{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T06:28:57Z","timestamp":1781764137797,"version":"3.54.5"},"reference-count":35,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T00:00:00Z","timestamp":1756771200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T00:00:00Z","timestamp":1756771200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Universit\u00e4tsklinikum Halle (Saale)"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Eur J Med Res"],"abstract":"<jats:title>Abstract<\/jats:title>\n          <jats:sec>\n            <jats:title>Purpose<\/jats:title>\n            <jats:p>Aseptic loosening remains a leading cause of revision in medial unicompartmental knee arthroplasty (UKA). This imaging study aimed to identify recurrent patterns of coronal alignment deviation in patients undergoing revision to total knee arthroplasty (TKA) to explore whether subtle malalignment may contribute to biomechanical failure.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>Imaging of patients who underwent revision surgery of a medial UKA to TKA for aseptic loosening of the tibial or femoral component was retrieved. Lower limb axes were evaluated using anteroposterior plain radiographs of the leg using the software MediCAD Knie 2D (mediCAD Hectec GmbH, Altdorf, Germany). The radiographic axes of revised patients were compared with established reference values, as defined by the MediCAD Knie 2D software and published literature, to identify common alignment patterns potentially associated with aseptic loosening.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Data from 62 patients were analysed. Before the revision surgery, the joint line convergence angle (JLCA, <jats:italic>P<\/jats:italic>\u2009=\u20090.002) and the anatomical\u2013mechanical angle (AMA, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001) were statistically significantly greater than the corresponding reference values. In contrast, the mechanical lateral distal femoral angle (mLDFA, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001), the mechanical and anatomical medial proximal tibial angle (mMPTA and aMPTA, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001), and the mechanical and anatomical lateral distal tibial angle (mLDTA and aLDTA, <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.0001) were significantly lower than reference. No statistically significant difference was found in the mechanical lateral proximal femoral angle (mLPFA, <jats:italic>P<\/jats:italic>\u2009=\u20090.9) or in the mechanical axis deviation (MAD, <jats:italic>P<\/jats:italic>\u2009=\u20090.5) when compared to normative data.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>Our cohort of patients revised from medial UKA to TKA for aseptic loosening frequently exhibited consistent deviations in lower limb alignment, particularly increased AMA and JLCA, and reduced mLDFA, mMPTA, and mLDTA. These subtle but recurrent patterns may alter load distribution across the medial compartment, contributing to implant micromotion and loosening. A detailed preoperative axis assessment may help identify patients at a higher biomechanical risk.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1186\/s40001-025-03112-2","type":"journal-article","created":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T02:44:59Z","timestamp":1756781099000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Coronal axis deviations in medial unicompartmental knee arthroplasty failures: an imaging study of patients revised for aseptic loosening"],"prefix":"10.1186","volume":"30","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7220-1221","authenticated-orcid":false,"given":"Filippo","family":"Migliorini","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola","family":"Maffulli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"K\u00e4mmer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulf