Objective:To establish a new classification system for distal clavicle fracture and evaluate its clinical effectiveness.Methods:A retrospective case series study was conducted to analyze the clinical data of 101 patients with distal clavicle fracture admitted to First Affiliated Hospital of Nanjing Medical University from January 2015 to March 2022, including 57 males and 44 females, aged 19-86 years [(53.8±14.0)years]. Before treatment, patients were routinely subjected to bilateral anteroposterior radiography of the shoulder joints to measure the length of the fractured fragments, coracoclavicular distance, and acromioclavicular distance. According to the correlation between the location of the fracture line and the insertion of the coracoclavicular ligament, distal clavicle fracture was divided into three types: type I, with the fracture line lateral to the coracoclavicular ligament region; type II, with the fracture line in the coracoclavicular ligament region; type III, with the fracture line medial to the coracoclavicular ligament region. According to the injury severity of the coracoclavicular ligament and acromioclavicular ligament, type I was further subdivided into type IA, IB, IC and ID, and type II fracture was further subdivided into type IIA, IIB, IIC, IID and IIE. All the 101 patients were classified and randomly reclassified at an interval of 3 months by 10 senior and 10 junior shoulder surgeons according to the new classification method. Kappa coefficients were used to evaluate the inter- and intra-observer consistency of the new classification. Fifty-two patients with stable fracture (types IA, IB, IIC, and IID) were treated non-surgically, while 49 patients with unstable fracture (types IC, ID, IIA, IIB, IIE, and III) were treated surgically, including 26 patients with anatomic coracoclavicular ligament reconstruction, 9 with locking plate fixation, 8 with clavicle hook plate fixation, 4 with anatomic coracoclavicular ligament reconstruction combined with locking plate fixation, and 2 with anatomic coracoclavicular ligament reconstruction combined with tension screw fixation. The patients were assessed using the visual analogue scale (VAS) and Constant-Murley shoulder score before treatment and at 3, 6, 12, and 18 months after treatment. The coracoclavicular distance and acromioclavicular distance on the anteroposterior radiographs of the healthy and affected shoulder joints were measured at 3, 6, 12, and 18 months after treatment, and fracture healing time and complications were observed.Results:The length of the fractured fragments was 12.9 (9.7, 17.6)mm in patients with type I fracture, 24.7 (21.8, 27.8)mm in patients with type II fracture, and 43.6 (41.2, 46.9)mm in patients with type III fracture ( P<0.01). There were no significant differences in the coracoclavicular distance and acromioclavicular distance of the affected and healthy shoulders among the patients with types IA, IB, IIC, IID, and III fracture ( P>0.05); For the patients with types IC, IIA, IIB and IIE fracture, the coracoclavicular distance of the affected shoulder was significantly increased compared with that of the healthy shoulder ( P<0.01), while there was no significant difference in the acromioclavicular distance of the affected and healthy shoulders ( P>0.05). Both of the inter- and intra-observer consistency of the new classification was good. The inter- and intra-observer Kappa values were 0.69 and 0.71 respectively among the senior shoulder surgeons, and 0.61 and 0.64 respectively among the junior shoulder surgeons. All the patients were followed up for 18-104 months [28(23, 32)months]. At 3, 6, 12 and 18 months after treatment, the VAS scores of non-surgical patients were 3(2, 3)points, 2(1, 2)points, 1(0, 1)points and 0(0, 1)points respectively, significantly decreased compared with 6(5, 6)points before treatment ( P<0.01); the VAS scores of surgical patients were 3(2, 3)points, 2(1, 2)points, 1(1, 1)points and 0(0, 1)points respectively, significantly decreased compared with 6(5, 7)points before treatment ( P<0.01); the Constant-Murley shoulder scores of non-surgical patients were (76.6±5.3)points, (84.3±5.0)points, (88.4±4.0)points and (91.9±3.8)points respectively, significantly higher than (42.7±5.2)points before treatment ( P<0.01); the Constant-Murley shoulder scores of surgical patients were (77.4±4.6)points, (84.4±4.7)points, (87.6±3.7)points and (91.7±4.0)points respectively, significantly higher than (42.8±5.3)points before treatment ( P<0.01). At 3, 6, 12 and 18 months after treatment, the coracoclavicular distance of the