osteomyelitis groups were reanalyzed using the chi-square test.
A sensitivity analysis was also performed after excluding all patients with diabetes mellitus to determine whether the principal differences between foot and non-foot osteomyelitis persisted. A temporal sensitivity analysis was also performed by comparing the early (2011–2018) and late (2019–2026) study periods to assess the potential influence of changes in clinical practice over time.
A two-tailed p-value of < 0.05 was considered statistically significant.
Results
A total of 202 adult patients with osteomyelitis were included in the study. Of these, 89 (44.1%) had foot osteomyelitis and 113 (55.9%) had non-foot osteomyelitis. The mean age of the overall cohort was approximately 48 years, and the majority of patients were male. The mean age was significantly higher in patients with foot osteomyelitis compared to those with non-foot osteomyelitis (51.6 ± 15.1 vs. 45.4 ± 16.9 years, p = 0.007). However, age was not identified as an independent predictor in multivariate analysis (p = 0.312) (Table 1).
Table 1.
Demographic and clinical characteristics
| Variable | Non-foot (n = 113) | Foot (n = 89) | p-value |
|---|---|---|---|
| Age (mean ± SD) | 45.4 ± 16.9 | 51.6 ± 15.1 | 0.007 |
| Male sex, n (%) | 87 (77.0) | 64 (71.9) | 0.39 |
| Diabetes mellitus, n (%) | 6 (5.3) | 44 (49.4) | < 0.001 |
| Amputation, n (%) | 18 (15.9) | 45 (50.6) | < 0.001 |
| Antibiotic cement use, n (%) | 40 (35.4) | 7 (7.9) | < 0.001 |
The most commonly affected bone was the tibia, observed in 56 patients (27.7%). In the non-foot group, the tibia was the most frequently affected bone (49.6%), whereas toe phalanges (40.4%) and metatarsals (31.5%) were the most commonly involved bones in the foot group. The anatomical distribution of osteomyelitis is summarized in Table 2 and illustrated in Fig. 1.
Table 2.
Anatomical distribution of osteomyelitis according to anatomical location
| Anatomical location | Foot osteomyelitis (n = 89) | Non-foot osteomyelitis (n = 113) |
|---|---|---|
| Toe phalanges | 36 (40.4%) | – |
| Metatarsals | 28 (31.5%) | – |
| Calcaneus | 20 (22.5%) | – |
| Midfoot bones* | 5 (5.6%) | – |
| Tibia | – | 56 (49.6%) |
| Femur | – | 28 (24.8%) |
| Hand phalanges | – | 18 (15.9%) |
| Humerus | – | 6 (5.3%) |
| Fibula | – | 1 (0.9%) |
| Iliac bone | – | 1 (0.9%) |
| Metacarpals | – | 1 (0.9%) |
| Radius | – | 1 (0.9%) |
| Ulna | – | 1 (0.9%) |
*Midfoot bones include the navicular, cuboid, and cuneiform bones.
Fig. 1.
Anatomical distribution of osteomyelitis
Diabetes mellitus was significantly more prevalent in the foot osteomyelitis group. Approximately half of the patients with foot osteomyelitis had diabetes (49.4%), whereas this rate was considerably lower in the non-foot group (5.3%) (p < 0.001). Multivariate logistic regression analysis demonstrated that diabetes was independently associated with foot osteomyelitis (OR: 14.15; 95% CI 4.32–46.42; p < 0.001) (Table 3). The final multivariable model showed good calibration according to the Hosmer–Lemeshow goodness-of-fit test (χ² = 4.20, df = 8, p = 0.838), and no evidence of problematic multicollinearity was identified (all VIF values < 2.3).
Table 3.
Multivariable logistic regression analysis of factors independently associated with foot osteomyelitis
| Variable | Adjusted OR | 95% CI | p value |
|---|---|---|---|
| Age | 0.99 | (0.96–1.01) | 0.312 |
| Male sex | 1.60 | (0.64–4.00) | 0.312 |
| Diabetes mellitus | 14.15 | (4.32–46.42) | < 0.001 |
| Etiology | |||
| Hematogenous | Reference | – | – |
| Post-traumatic | 2.55 | (0.82–7.88) | 0.104 |
| Surgical complication | 0.13 | (0.01–1.27) | 0.079 |
| Contiguous spread | 11.84 | (3.82–36.71) | < 0.001 |
OR odds ratio, CI confidence interval. Model adjusted for age, sex, diabetes mellitus, and etiology.
