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Developmental dysplasia of the hip in Najran province, Saudi Arabia: Incidence and risk factors
EFOT, Yasser I. Alkhalife2MD, Abdalla O. Abdalla1FICMS (Orth), Hidar S. Alqudhaya3MBBS, Khairy I. Abdella4FEBR, Rashed S. Alqudhaya5MD
*Corresponding author: Ahmed M. Abouelenein, Department of Orthopedic Surgery, New Najran General Hospital, Najran, Saudi Arabia. dr.a.abdelhay@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Abouelenein AM, Alkhalife YI, Abdalla AO, Alqudhaya HS, Abdella KI, Alqudhaya RS. Developmental dysplasia of the hip in Najran province, Saudi Arabia: Incidence and risk factors. J Musculoskelet Surg Res. 2026;10:538-45. doi: 10.25259/JMSR_119_2026
Abstract
Objectives:
The objective of the study is to estimate the incidence of developmental dysplasia of the hip (DDH) in Najran Province, Saudi Arabia, and to identify associated risk factors.
Methods:
We conducted a retrospective observational study of 7,181 live births recorded in 2023 at the main maternity and children’s hospital in Najran, which accounted for approximately 71.4% of all live births in Najran Province that year. Infants meeting local DDH screening criteria underwent hip ultrasonography (Graf method) at 4–10 weeks. DDH was defined as Graf type IIc or higher. Multivariable logistic regression was used to evaluate risk factors.
Results:
Among 597 infants who underwent hip ultrasonography, 117 were diagnosed with DDH. This corresponds to an incidence of 16.29/1,000 hospital-recorded live births (95% confidence interval [CI] 13.61–19.49). Most DDH cases were mild (Graf IIc, 66.7%). Independent predictors of DDH were breech presentation (odds ratio [OR]: 4.99, 95% CI 2.77–8.99; p < 0.001), positive family history (OR = 3.37, 95% CI 2.07–5.48; p < 0.001), and improper swaddling (OR = 2.29, 95% CI 1.24–4.25; p = 0.007). Female sex was not an independent risk factor in this cohort.
Conclusion:
Najran demonstrates a notably higher DDH incidence than other Saudi regions, with breech presentation and family history as strong predictive factors, warranting mandatory screening. Improper swaddling emerges as a modifiable risk factor suitable for targeted public health intervention. These findings provide critical evidence to inform the development of region-specific healthcare policies and the appropriate allocation of resources to align with Vision 2030 for Saudi Arabia.
Keywords
Breech presentation
Developmental dysplasia of the hip
Mass screening
Saudi Arabia
Swaddling
Ultrasonography
INTRODUCTION
Developmental dysplasia of the hip (DDH) encompasses a spectrum of abnormalities ranging from mild acetabular dysplasia to complete hip dislocation.[1] This condition is among the most common developmental musculoskeletal disorders, with significant implications for long-term joint health and quality of life. Untreated cases frequently progress to serious complications, including hip instability, gait abnormalities, chronic pain, and premature osteoarthritis, requiring complex reconstructive procedures in adulthood.[2] Early detection through systematic newborn screening programs remains fundamental for achieving optimal treatment outcomes and preventing these debilitating late-presenting complications.[1,2]
The global incidence of DDH varies considerably, influenced by complex interactions between genetic and environmental factors, cultural practices, and screening methods.[3,4] A comprehensive 2023 meta-analysis established a global prevalence of approximately 14/1,000 infants (1.40%, 95% confidence interval [CI]: 0.86–2.28), though significant regional variation persists across different populations.[4] Western populations typically report rates between 1.5 and 20/1,000 births, with this wide range reflecting differences in diagnostic criteria, screening protocols, and population characteristics.[3,4]
Ultrasound screening generally detects higher rates than clinical examination alone, though many mild sonographic abnormalities resolve spontaneously without intervention.[2,3] Most contemporary screening programs combine universal physical examination using Ortolani and Barlow maneuvers with selective ultrasonography for high-risk infants, balancing detection sensitivity with resource utilization.[1,2] Recent large-scale meta-analysis confirmed breech presentation and family history as primary risk factors, while female sex showed a more modest association than previously reported in earlier literature.[5]
Middle Eastern populations, particularly in Saudi Arabia, appear to experience higher DDH rates than in Western countries, though published data show considerable variation across regions.[6-8] National estimates suggest Saudi rates around 10.46/1,000 births.[7] These regional differences underscore the critical importance of population-specific data for developing effective public health strategies and allocating healthcare resources appropriately.