affected shoulder in non-surgical patients was not significantly different from that before treatment ( P>0.05), while the acromioclavicular distance of the affected shoulder in surgical patients was significantly reduced compared with that before treatment ( P<0.01). There were no significant differences in the coracoclavicular distance of the healthy shoulder or bilateral acromioclavicular distance in non-surgical and surgical patients at 3, 6, 12, and 18 months after treatment compared with those before treatment ( P>0.05). Fractures were healed within 12 months after treatment in all the patients, without dislocation or subluxation of the acromioclavicular joint, internal fixation failure or internal fixator breakage. Eight patients treated with clavicular hook plate fixation had shoulder pain associated with limited mobility after operation, and all underwent a second operation to remove the clavicular hook plate at 12 months after operation. Conclusions:The new classification system for distal clavicle fracture is established, which comprehensively considers the position of the fracture line, injury of the coracoclavicular and acromioclavicular ligaments, and fracture stability. The new classification system exhibits good inter- and intra- observer consistency, and the effectiveness of its preliminary clinical application is satisfactory.

Objective:To establish a decision tree model of pediatric complicated appendicitis (CA) based on Pediatric Appendicitis Score (PAS) combined with inflammatory indicators, and to evaluate its clinical application efficacy in pediatrics.Methods:The clinical data of 544 children diagnosed with appendicitis in Children′s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2018 to December 2021 was retrospectively analyzed. According to postoperative pathology, the children were divided into uncomplicated appendicitis group and CA group. The independent risk factors of CA were screened by univariate and multivariate logistic regression analysis, and these parameters were included to establish the decision tree model. The accuracy of the decision tree model was verified by receiver operating characteristic (ROC) curve.Results:Binary logistic regression analysis indicated that the PAS, C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) were identified as independent risk factors for complicated appendicitis in children (all P<0.05). PAS, CRP and NLR were included as covariables to construct the decision tree model and binary logistic regression model for predicting CA. The decision tree demonstrated an overall accuracy of 79.2% with a sensitivity of 86.7% and specificity of 71.9%, and achieved an area under curve (AUC) of 0.821(95% CI: 0.786-0.857). The binary logistic regression model had a sensitivity of 79.6% and specificity of 69.1%, with an overall accuracy of 75.1% and achieved an AUC of 0.808(95% CI: 0.770-0.845). Conclusions:The decision tree model based on PAS score combined with CRP, NLR is a simple, intuitive and effective tool , which can provide pediatric emergency physicians a reliable basis for diagnosis of pediatric CA.

Objective:To compare the clinical efficacy of anatomical reconstruction of coracoclavicular ligament at the original insertion point and clavicular hook plate fixation in the treatment of acromioclavicular joint dislocation.Methods:Retrospective analysis was made on the data of 67 patients with acromioclavicular joint dislocation who received surgical treatment in the Department of Orthopaedics of the First Affiliated Hospital of Nanjing Medical University from June 2015 to January 2021. According to the surgical method, they were divided into reconstruction group (using the technique of anatomical reconstruction of coracoclavicular ligament at the original insertion point) and hook plate group (using the clavicular hook plate). There were 37 cases in the reconstruction group, including 26 males and 11 females, aged 47.2±9.6 years (range, 18-65 years), 13 cases on the left and 24 cases on the right. Among the 37 patients, 8 were sports injuries, 14 were falls, 11 were traffic accidents, and 4 were external force injuries. The average time from injury to surgery was 8.3±2.3 days. There were 30 cases in the hook plate group, including 24 males and 6 females, aged 47.4±9.7 years (range, 18-67 years), 12 cases on the left and 18 cases on the right. Among the 30 patients, 7 were sports injuries, 11 were falls, 9 were traffic accidents, and 3 were external force injuries. The average time from injury to surgery was 7.9±2.6 days. The surgical time, incision length, intraoperative