In terms of etiology, infections in the foot osteomyelitis group predominantly developed via contiguous spread (73.0%). In contrast, the non-foot osteomyelitis group exhibited a more heterogeneous distribution, with post-traumatic (30.1%), hematogenous (27.4%), and surgery-related (24.8%) causes being the most common (p < 0.001) (Table 4).
Table 4.
Etiological characteristics of foot and non-foot osteomyelitis
| Etiology | Non-foot (n = 113) | Foot (n = 89) | P value |
|---|---|---|---|
| Contiguous | 20 (17.7%) | 65 (73.0%) | < 0.001† |
| Post-traumatic | 34 (30.1%) | 17 (19.1%) | |
| Hematogenous | 31 (27.4%) | 6 (6.7%) | |
| Surgical complication | 28 (24.8%) | 1 (1.1%) |
†Overall comparison using the chi-square test.
Significant microbiological differences were observed between the two groups (p < 0.001). In the non-foot osteomyelitis group, Staphylococcus aureus was the most frequently isolated pathogen (30.1%), followed by Gram-negative bacteria (23.9%) and other Gram-positive bacteria (15.0%). In contrast, the foot osteomyelitis group demonstrated a more heterogeneous microbiological profile. After excluding cases in which cultures were not obtained, Gram-positive and Gram-negative bacteria were more evenly distributed, and the proportion of polymicrobial infections was higher (Table 5).
Table 5.
Comparison of pathogen distribution after excluding “culture not obtained” cases
| Pathogen group | Non-foot (n = 102) | Foot (n = 65) | p-value |
|---|---|---|---|
| Staphylococcus aureus | 34 (33.3%) | 9 (13.8%) | 0.006 |
| Gram-negative bacteria | 27 (26.5%) | 16 (24.6%) | 0.78 |
| Other gram-positive bacteria | 17 (16.7%) | 19 (29.2%) | 0.06 |
| Polymicrobial infection | 5 (4.9%) | 10 (15.4%) | 0.027 |
| Culture-negative | 19 (18.6%) | 11 (16.9%) | 0.76 |
Cases classified as “culture not obtained” were excluded from this analysis. Percentages were calculated within each group. P-values were derived using the chi-square test.
Among the 34 cases classified as “culture not obtained,” 28 (82.4%) were patients undergoing amputation with clinically clear surgical margins in whom no additional bone cultures were obtained. The remaining six cases (17.6%) were attributable to incomplete or missing microbiological records. In a subgroup analysis excluding “culture not obtained” cases, the differences in pathogen distribution between the two groups remained statistically significant (p = 0.008). In the non-foot osteomyelitis group, Staphylococcus aureus remained the most common pathogen (33.3%), followed by Gram-negative bacteria (26.5%) and other Gram-positive bacteria (16.7%). In the foot osteomyelitis group, other Gram-positive bacteria (29.2%) and Gram-negative bacteria (24.6%) were more frequently observed, while Staphylococcus aureus was less common (13.8%). Polymicrobial infections were more frequent in the foot group (15.4% vs. 4.9%). Culture-negative infection rates were similar between the two groups (16.9% vs. 18.6%, p = 0.76).
A sensitivity analysis was performed after excluding all patients with diabetes mellitus. The principal differences between foot and non-foot osteomyelitis persisted. Contiguous spread remained more frequent in foot osteomyelitis (57.8% vs. 17.8%, p < 0.001), whereas Staphylococcus aureus remained less common (12.1% vs. 34.0%, p = 0.014) and polymicrobial infections remained more frequent (24.2% vs. 5.2%, p = 0.003). In addition, amputation remained more common (44.4% vs. 16.8%, p = 0.001), whereas antibiotic-loaded cement use remained less frequent (13.3% vs. 34.6%, p = 0.014) in the foot osteomyelitis group.
Regarding treatment, the use of antibiotic-loaded cement/spacers was significantly more common in the non-foot osteomyelitis group (35.4% vs. 7.9%, p < 0.001). Amputation rates were significantly higher in the foot osteomyelitis group (50.6% vs. 15.9%, p < 0.001). Among patients with foot osteomyelitis who underwent amputation, 37 (82.2%) underwent minor amputations and 8 (17.8%) underwent major amputations.
A sensitivity analysis comparing the early (2011–2018) and late (2019–2026) study periods demonstrated no significant temporal differences in the proportions of foot osteomyelitis (p = 1.000), culture-negative infections (p = 1.000), polymicrobial infections (p = 0.755), or amputation rates (p = 0.925). The only significant temporal difference was a higher use of antibiotic-loaded cement during the later study period (p = 0.045).