Despite the clinical significance of DDH in Saudi Arabia, the Najran region remains critically understudied. While major urban centers such as Riyadh, Jeddah, and Almadinah have generated epidemiological information, no comprehensive data exist for Najran province.[7] This knowledge gap limits evidence-based policy development, resource allocation, and implementation of targeted prevention strategies in this region.
The clinical significance of DDH in Najran became apparent through our pediatric orthopedic department’s experience at the region’s main pediatric orthopedic center, the referral center for all pediatric orthopedic cases in Najran. In 2023, DDH accounted for 28.6% of all pediatric orthopedic consultations at regional facilities, indicating a considerable healthcare burden. Particularly concerning was the finding that approximately 31% presented as neglected cases after age 2 years, requiring complex surgical interventions, including pelvic osteotomy with or without open reduction and femoral shortening. This considerable burden of late presentations highlighted the urgent need for improved early detection and prevention strategies.
Our primary goal was to estimate the incidence of DDH in Najran based on our current screening protocols. Beyond this, we wanted to identify the most common risk factors in our local population, as this information could help us refine our screening approach. Ultimately, we hoped that these findings would provide the evidence needed to establish more effective regional healthcare policies, thereby improving the early identification of cases and minimizing the need for major surgical procedures.
MATERIALS AND METHODS
Study design and setting
We conducted a retrospective observational cohort study of all births at the region’s main maternity and child hospital during calendar year 2023. The main maternity and child hospital in the region serves as the Najran region’s primary maternity facility, providing comprehensive obstetric and neonatal care throughout the province. The region’s main pediatric orthopedic center provides comprehensive pediatric orthopedic care for the province. It maintains a specialized DDH follow-up clinic at the main maternity and child hospital for convenient access and continuity of care.
In 2023, the study hospital recorded 7,181 live births, accounting for 71.4% of the 10,059 live births in Najran Province. This substantial coverage supports the cohort as broadly representative of the regional birth population. Therefore, hospital-recorded births were used as the denominator for the hospital-based incidence estimate.
The idea for this study emerged from clinical observations in the pediatric orthopedic department at the region’s main pediatric orthopedic center. During 2023, we documented 4,368 total patient visits encompassing DDH, trauma, congenital conditions, tumors, and other orthopedic disorders. DDH cases alone accounted for 1,247 visits (28.6% of the total volume), demonstrating the considerable healthcare impact of this condition in our region. Most concerning was the observation that approximately 31% of DDH visits involved neglected cases presenting after age 2 years, indicating significant delays in diagnosis and treatment. During this period, we performed 47 DDH surgeries, including complex procedures such as open reduction and pelvic osteotomy with or without femoral shortening, while early-diagnosed infants received less invasive treatments, including braces, arthrogram, and closed reduction followed by hip spica casting. This considerable clinical burden motivated our epidemiological investigation to understand better the scope and risk factors of DDH in Najran province.
Inclusion and exclusion criteria
We included all neonates born at the main maternity and child hospital in the region during 2023 who met established risk criteria for DDH screening: breech presentation (frank, complete, or footling) at any gestational age; positive family history of DDH in first-degree relatives (parents or siblings); clinical suspicion of hip instability detected during routine neonatal examination; multiple births (twins, triplets); oligohydramnios documented on prenatal ultrasound; or presence of other musculoskeletal abnormalities including calcaneovalgus or torticollis.[1,2] We excluded infants whose families declined screening, those transferred to other facilities before screening completion, and cases with incomplete medical records preventing adequate data extraction.