bleeding, hospital stay, postoperative coracoclavicular separation ratio, and postoperative complications were compared between the two groups. Constant-Murley score and visual analog scale (VAS) were used to assess the shoulder joint function and pain degree of patients.Results:Both groups of patients were followed up, with a follow-up time of 12.3±0.4 months for the reconstruction group and 12.2±0.5 months for the hook plate group. The operation time (105.8±10.0 min), incision length [12.0 (11.0, 13.0) cm] and hospitalization time (6.8±2.1 d) in the reconstruction group were longer than those in the hook plate group [48.3±4.9 min, 10.0 (10.0, 11.0) cm, and 5.5±2.7 d], while the intraoperative blood loss (75.1±3.9 ml) was less than that in the hook plate group (90.3±6.3 ml), the differences were statistically significant ( P<0.05). The VAS [4.0 (3.0, 5.0), 3.0 (3.0, 3.0), 2.0 (1.0, 2.0) points] and Constant-Murley score (65.4±4.5, 84.9±2.5, 90.1±2.5 points) of the reconstruction group at 3 days, 3 months, and 12 months after surgery were better than those of the hook plate group [5.0 (4.0, 5.0), 4.0 (4.0, 4.0), 3.0 (3.0, 4.0) and 56.9±3.5, 79.6±4.0, 86.8±2.4 points], the difference was statistically significant ( P<0.05). At the last follow-up, there was a statistically significant difference in the separation ratio of coracoclavicular distance between the reconstruction group (0.12±0.08) and the hook plate group 0.22±0.15 ( t=3.25, P=0.002). There was no significant difference ( Z=-0.52, P=0.605) in the separation ratio of acromioclavicular distance [0.16 (0.05, 0.25) and 0.16 (0.04, 0.40)]. In the hook plate group, 6 cases had shoulder joint foreign body sensation and 2 cases had acromioclavicular joint redislocation (both Rockwood type III). Because the shoulder joint function did not affect their daily life, neither patient underwent secondary surgery. And no case of acromioclavicular joint redislocation occurred in the reconstruction group. Conclusion:Compared with the clavicular hook plate fixation, anatomic reconstruction of coracoclavicular ligament at the original insertion point in the treatment of acromioclavicular joint dislocation can reduce the pain of the shoulder joint earlier, which has the characteristics of small trauma, good effect, and reduces the steps of internal fixation removal, and has good clinical curative effect.

Objective:To retrospectively analyze the independent risk factors of complicated appendicitis(CA)in children under five years old and establish a clinical prediction model, and to evaluate the clinical application of this model.Methods:A retrospective analysis was performed on children under five years old who underwent appendectomy at Children′s Hospital of Shanghai Jiao Tong University School of Medicine from January 2018 to December 2021.The children were divided into CA group and uncomplicated appendicitis group according to whether there was sign of perforation or gangrene in appendiceal tissue after operation.The differences in clinical features and preoperative laboratory test results between two groups were compared.The independent risk factors of CA were identified and a clinical prediction model was established.The clinical prediction model was verified by receiver operating characteristic curve.Results:A total of 140 children were enrolled in this study, including 84 cases in the CA group and 56 cases in uncomplicated appendicitis group.Univariate and binary Logistic regression analysis showed that the duration of symptoms>23.5 h( OR=6.650, 95% CI 2.469-17.912, P<0.05), abdominal muscle tension( OR=3.082, 95% CI 1.190-7.979, P<0.05) and C-reactive protein>41 mg/L ( OR=3.287, 95% CI 1.274-8.480, P<0.05) were independent risk factors for CA( P<0.05). The clinical prediction model of CA was constructed by the above mentioned three independent risk factors.The area under the receiver operating characteristic curve of the clinical prediction model was 0.881(95% CI 0.825-0.936), the sensitivity was 77.4%, the specificity was 87.5%, the positive predictive value was 91.3% and the negative predictive value was 70.0%. Conclusion:Acute appendicitis in children under five years old is more likely to progress to CA if the duration of symptoms>23.5 h, the level of C-reactive protein is increased, and the abdominal muscle tension is accompanied.The clinical prediction model of CA constructed by common clinical information in pediatric clinics has good prediction efficiency, which provides a simple and feasible reference method for clinicians to distinguish CA from uncomplicated appendicitis.