Krister","family":"Hofmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00f6rg","family":"Eschweiler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Bell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,9,2]]},"reference":[{"issue":"7","key":"3112_CR1","doi-asserted-by":"publisher","first-page":"937","DOI":"10.1302\/0301-620X.85B7.14650","volume":"85","author":"CE Ackroyd","year":"2003","unstructured":"Ackroyd CE. Medial compartment arthroplasty of the knee. J Bone Joint Surg Br. 2003;85(7):937\u201342.","journal-title":"J Bone Joint Surg Br"},{"key":"3112_CR2","doi-asserted-by":"publisher","first-page":"558","DOI":"10.2174\/1874325001206010558","volume":"6","author":"UG Longo","year":"2012","unstructured":"Longo UG, Loppini M, Fumo C, Rizzello G, Khan WS, Maffulli N, et al. Osteoarthritis: new insights in animal models. Open Orthop J. 2012;6:558\u201363. https:\/\/doi.org\/10.2174\/1874325001206010558.","journal-title":"Open Orthop J"},{"issue":"1","key":"3112_CR3","doi-asserted-by":"publisher","first-page":"145","DOI":"10.2106\/00004623-198971010-00023","volume":"71","author":"SC Kozinn","year":"1989","unstructured":"Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am. 1989;71(1):145\u201350.","journal-title":"J Bone Joint Surg Am"},{"issue":"1","key":"3112_CR4","doi-asserted-by":"publisher","first-page":"545","DOI":"10.1186\/s13018-020-02079-6","volume":"15","author":"F Migliorini","year":"2020","unstructured":"Migliorini F, Driessen A, Oliva F, Maffulli GD, Tingart M, Maffulli N. Better outcomes and reduced failures for arthroplasty over osteotomy for advanced compartmental knee osteoarthritis in patients older than 50 years. J Orthop Surg Res. 2020;15(1):545. https:\/\/doi.org\/10.1186\/s13018-020-02079-6.","journal-title":"J Orthop Surg Res"},{"issue":"6","key":"3112_CR5","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1016\/j.knee.2009.04.006","volume":"16","author":"CA Willis-Owen","year":"2009","unstructured":"Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee. 2009;16(6):473\u20138. https:\/\/doi.org\/10.1016\/j.knee.2009.04.006.","journal-title":"Knee"},{"issue":"2","key":"3112_CR6","doi-asserted-by":"publisher","first-page":"301","DOI":"10.1007\/s00402-021-03827-x","volume":"142","author":"ML Tay","year":"2022","unstructured":"Tay ML, McGlashan SR, Monk AP, Young SW. Revision indications for medial unicompartmental knee arthroplasty: a systematic review. Arch Orthop Trauma Surg. 2022;142(2):301\u201314. https:\/\/doi.org\/10.1007\/s00402-021-03827-x.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"9952","key":"3112_CR7","doi-asserted-by":"publisher","first-page":"1437","DOI":"10.1016\/S0140-6736(14)60419-0","volume":"384","author":"AD Liddle","year":"2014","unstructured":"Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet. 2014;384(9952):1437\u201345. https:\/\/doi.org\/10.1016\/S0140-6736(14)60419-0.","journal-title":"Lancet"},{"key":"3112_CR8","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.l352","volume":"364","author":"HA Wilson","year":"2019","unstructured":"Wilson HA, Middleton R, Abram SGF, Smith S, Alvand A, Jackson WF, et al. Patient relevant outcomes of unicompartmental versus total knee replacement: systematic review and meta-analysis. BMJ. 2019;364:l352. https:\/\/doi.org\/10.1136\/bmj.l352.","journal-title":"BMJ"},{"issue":"4","key":"3112_CR9","doi-asserted-by":"publisher","first-page":"947","DOI":"10.1007\/s00590-018-2358-9","volume":"29","author":"F Migliorini","year":"2019","unstructured":"Migliorini F, Tingart M, Niewiera M, Rath B, Eschweiler J. Unicompartmental versus total knee arthroplasty for knee osteoarthritis. Eur J Orthop Surg Traumatol. 2019;29(4):947\u201355. https:\/\/doi.org\/10.1007\/s00590-018-2358-9.","journal-title":"Eur J Orthop Surg Traumatol"},{"issue":"3","key":"3112_CR10","doi-asserted-by":"publisher","first-page":"477","DOI":"10.1007\/s00402-020-03675-1","volume":"141","author":"SB Han","year":"2021","unstructured":"Han SB, Song SY, Shim JH, Shin YS. Risk of a complete exchange or failure in total knee arthroplasty and unicompartmental knee arthroplasty: a nationwide population-based cohort study from South Korea. Arch Orthop Trauma Surg. 2021;141(3):477\u201388. https:\/\/doi.org\/10.1007\/s00402-020-03675-1.