Screening protocol
Our screening protocol follows the current international guidelines for selective ultrasonographic screening of high-risk infants.[1,2] Pediatricians performed initial clinical examination on all newborns using standardized Ortolani and Barlow maneuvers to detect hip instability. Infants meeting any risk criteria underwent referral for hip ultrasonography, typically performed between 4 and 10 weeks of age to allow physiological hip immaturity to resolve while enabling early detection of pathology.[1]
Ultrasound examination and Graf classification
Hip ultrasonography was performed and formally interpreted by trained radiologists using high-frequency linear transducers (7–12 MHz) and the standardized static Graf technique. The assessment was not based on the alpha angle alone; it included alpha angle, beta angle, acetabular morphology, bony acetabular rim configuration, and femoral head position/centering or decentering according to Graf criteria.[9] Pediatric orthopedic surgeons reviewed clinical findings and ultrasound reports during follow-up and management decisions. For this study, DDH was defined as Graf Type IIc or higher. Type I and Type IIa hips were classified as non-DDH, recognizing that Type IIa represents physiological immaturity in infants younger than 3 months and requires observation rather than immediate classification as pathological DDH. Graf Type IIb was defined as persistent acetabular immaturity with an alpha angle of 50–59° after 3 months of age.[9] Quantitative femoral head coverage percentage was not routinely documented in the retrospective ultrasound reports and was therefore not analyzed as a separate variable.
Data collection
We extracted comprehensive data from electronic medical records, including maternal demographics (age, parity), pregnancy characteristics (gestational age, prenatal complications), delivery details (mode, presentation), and neonatal factors (birth weight, sex, Apgar scores). We specifically documented all recognized DDH risk factors, including breech presentation, family history, clinical hip instability, multiple births, oligohydramnios, and associated musculoskeletal anomalies. Cultural practice assessment included detailed swaddling methods, categorized as proper (hips flexed and abducted, allowing natural positioning) or improper (legs extended and tightly wrapped together, restricting hip movement).[10] Ultrasound reports provided Graf classification, alpha and beta angles, and laterality.
Statistical analysis
We calculated the DDH incidence as cases per 1,000 live births with 95% CIs estimated using the Wilson score method. Descriptive statistics summarized demographic and clinical characteristics, with continuous variables presented as means ± standard deviations and categorical variables as frequencies and percentages.
We performed univariable analysis comparing DDH-positive and DDH-negative groups using Chi-square tests for categorical variables and independent t-tests for continuous variables. Variables showing associations with p < 0.20 in univariable analysis were entered into multivariable logistic regression to identify independent risk factors while controlling for potential confounders. We calculated adjusted odds ratios (OR) with 95% CIs, with statistical significance defined as p < 0.05 (two-tailed).
Because this was a retrospective cohort including all eligible infants screened during 2023, no a priori sample size calculation was performed. A post hoc power assessment was conducted using the observed sample of 117 DDH cases and 480 controls, a two-sided alpha level of 0.05, and the observed event rate. The sample provided adequate power (>80%) to detect clinically meaningful associations, particularly for the main predictors identified in the multivariable analysis. We performed all statistical analyses using the Statistical Package for the Social Sciences version 26.0 (IBM Corp., Armonk, NY, USA).
RESULTS
Study population and screening completion
In 2023, the study hospital recorded 7,181 live births, accounting for 71.4% of the 10,059 live births in Najran Province. Based on established risk criteria, pediatricians referred 638 infants (8.9% of births) for hip ultrasonography. Among referred infants, 597 (93.6%) completed screening, while 41 (6.4%) were lost to follow-up due to family relocation, noncompliance, or refusal to participate. The screened cohort included 317 females (53.1%) and 280 males (46.9%), with a mean gestational age of 38.2 ± 1.8 weeks and a mean birth weight of 3,150 ± 520 g.
Referral indications included breech presentation in 112 infants (18.7%), positive family history in 89 infants (14.9%), clinical hip instability in 330 infants (55.2%), multiple births in 28 infants (4.7%), oligohydramnios in 19 infants (3.2%), and associated musculoskeletal abnormalities in 14 infants (2.3%). Many infants had multiple risk factors: 364 (61.0%) had single risk factors, and 233 (39.0%) had two or more concurrent risk factors.
DDH incidence
Among 597 screened infants, we identified 117 with DDH (Graf Type IIc or higher), yielding a hospital-based incidence of 16.29/1,000 hospital-recorded live births (95% CI: 13.61–19.49), based on the 7,181 live births recorded at the study hospital.
Demographic and clinical characteristics
The mean age at ultrasound imaging was 6.8 ± 1.4 weeks (range: 4–10 weeks). Our screened population included 317 females (53.1%) and 280 males (46.9%). Among the 117 infants diagnosed with DDH, we observed a non-significant female predominance (n = 62, 53.0%) over males (n = 55, 47.0%), with sex not emerging as a statistically significant risk factor in our cohort (OR = 1.43, 95% CI 0.93–2.20, p = 0.097).