Objective:To provide anatomic data of the coracoclavicular (CC) ligament attachment regions in Chinese population for anatomic reconstruction of CC ligament to treat acromioclavicular dislocation.Methods:The CC ligaments were first dissected layer by layer out of the bilateral acromioclavicular joint specimens taken from 87 adult cadavers. The CC width and thickness on the attachments of the clavicle and the coracoid process were measured by an electronic digital caliper. The conoid ligament and trapezoid ligament were mapped on the surface of the clavicle and the coracoid process by transecting the ligaments close to their insertions. The distances from the ligament footprint center to the lateral, anterior and posterior margins of the clavicle were measured. The distances from the ligament footprint center to the tip, medial and lateral margin borders of the coracoid process were measured.Results:The distances from the lateral edge of the clavicle to the footprint centers of the conoid and trapezoid ligaments were (35.7 ± 3.4) mm and (21.8 ± 2.7) mm, and the ratio of the distance divided by the clavicular length was 25.5% ± 0.9% and 15.6% ± 1.1%, respectively. The distances from the tip of coracoid to the footprint centers of the conoid and trapezoid ligaments were (35.1 ± 3.2) mm and (29.7 ± 2.9) mm, and the ratio of the distances divided by the coracoidal length was 86.7% ± 1.9% and 73.3% ± 2.1%, respectively.Conclusion:Although the absolute position of the CC ligament attaching to the clavicle and the coracoid process varies greatly among Chinese individuals, the ratio of its relative position to the length and width of the clavicle and the coracoid process is a relatively stable set of data.

Objective : To investigate the effects of gestational diabetes mellitus (GDM) on birth outcome and umbilical artery (UA) blood flow parameters in the third trimester, and to analyze the role of UA blood flow parameters in GDM and birth outcome. Methods : Based on the birth cohort from Wuhu , Anhui , China , 189 pregnant women with GDM were collected as the case group. The non⁃GDM pregnant women were matched 1 ∶ 1 according to age and pre⁃pregnancy body mass index , and 189 normal pregnant women were selected as the control group. Pregnant women with GDM were divided into poorly controlled group and well controlled group according to fasting blood glucose in the third trimester. The UA blood flow parameters and fetal birth outcomes in the third trimester were tracked. Results : Compared with the control group , UA parameters in poorly controlled and well controlled groups significantly increased (F = 6. 63 , P < 0. 05 ; F = 4. 43 , P < 0. 05 ; F = 5. 57 , P < 0. 05) . Poor glycemic control of GDM was associated with increased birth weight and risk of larger than gestational age. The multi⁃factor linear regression model showed that the Z score of the peak systolic velocity/end diastolic velocity (S/D) in the poorly controlled group was negatively correlated with birth weight (β = - 209. 78 , 95% CI: - 301. 48 - 118. 07) . S/D index Z score mediated the relationship between poor blood glucose control and birth weight. The intermediate effect value was - 58. 41 (95% CI: - 106. 40 ~ - 19. 65) , accounting for 25. 98% of the total effect. Conclusion Poor glycemic control in GDM is a risk factor for fetal weight gain , and UA function plays a partial mediating role in influencing neonatal birth weight. GDM pregnant women should strictly control blood glucose level to better protect maternal and infant health.