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"6","key":"3112_CR11","doi-asserted-by":"publisher","first-page":"807","DOI":"10.1007\/s00402-020-03413-7","volume":"140","author":"J Schraknepper","year":"2020","unstructured":"Schraknepper J, Dimitriou D, Helmy N, Hasler J, Radzanowski S, Flury A. Influence of patient selection, component positioning and surgeon\u2019s caseload on the outcome of unicompartmental knee arthroplasty. Arch Orthop Trauma Surg. 2020;140(6):807\u201313. https:\/\/doi.org\/10.1007\/s00402-020-03413-7.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"4","key":"3112_CR12","doi-asserted-by":"publisher","first-page":"406","DOI":"10.1055\/s-0039-1696734","volume":"34","author":"TJ Shelton","year":"2021","unstructured":"Shelton TJ, Gill M, Athwal G, Howell SM, Hull ML. Revision of a medial UKA to a kinematic aligned TKA: comparison of operative complexity, postoperative alignment, and outcome scores to a primary TKA. J Knee Surg. 2021;34(4):406\u201314. https:\/\/doi.org\/10.1055\/s-0039-1696734.","journal-title":"J Knee Surg"},{"issue":"4","key":"3112_CR13","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","volume":"61","author":"E von Elm","year":"2008","unstructured":"von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344\u20139. https:\/\/doi.org\/10.1016\/j.jclinepi.2007.11.008.","journal-title":"J Clin Epidemiol"},{"key":"3112_CR14","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-642-59373-4","volume-title":"Hardware and Osteotomy Considerations. Principles of Deformity Correction","author":"D Paley","year":"2002","unstructured":"Paley D. Hardware and Osteotomy Considerations. Principles of Deformity Correction. Berlin, Heidelberg: Springer; 2002."},{"key":"3112_CR15","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-642-59373-4","volume-title":"Sagittal Plane Knee Considerations. Principles of Deformity Correction","author":"D Paley","year":"2002","unstructured":"Paley D. Sagittal Plane Knee Considerations. Principles of Deformity Correction. Berlin, Heidelberg: Springer; 2002."},{"issue":"11","key":"3112_CR16","doi-asserted-by":"publisher","first-page":"3480","DOI":"10.1007\/s00167-016-4141-y","volume":"25","author":"G Maderbacher","year":"2017","unstructured":"Maderbacher G, Keshmiri A, Schaumburger J, Zeman F, Birkenbach AM, Craiovan B, et al. What is the optimal valgus pre-set for intramedullary femoral alignment rods in total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc. 2017;25(11):3480\u20137. https:\/\/doi.org\/10.1007\/s00167-016-4141-y.","journal-title":"Knee Surg Sports Traumatol Arthrosc"},{"issue":"4","key":"3112_CR17","doi-asserted-by":"publisher","first-page":"451","DOI":"10.1007\/s00402-009-0999-1","volume":"130","author":"K Radtke","year":"2010","unstructured":"Radtke K, Becher C, Noll Y, Ostermeier S. Effect of limb rotation on radiographic alignment in total knee arthroplasties. Arch Orthop Trauma Surg. 2010;130(4):451\u20137. https:\/\/doi.org\/10.1007\/s00402-009-0999-1.","journal-title":"Arch Orthop Trauma Surg"},{"issue":"1","key":"3112_CR18","doi-asserted-by":"publisher","first-page":"108","DOI":"10.1055\/s-0039-1693668","volume":"34","author":"G Maderbacher","year":"2021","unstructured":"Maderbacher G, Matussek J, Greimel F, Grifka J, Schaumburger J, Baier C, et al. Lower limb malrotation is regularly present in long-leg radiographs resulting in significant measurement errors. J Knee Surg. 2021;34(1):108\u201314. https:\/\/doi.org\/10.1055\/s-0039-1693668.","journal-title":"J Knee Surg"},{"issue":"2S","key":"3112_CR19","doi-asserted-by":"publisher","first-page":"38","DOI":"10.23750\/abm.v88i2-S.6510","volume":"88","author":"A Fiocchi","year":"2017","unstructured":"Fiocchi A, Condello V, Madonna V, Bonomo M, Zorzi C. Medial vs lateral unicompartmental knee arthrroplasty: clinical results. Acta Biomed. 