Unilateral DDH was more common than bilateral involvement, accounting for 73 cases (62.4%). Among unilateral cases, the left hip was affected in 43 (58.9%), and the right in 30 (41.1%). We diagnosed bilateral DDH in 44 infants (37.6%).
Graf ultrasound classification and severity distribution
Among 597 screened infants, we identified 117 with DDH (Graf Type IIc or higher), representing 19.6% of all screened infants [Table 1]. Most screened infants demonstrated mature, stable hips (Type I, 63.1%), or physiologically immature hips expected to mature spontaneously (Type IIa, 17.3%), consistent with international patterns of neonatal hip development.[9] No infants were classified as Graf Type IIb, which is defined as an alpha angle of 50–59° after 3 months of age. Because all ultrasound examinations in this cohort were performed between 4 and 10 weeks of age, no Type IIb cases were expected or identified.
| Graf classification | Total cases | Percentage |
|---|---|---|
| Type I (Alpha>60°) | 377 | 63.15 |
| Type IIa (Alpha 50–59°; <3 months) | 103 | 17.25 |
| Type IIb (Alpha 50–59°; >3 months) | 0 | 0 |
| Type IIc (Alpha 43–49°) | 78 | 13.07 |
| Type IId (Beta>77°; about to decenter) | 29 | 4.86 |
| Type IIIa (Decentered; no cartilage echoes) | 5 | 0.84 |
| Type IIIb (Decentered; cartilage echoes) | 4 | 0.67 |
| Type IV (Fully decentered hip) | 1 | 0.17 |
| Total DDH | 117 | 19.60 |
DDH: Developmental dysplasia of the hip
Among the 117 DDH cases, the severity distribution revealed that Type IIc (mild dysplasia) was most common, accounting for 78 cases (66.7% of DDH cases). More severe classifications included Type IId (beta angle >77°, hip about to decenter) in 29 cases (24.8%), Type IIIa (decentered hip without cartilage echoes) in 5 cases (4.3%), Type IIIb (decentered hip with cartilage echoes) in 4 cases (3.4%), and Type IV (fully decentered hip) in only 1 case (0.9%). This distribution indicates that most cases were detected at earlier, more treatable stages, though the presence of Types III and IV underscores the importance of systematic screening.
Risk factor analysis
Following multivariable logistic regression analysis [Figure 1], three factors emerged as statistically significant independent predictors of DDH [Table 2].
| Risk factor | DDH cases (n=117) % | Controls (n=480) % | Total (n=597) | Prevalence (%) | Odds ratio (95% CI) | p-value |
|---|---|---|---|---|---|---|
| Breech presentation | 26 (22.2) | 26 (5.4) | 52 | 8.7 | 4.99 (2.77–8.99) | <0.001 |
| Family history | 35 (29.9) | 54 (11.3) | 89 | 14.9 | 3.37 (2.07–5.48) | <0.001 |
| Improper swaddling | 104 (88.9) | 373 (77.7) | 477 | 79.9 | 2.29 (1.24–4.25) | 0.007 |
| Female sex | 62 (53.0) | 214 (44.6) | 276 | 46.2 | 1.43 (0.93–2.20) | 0.097 |
| Multiple births | 8 (6.8) | 25 (5.2) | 33 | 5.5 | 1.33 (0.59–3.01) | 0.489 |
| Oligohydramnios | 12 (10.3) | 38 (7.9) | 50 | 8.4 | 1.33 (0.68–2.61) | 0.405 |
| Cesarean delivery | 89 (76.1) | 348 (72.5) | 437 | 73.2 | 1.20 (0.74–1.95) | 0.456 |
| Prematurity (<37 weeks) | 18 (15.4) | 89 (18.5) | 107 | 17.9 | 0.80 (0.46–1.39) | 0.428 |
| Low birth weight (<2500 g) | 15 (12.8) | 67 (14.0) | 82 | 13.7 | 0.90 (0.49–1.65) | 0.734 |
DDH: Developmental dysplasia of the hip; CI: Confidence interval; p< 0.05 was considered statistically significant.