Objective:To compare the clinical efficacy between coracoclavicular ligament anatomical reconstruction and clavicular hook plate in the treatment of Neer Ⅱb distal clavicular fractures.Methods:A total of 64 patients with Neer Ⅱb clavicular fracture were treated at Department of Orthopaedics, The First Affiliated Hospital to Nanjing Medical University from September 2016 to June 2019. They were 35 males and 29 females, aged from 19 to 68 years (average, 50.7 years). They were assigned into 2 groups according to their operative methods: a reconstruction group of 30 cases undergoing coracoclavicular ligament anatomical reconstruction and a hook plate group of 34 cases undergoing fixation with a clavicular hook plate. The 2 groups were compared in terms of hospital stay, operation time, intraoperative blood loss, surgical incision length, postoperative coracoclavicular separation ratio, visual analogue scale (VAS) and Constant-Murley shoulder scores at 3, 6 and 12 months after operation, and postoperative complications.Results:There was no significant difference in general data between the 2 groups, showing comparability between groups ( P>0.05). Operations were completed uneventfully and surgical incisions healed by primary intention in both groups after operation. All the patients were followed up for 12 to 24 months (average, 14.6 months). The operation time [(74.6±22.0) min] and incision length [(10.4±0.4) cm] were significantly shorter but the intraoperative blood loss [(90.2±5.3) mL] was significantly less in the hook plate group than those in the reconstruction group [(95.6±20.8) min, (12.4±0.9) cm and (74.2±3.5) mL] ( P<0.05). There was no significant difference in hospital stay between the 2 groups ( P>0.05). At 3, 6 and 12 months after operation, the VAS scores (1.8±0.5, 1.2±0.3 and 1.1±0.2) and Constant-Murley scores (85.2±4.6, 91.1±2.6 and 92.1±2.2) in the reconstruction group were significantly better than those in the hook plate group (3.2±1.0, 1.6±0.3 and 1.5±0.3; 73.6±2.9, 85.9±4.6 and 87.0±3.1) ( P<0.05). At the last follow-up, the postoperative coracoclavicular separation ratio (elevation) in the hook plate group (0.20±0.16) was significantly greater than that in the reconstruction group (0.10±0.05) ( P<0.05). Conclusion:In the treatment of Neer ⅡB distal clavicular fractures, coracoclavicular ligament anatomical reconstruction may lead to better fixation and fewer postoperative complications than a clavicular hook plate, demonstrating fine clinical efficacy.

Objective:To conduct an MRI observation on the incidences of ligamentous injuries and fracture morphology in Schatzker type Ⅳ tibial plateau fracture (TPF) and investigate their influence on knee stability.Methods:A retrospective analysis was conducted of the 30 patients with Schatzker type Ⅳ TPF who had undergone surgery at Department of Orthopaedic Trauma, Jiangsu Provincial People's Hospital from January 2010 to December 2019 and whose preoperative X-ray, CT and MRI were available. They were 18 males and 12 females, aged from 22 to 75 years (mean, 45.4 years). They were divided into a dislocation-free group and a dislocation group according to the absence or presence of knee dislocation on their anteroposterior X-ray films. The fracture morphology was assessed on CT according to the modified three-column classification. The incidences of ligamentous injuries [involving anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), posterolateral complex (PLC) and anterolateral ligament (ALL)] were investigated on MRI. The 2 groups were compared in fracture morphology and incidences of ligamentous injuries. Multiple linear regression (MLR) analysis was used to identify the main factor contributing to preoperative knee dislocation.Results:The dislocation group had 12 patients and the dislocation-free group 18. The fracture involving medial+posteromedial+posterolateral columns was found in 66.7% of the patients (20 cases), and accounted for 83.3% (10 cases) in the dislocation group. The incidence was 96.7% (29 cases) for ACL injury, 43.3% (13 cases) for PCL injury, 70.0% (21 cases) for MCL injury, 90% (27 cases) for PLC injury, 73.3% (22 cases) for ALL injury and 90% (27 cases) for the multiple-ligament disruption. There was a significant difference in the posterolateral column injury between the dislocation-free group [55.6% (10/18)] and the dislocation group [91.7% (11/12)] ( P < 0.05), but there were no significant differences between the 2 group in the injury to any other single ligament or multiple ligaments ( P>0.05). The MLR analysis confirmed that the posterolateral column injury was a risk factor for coronary plane dislocation in Schatzker type Ⅳ TPF( P<0.05). Conclusions:In Schatzker type Ⅳ TPF, the incidences of ligamentous injuries are very high but the fracture of posterolateral column may be the main cause for preoperative knee dislocation in some patients.