Discussion
The most important finding of this study is that foot and non-foot osteomyelitis differ significantly in clinical, etiological, and microbiological characteristics. The results indicate that these two groups differ not only in terms of anatomical localization but also in underlying pathogenesis, microbiological profile, and treatment strategies. The strong association between diabetes and foot osteomyelitis, the predominance of infections arising via contiguous spread, and the higher frequency of polymicrobial infections support the notion that foot osteomyelitis demonstrate a distinct clinical profile. In contrast, the more heterogeneous etiological distribution and the predominance of Staphylococcus aureus in non-foot osteomyelitis suggest that these infections should be considered separately from foot osteomyelitis.
Previous studies have shown that diabetic foot infections typically arise from contiguous spread from soft tissue and represent the most common form of osteomyelitis [1]. In our study, diabetes was strongly and independently associated with foot osteomyelitis, supporting these findings. The high odds ratio observed in the multivariable analysis suggests that diabetes mellitus is not merely a comorbidity but a key determinant in the development of foot osteomyelitis.
In diabetic patients, peripheral neuropathy, vascular insufficiency, and impaired immune response facilitate the progression of infection and contribute to the development of osteomyelitis [4]. Furthermore, the polymicrobial nature of infections in this population complicates clinical management [8]. In many patients, foot osteomyelitis represents a manifestation of diabetic foot infection. As discussed above, because diabetic foot osteomyelitis constitutes a substantial proportion of foot osteomyelitis, diabetes mellitus may act as a potential confounder when comparing foot and non-foot osteomyelitis. To address this issue, we performed a sensitivity analysis excluding all patients with diabetes mellitus. The principal clinical, microbiological, and treatment-related differences remained unchanged, suggesting that the observed differences cannot be explained solely by the presence of diabetes mellitus.
It has been reported that in diabetic foot osteomyelitis, the primary source of infection is an ulcer in 91.8% of cases, whereas the remaining cases are associated with penetrating injuries [9]. In long bone fractures, post-traumatic spread is the most common mechanism, followed by hematogenous spread [10]. Post-traumatic osteomyelitis most frequently affects the tibia, with reported incidence rates ranging from 2 to 16% [10, 11]. In our study, 73% of foot osteomyelitis cases developed via contiguous spread. In non-foot osteomyelitis, the most commonly affected bone was the tibia, and post-traumatic spread was the most frequent mechanism; however, no significant difference was observed compared to hematogenous spread.
Hematogenous osteomyelitis is generally considered to be monomicrobial, whereas polymicrobial infections are more frequently observed in trauma-related or contiguous spread osteomyelitis [12, 13]. Similarly, diabetic foot osteomyelitis is often characterized by polymicrobial infections [8]. In our study, the rate of polymicrobial infections was significantly higher in foot osteomyelitis compared to non-foot osteomyelitis; however, polymicrobial infections were not the predominant type, as monomicrobial infections were more common overall. Kaimkhani et al. reported a high polymicrobial infection rate of 83% in diabetic foot osteomyelitis, with Escherichia coli isolated in 63% and Staphylococcus aureus in 58% of cases [14]. However, in that study, cultures were obtained from ulcer surfaces, which may have contributed to the higher polymicrobial rates. Indeed, several studies have demonstrated that soft tissue or sinus tract cultures are not sufficiently reliable in predicting bone pathogens [15, 16]. Current evidence supports bone biopsy as the most reliable diagnostic method for identifying causative organisms in osteomyelitis [17]. Elsheikh et al. reported a polymicrobial infection rate of 30.3% in long bone osteomyelitis based on bone samples [18]. In our study, polymicrobial infection rates were relatively low, with 15.4% in foot osteomyelitis and 4.9% in non-foot osteomyelitis. While the higher rate of polymicrobial infections in foot osteomyelitis is consistent with the literature, the overall lower rates may be explained by differences in sampling techniques, culture methods, and patient population.
Staphylococcus aureus is the most commonly isolated pathogen in osteomyelitis [1–5, 7, 11–13, 18, 19]. Coagulase-negative staphylococci are the second most frequently encountered organisms [12, 13]. In cases of open fractures, heavy contamination, or hospital-acquired infections, Gram-negative organisms such as Pseudomonas aeruginosa become more prevalent [13, 18, 20]. In our study, Staphylococcus aureus was the most frequently isolated pathogen in non-foot osteomyelitis (33.3%), followed by Gram-negative bacteria (26.5%). In contrast, in the foot osteomyelitis group, the proportion of Staphylococcus aureus was lower (13.8%), whereas other Gram-positive (29.2%) and Gram-negative bacteria (24.6%) were more commonly observed.