Breech presentation demonstrated the strongest association with DDH, present in 26 of 117 DDH cases (22.2%) compared with only 26 of 480 controls (5.4%), yielding an OR of 4.99 (95% CI, 2.77–8.99; p < 0.001). This represents nearly a fivefold increase in risk, confirming breech presentation as the strongest predictor in our population.
Positive family history of DDH in first-degree relatives showed the second strongest association, present in 35 DDH cases (29.9%) versus 54 controls (11.3%), with an OR of 3.37 (95% CI 2.07–5.48, p < 0.001). This more-than-threefold increase in risk underscores the significant genetic component of DDH.
Improper swaddling practices emerged as a significant modifiable risk factor, present in 104 DDH cases (88.9%) compared with 373 controls (77.7%), yielding an OR of 2.29 (95% CI 1.24–4.25, p = 0.007). This finding holds particular public health importance, as swaddling is a culturally modifiable practice [Figure 2].
DISCUSSION
This comprehensive epidemiological investigation provides a detailed assessment of DDH in Najran province, revealing several important findings. We identified a DDH incidence of 16.29/1,000 hospital-recorded live births, substantially exceeding rates from other Saudi regions and the national average.[7,8,11,12] Three independent risk factors emerged as significant predictors: Breech presentation (OR = 4.99), positive family history (OR = 3.37), and improper swaddling practices (OR = 2.29). The substantial burden of late-presenting cases (31% after age 2 years) underscores urgent needs for enhanced screening and prevention strategies.
Our observed incidence of 16.29/1,000 births considerably exceeds rates reported from other major Saudi cities. Previous studies documented rates of 8.05/1,000 in Makkah,[8] 11.58/1,000 in Jeddah,[11] Al Jouf province demonstrated an incidence of 14.2/1,000 live births,[12] and a national average estimated at 10.46/1,000.[7] This positions Najran among the regions with the highest reported DDH frequencies in the studied Saudi regions, representing a 56% increase over the national average [Figure 3].
Internationally, our findings align more closely with populations known for elevated DDH rates. Recent meta-analyses have documented varying rates across different screening strategies and populations.[3,4] This suggests that Najran’s elevated rates may reflect a combination of genetic predisposition, cultural practices, and screening methods rather than a unique phenomenon.
Our findings represent an elevated but not unprecedented rate. DDH frequency varies dramatically worldwide, from 0.06/1,000 in African populations to 76.1/1,000 in Native Americans, placing our Najran rate of 16.29/1,000 within the documented range of ethnic and geographic variations.[13] Compared with other developing countries, our rate exceeds the reported rate in China (1.3/1,000).[14] However, it resembles rates in some South Asian populations, where cultural swaddling practices and genetic factors may contribute to elevated DDH prevalence.[15]
An intriguing finding in our study is the non-significant female predominance (53.0% vs. 47.0%, p = 0.097), which deviates from typical international patterns, in which female sex consistently emerges as a significant DDH risk factor. This finding aligns with recent meta-analysis data suggesting that female sex risk may be lower than previously reported (OR = 2.5).[16]
Breech presentation emerged as our strongest predictor (OR = 4.99), consistent with extensive international literature.[5] The mechanical hypothesis suggests that breech positioning restricts normal hip development through sustained hip extension and limited mobility.[2,11] Our finding reinforces the critical importance of mandatory screening for all infants with breech presentation at any time during pregnancy, regardless of delivery mode.[1]
The strong association with family history (OR = 3.37) confirms the significant genetic component of DDH.[17] Recent genetic studies have identified multiple susceptibility loci, though the inheritance pattern remains complex and likely polygenic.[17] This finding supports implementing family history-based screening protocols and genetic counseling for affected families.
Improper swaddling, a significant modifiable risk factor (OR = 2.29), presents a unique opportunity for primary prevention. With 79.9% of our cohort practicing inappropriate swaddling (88.9% in DDH cases), comprehensive community education programs are urgently needed. International experience demonstrates that educational campaigns can effectively reduce the frequency of DDH by modifying traditional swaddling practices.