2017;88(2S):38\u201344. https:\/\/doi.org\/10.23750\/abm.v88i2-S.6510.","journal-title":"Acta Biomed"},{"issue":"5","key":"3112_CR20","doi-asserted-by":"publisher","first-page":"1016","DOI":"10.1016\/j.arth.2015.11.030","volume":"31","author":"JP van der List","year":"2016","unstructured":"van der List JP, Zuiderbaan HA, Pearle AD. Why do medial unicompartmental knee arthroplasties fail today? J Arthroplasty. 2016;31(5):1016\u201321. https:\/\/doi.org\/10.1016\/j.arth.2015.11.030.","journal-title":"J Arthroplasty"},{"key":"3112_CR21","unstructured":"Australian Orthopaedic Association. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip kasaArAOA, Adelaide. 2019."},{"key":"3112_CR22","unstructured":"National Joint Registry. National Joint Registry for England W, Northern Ireland and the Isle of Man: 16th Annual Report 2019. National Joint Registry, Hemel Hempstead. 2019."},{"key":"3112_CR23","unstructured":"New Zealand Orthopaedic Association. The New Zealand Joint Registry twenty year report January 1999 to December 2018. New Zealand Orthopaedic Association C. 2018."},{"key":"3112_CR24","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1097\/00003086-200211000-00011","volume":"404","author":"RH Emerson Jr","year":"2002","unstructured":"Emerson RH Jr, Hansborough T, Reitman RD, Rosenfeldt W, Higgins LL. Comparison of a mobile with a fixed-bearing unicompartmental knee implant. Clin Orthop Relat Res. 2002;404:62\u201370. https:\/\/doi.org\/10.1097\/00003086-200211000-00011.","journal-title":"Clin Orthop Relat Res"},{"issue":"8","key":"3112_CR25","doi-asserted-by":"publisher","first-page":"599","DOI":"10.1016\/j.otsr.2009.10.006","volume":"95","author":"TO Smith","year":"2009","unstructured":"Smith TO, Hing CB, Davies L, Donell ST. Fixed versus mobile bearing unicompartmental knee replacement: a meta-analysis. Orthop Traumatol Surg Res. 2009;95(8):599\u2013605. https:\/\/doi.org\/10.1016\/j.otsr.2009.10.006.","journal-title":"Orthop Traumatol Surg Res"},{"key":"3112_CR26","doi-asserted-by":"publisher","DOI":"10.3390\/ma14247554","author":"MI Ammarullah","year":"2021","unstructured":"Ammarullah MI, Afif IY, Maula MI, Winarni TI, Tauviqirrahman M, Akbar I, et al. Tresca stress simulation of metal-on-metal total hip arthroplasty during normal walking activity. Materials. 2021. https:\/\/doi.org\/10.3390\/ma14247554.","journal-title":"Materials"},{"key":"3112_CR27","doi-asserted-by":"publisher","DOI":"10.3390\/jfb12020038","author":"J Jamari","year":"2021","unstructured":"Jamari J, Ammarullah MI, Saad APM, Syahrom A, Uddin M, van der Heide E, et al. The effect of bottom profile dimples on the femoral head on wear in metal-on-metal total hip arthroplasty. J Funct Biomater. 2021. https:\/\/doi.org\/10.3390\/jfb12020038.","journal-title":"J Funct Biomater"},{"issue":"3","key":"3112_CR28","doi-asserted-by":"publisher","first-page":"141","DOI":"10.5792\/ksrr.2015.27.3.141","volume":"27","author":"YB Ko","year":"2015","unstructured":"Ko YB, Gujarathi MR, Oh KJ. Outcome of unicompartmental knee arthroplasty: a systematic review of comparative studies between fixed and mobile bearings focusing on complications. Knee Surg Relat Res. 2015;27(3):141\u20138. https:\/\/doi.org\/10.5792\/ksrr.2015.27.3.141.","journal-title":"Knee Surg Relat Res"},{"issue":"5","key":"3112_CR29","doi-asserted-by":"publisher","first-page":"379","DOI":"10.1016\/j.knee.2004.06.006","volume":"11","author":"RE Gleeson","year":"2004","unstructured":"Gleeson RE, Evans R, Ackroyd CE, Webb J, Newman JH. Fixed or mobile bearing unicompartmental knee replacement? A comparative cohort study. Knee. 2004;11(5):379\u201384. https:\/\/doi.org\/10.1016\/j.knee.2004.06.006.","journal-title":"Knee"},{"key":"3112_CR30","doi-asserted-by":"publisher","first-page":"137","DOI":"10.1097\/01.blo.0000229358.19867.60","volume":"452","author":"JN Argenson","year":"2006","unstructured":"Argenson JN, Parratte S. The unicompartmental knee: design and technical considerations in minimizing wear. Clin Orthop Relat Res. 2006;452:137\u201342. https:\/\/doi.org\/10.1097\/01.blo.0000229358.19867.60.","journal-title":"Clin Orthop Relat Res"},{"issue":"6 Suppl","key":"3112_CR31","doi-asserted-by":"publisher","first-page":"108","DOI":"10.1016\/j.arth.2010.05.004","volume":"25","author":"TT Manson","year":"2010","unstructured":"Manson TT, Kelly NH, Lipman JD, Wright TM, Westrich GH. Unicondylar knee retrieval analysis. J Arthroplasty. 