Objective To investigate the therapeutic efficacy of truly anatomic reconstruction of the coracoclavicular ligament with two Endobutton devices for acute acromioclavicular joint dislocation of Rock-wood type Ⅴ.Methods From May 2013 to October 2015,25 patients with acromioclavicular joint dislocation of Rockwood type Ⅴ underwent truly anatomic reconstruction of the coracoclavicular ligament using two Endobutton devices.They were 15 men and 10 women,from 18 to 67 years of age (mean,43.0 years).All the dislocations were unilateral,involving 14 left and 11 right sides.The visual analog scale (VAS) and the Constant scoring were used at 3,6,12,18 and 24 months postoperatively for assessments of pain and shoulder function.The coracoclavicular distances on the healthy and affected sides were measured on their anteroposterior X-ray films of bilateral shoulders.Results The 25 patients were followed up for 24 to 48 months (mean,34.0 months).Their VAS score were decreased significantly from preoperative 5.0 ± 0.9 points to 0 ±0.5 points at 24 months after surgery,their Constant score increased significantly from preoperative 45.0 ± 5.6 points to 95.0 ± 2.9 points at 24 months after surgery,and their coracoclavicular distances at the affected side restored significantly from preoperative 23.0± 5.4 mm to 8.0 ± 0.9 mm at 24 months after surgery (all P ＜ 0.05).There was no significant difference in the coracoclavicular distance between the affected and the healthy sides at 24 months after surgery (P ＞ 0.05).No serious complications like acromioclavicular joint re-dislocation or clavicular condylar fracture occurred in any patient.Conclusions Truly anatomic double Endobutton reconstruction of the coracoclavicular ligament is a safe,reliable and creative surgical technique that may yield good to excellent clinical and radiological outcomes in the treatment of acute acromioclavicular joint dislocation of Rockwood type Ⅴ.

Objective: To study serum zinc level in pregnancy and umbilical cord blood and their association with newborn birth weight. Methods: Pregnant women accepting obstetric examination in Ma'anshan Maternal and Child Care Center were recruited from May 2013 to September 2014. The follow up was conducted during their first, second and third trimesters of pregnancy and the self-designed questionnaire was used to collect information of social and demographic characteristics. Blood samples in the first, second pregnancy period and umbilical cord blood samples were collected and serum concentrations of zinc were assayed. 3 239 mother-infant entered the final analysis. We divided serum zinc level into low (<P₂₅), medium (P₂₅-P₇₅) and high (>P₇₅) groups according to their exposure concentrations at each trimesters. Non-conditional multivariate logistic regression model was conducted to evaluate the association between serum zinc level in first, second trimesters of pregnancy and umbilical cord blood with small for gestational age (SGA) and large for gestational age (LGA). Results: Serum zinc level in P₅₀ (P₂₅-P₇₅) during the first, second trimesters and cord blood were 1 016.18 (907.09-1 145.60), 813.36 (732.47-897.89) and 903.44 (808.71-1 015.64) μg/L, respectively. The prevalence of zinc deficiency during the first, second trimesters and cord blood were 1.5% (44/2 957), 15.9% (492/3 087) and 6.5% (176/2 707), respectively. The prevalence of total SGA and LGA were 9.7% (313/3 239) and 16.5% (536/3 239), respectively. Compared to high-level serum zinc group, the risk of SGA (OR (95%CI) in low-level serum zinc group during first trimesters was 1.51 (1.05-2.19)). Serum zinc level among second pregnancy period and umbilical cord blood had no statistically significant effect on SGA and LGA (both P values >0.05). Conclusion Zinc nutritional status of pregnant women in Ma'anshan city was at a good level. The low serum zinc level in first trimester increased the risk of SGA.