The most compelling example comes from Japan, where a nationwide educational campaign against traditional tight swaddling reduced the frequency of DDH from 3.5% before 1975 to 0.2% after its implementation.[18,19] Similar success was documented in Mongolia, where traditional swaddling increased DDH risk by 5-fold compared to hip-healthy positioning.[20]
Based on these successes and our findings, we recommend the immediate implementation of comprehensive health education programs throughout Najran and Saudi Arabia. These initiatives resonate strongly with Saudi Arabia’s Vision 2030, particularly its commitment to elevating the quality of life and revolutionizing healthcare delivery through robust preventive care and superior health outcomes for all citizens.[21] Key components should include healthcare provider education, community outreach engaging traditional birth attendants and family elders, multimedia campaigns in Arabic, and integration into existing maternal health programs.[22-28]
The considerable clinical burden in Najran, with 28.6% of pediatric orthopedic visits attributed to DDH and 31% presenting as late cases, has significant economic implications. Recent analyses demonstrate that DDH screening costs $10–14/child, while untreated DDH creates 3.4 disability-adjusted life years lost per person.[29] In our hospital, operative intervention averages 15,000–22,000 Saudi Riyals ($4,000–$5,900 USD)/hip, with 47 procedures in 2023 totaling over 800,000 Saudi Riyals ($213,000 USD) in direct costs alone.
Combining health education with screening programs could be particularly cost-effective since improper swaddling is a modifiable risk factor and can be reduced through targeted education.[30,31]
Strengths and limitations
This study possesses several strengths. We included all births at the region’s primary maternity facility, minimizing selection bias. Our use of standardized Graf classification by trained radiologists ensures diagnostic consistency. The comprehensive risk factor assessment and rigorous statistical methodology, including multivariable analysis, strengthen our conclusions.
However, several limitations warrant consideration. The retrospective design relies on the accuracy and completeness of medical records. Our selective screening approach targeting high-risk infants may underestimate true population incidence, as some cases in low-risk infants might remain undetected.[2,3] The relatively wide CI for swaddling (OR = 1.24–4.25) suggests that this association requires confirmation in larger prospective studies. In addition, our single-center design may limit generalizability to other Saudi regions with different population characteristics or screening protocols. We also did not collect parental consanguinity data; given the relatively high rates of consanguineous marriage reported in Saudi and neighboring populations, this unmeasured factor may partly contribute to familial clustering and should be evaluated in future regional studies.
CONCLUSION
This study establishes Najran as having notably elevated DDH incidence (16.29/1,000 live births) compared to other Saudi regions, with breech presentation and family history representing strong predictive factors supporting mandatory targeted screening in these high-risk groups. The identification of improper swaddling as a modifiable risk factor opens opportunities for targeted preventive interventions through community education programs.
The considerable burden of late-presenting cases (31% after age 2 years) highlights critical gaps in current screening and referral systems. Addressing these gaps through enhanced primary care screening protocols, improved referral pathways, and community awareness programs could significantly reduce the need for complex surgical interventions and improve long-term outcomes for affected children.
Acknowledgment:
The authors gratefully acknowledge the medical and nursing staff for their support in facilitating patient screening, data collection, and statistical analysis during this study.
Recommendations:
Based on the findings of this study, we strongly recommend the implementation of a comprehensive, region-wide community education program focused on hip-healthy swaddling practices, targeting both parents and traditional caregivers. Furthermore, mandatory and standardized ultrasound screening protocols should be strictly enforced for all infants with a positive family history or a history of breech presentation. Finally, we recommend integrating these preventive strategies into the primary healthcare system to align with the goals of Saudi Vision 2030, ensuring early detection and minimizing the burden of late-presenting surgical cases.
Authors’ contributions:
AMA: Conceived and designed the study, conducted research, and collected and organized data, wrote the initial and final draft of the article. YIA and AOA: Contributed to the conception and design of the work and revised the manuscript critically for important intellectual content; HSA: Provided logistical support and contributed to data collection; KIA: Performed and interpreted the ultrasound examinations and contributed to data analysis; RSA: Contributed to data interpretation and provided clinical oversight. All authors have critically reviewed and approved the final draft and are responsible for the manuscript’s content and similarity index.
Ethical approval:
The research/study approved by the Institutional Review Board at Najran Health Cluster, New Najran General Hospital, number 2024-03 E, dated May 21, 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was use of AI-assisted technology. Large language models were used for writing assistance during manuscript preparation. The content was subsequently revised by the authors for scientific accuracy and integrity.
Conflicts of interest:
There are no conflicting relationships or activities.
Financial support and sponsorship: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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