2010;25(6 Suppl):108\u201311. https:\/\/doi.org\/10.1016\/j.arth.2010.05.004.","journal-title":"J Arthroplasty"},{"key":"3112_CR32","doi-asserted-by":"publisher","DOI":"10.1155\/2013\/245915","volume":"2013","author":"B Akan","year":"2013","unstructured":"Akan B, Karaguven D, Guclu B, Yildirim T, Kaya A, Armangil M, et al. Cemented versus Uncemented Oxford Unicompartmental Knee Arthroplasty: Is there a difference? Adv Orthop. 2013;2013:245915. https:\/\/doi.org\/10.1155\/2013\/245915.","journal-title":"Adv Orthop"},{"issue":"2","key":"3112_CR33","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1016\/j.artd.2020.02.016","volume":"6","author":"R Kagan","year":"2020","unstructured":"Kagan R, Anderson MB, Bailey T, Hofmann AA, Pelt CE. Ten-year survivorship, patient-reported outcomes, and satisfaction of a fixed-bearing unicompartmental knee arthroplasty. Arthroplast Today. 2020;6(2):267\u201373. https:\/\/doi.org\/10.1016\/j.artd.2020.02.016.","journal-title":"Arthroplast Today"},{"issue":"2","key":"3112_CR34","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1302\/0301-620X.95B2.30411","volume":"95-B","author":"AD Liddle","year":"2013","unstructured":"Liddle AD, Pandit H, O\u2019Brien S, Doran E, Penny ID, Hooper GJ, et al. Cementless fixation in Oxford unicompartmental knee replacement: a multicentre study of 1000 knees. Bone Joint J. 2013;95-B(2):181\u20137. https:\/\/doi.org\/10.1302\/0301-620X.95B2.30411.","journal-title":"Bone Joint J"},{"issue":"20","key":"3112_CR35","doi-asserted-by":"publisher","first-page":"1777","DOI":"10.2106\/JBJS.19.01443","volume":"102","author":"V Gupta","year":"2020","unstructured":"Gupta V, Kejriwal R, Frampton C. Revision following cemented and uncemented Oxford-III primary medial unicompartmental knee replacements: a 19-year analysis from the New Zealand joint registry. J Bone Joint Surg Am. 2020;102(20):1777\u201383. https:\/\/doi.org\/10.2106\/JBJS.19.01443.","journal-title":"J Bone Joint Surg Am"}],"container-title":["European Journal of Medical Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40001-025-03112-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s40001-025-03112-2\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40001-025-03112-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,10]],"date-time":"2025-09-10T03:32:54Z","timestamp":1757475174000},"score":1,"resource":{"primary":{"URL":"https:\/\/eurjmedres.biomedcentral.com\/articles\/10.1186\/s40001-025-03112-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,2]]},"references-count":35,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["3112"],"URL":"https:\/\/doi.org\/10.1186\/s40001-025-03112-2","relation":{},"ISSN":["2047-783X"],"issn-type":[{"value":"2047-783X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,2]]},"assertion":[{"value":"22 April 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 July 2025","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 August 2025","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"2 September 2025","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was approved by the Ethics Committee of the Medical Faculty of the RWTH University of Aachen (project ID EK 438-20).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Professor Migliorini is Deputy Editor of the European Journal of Medical Research.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"832"}}