Pathogen identification using conventional culture methods is not always successful. Asten et al. reported a 23.5% rate of culture-negative bone biopsies in diabetic foot infections and demonstrated that advanced molecular techniques could detect pathogens in 83.3% of previously negative samples [21]. Aragon-Sanchez et al. reported an 11% culture-negative rate in diabetic foot osteomyelitis [9], and a meta-analysis reported a rate of 11.7% [8]. In non-foot osteomyelitis, culture-negative rates of approximately 15.2% have been reported [18]. In our study, the overall culture-negative rate was 17.9%, with similar rates observed between foot and non-foot osteomyelitis groups. This relatively high rate may be influenced by factors such as prior antibiotic use, sample quality, and culture conditions. Studies have shown that anaerobic bacteria and Gram-negative bacilli may be present in culture-negative cases when conventional methods are used [21]. These findings highlight the importance of proper sampling techniques and appropriate microbiological evaluation.
The management of osteomyelitis is complex and often requires surgical debridement, antimicrobial therapy, local antibiotic delivery methods in selected cases, and, in some instances, amputation [3, 11]. Although debridement and culture-directed antibiotic therapy are standard approaches in all osteomyelitis cases, treatment strategies differ significantly between foot and non-foot osteomyelitis. In particular, the risk of amputation is substantially higher in moderate to severe diabetic foot osteomyelitis [11, 22, 23]. In our study, the amputation rate was high in foot osteomyelitis; however, most procedures involved distal amputations, such as phalangeal disarticulation or ray resections. The primary goal of amputation is to eradicate infection while preserving a functional limb, typically through amputation proximal to the infected bone or disarticulation at the joint level. In such cases, obtaining bone cultures is often not feasible, which may explain the high rate of “culture not obtained” cases in foot osteomyelitis. Amputation may also be required in non-foot osteomyelitis in cases of refractory infection or nonunion, although it is less frequently performed than in foot osteomyelitis [23]. In contrast, local antibiotic delivery systems play a more prominent role in the treatment of long bone osteomyelitis [24–26]. Antibiotic-loaded polymethylmethacrylate (PMMA) beads and spacers have been widely used for decades, providing high local antibiotic concentrations. In addition, biodegradable carriers such as calcium sulfate and hydroxyapatite have gained increasing attention in recent years [10]. In our practice, PMMA was the only material used for local antibiotic delivery, and its use was significantly more common in long bone osteomyelitis. Additionally, the sensitivity analysis comparing the early and late study periods showed an increased use of antibiotic-loaded cement in the later period, likely reflecting the gradual adoption of local antibiotic delivery strategies in orthopedic infection surgery.
This study has several limitations. First, its retrospective and single-center design may limit the generalizability of the findings. Second, the high proportion of “culture not obtained” cases, particularly in the foot osteomyelitis group, may have influenced microbiological results. Third, the lack of molecular diagnostic methods may have led to underdetection of certain pathogens. Finally, the evaluation of polymicrobial infections was based solely on culture results, which may not fully reflect the true microbiological diversity. Histopathological confirmation was not routinely available because only amputation specimens underwent pathological examination; therefore, histopathological findings were not included in the analysis. Another limitation of this study is that only surgically treated patients were included. Therefore, our findings primarily reflect osteomyelitis cases requiring operative management and may not be generalizable to patients successfully managed with medical treatment alone. Consequently, the results should be interpreted within the context of a surgically treated orthopaedic cohort.
Conclusion
In conclusion, foot and non-foot osteomyelitis differ in their etiology, microbiological profile, and treatment characteristics. Foot osteomyelitis is strongly associated with diabetes, contiguous spread, and polymicrobial infections, whereas non-foot osteomyelitis is characterized by a more heterogeneous etiology and Staphylococcus aureus predominance. These findings demonstrate that surgically treated foot and non-foot osteomyelitis exhibit different clinical, etiological, microbiological, and treatment characteristics. These differences should be considered when interpreting microbiological findings and planning surgical management.
Author contributions
BK: study design, data collection, manuscript writing, YD data collection, critical revision, KAD: data analysis, critical revision, HCO: data analysis, critical revision, AM: data analysis, critical revision, MT: data analysis, critical revision.
Funding
No funding was received for conducting this study.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Conflict of intrest
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.