Associations between physical fitness and idiopathic scoliosis in Chinese adolescents: A case-control study

Abstract

Objective

Adolescent idiopathic scoliosis (AIS) screening and physical fitness testing are important components of health management for Chinese adolescents. This study aimed to evaluate the independent associations between prior-year physical fitness scores and AIS, with sex-stratified analysis.

Methods

This case-control study was conducted in Jincheng, Shanxi Province, China, from March to October 2025, including 401 cases of AIS aged 13–18 years and 820 healthy controls matched to the cases by age and sex. Multiple logistic regression was used to evaluate the independent associations between prior-year physical fitness and AIS.

Results

In the male subgroup, for each 1 kg/m² increase in BMI, the odds of AIS decrease by 8.2%; for each 10-point increase in vital capacity, 50 m run, and sit-and-reach score, the odds of AIS decrease by 14.4%, 16.3%, and 23.8%, respectively. In the female subgroup, for each 1 kg/m² increase in BMI, the odds of AIS decrease by 9.2%; for each 10-point increase in vital capacity and standing long jump score, the odds of AIS decrease by 12.7% and 9.6%, respectively.

Conclusions

This study suggests incorporating physical fitness monitoring into the AIS screening and preventive strategies.

Highlights

• •Prior-year physical fitness was associated with adolescent idiopathic scoliosis.
• •Males relate to body mass index, vital capacity, sit-and-reach, and 50-m run.
• •Females relate to body mass index, vital capacity, and the standing long jump.
• •Findings suggest incorporating physical fitness monitoring into scoliosis screening.

1. Introduction

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity involving the coronal, sagittal, and transverse planes, with a global prevalence of 1–3% (Weinstein et al., 2008). It is the most common type of scoliosis in adolescents, of unknown etiology, and is typically diagnosed in the absence of congenital, neuromuscular, or syndromic causes (Kuznia et al., 2020; Weinstein et al., 2008). In China, AIS has become another serious health problem for adolescents after myopia and obesity. Epidemiological studies from different regions of China indicate that the prevalence of AIS ranges from approximately 0.22% to 5.14%, and is higher in girls than in boys, with significant regional and gender variation (Hengwei et al., 2016; Zheng et al., 2016; Zhou et al., 2022). The severity of AIS is measured using the Cobb angle, which refers to the maximum angle between the two most tilted vertebrae in the spine on a standing full-spine coronal radiograph (Negrini et al., 2018). Evidence suggests that in the early stages, most cases are mild (Cobb angle 10–19°), and nearly two-thirds of patients experience progression of the Cobb angle before skeletal maturity, with the most rapid progression occurring during the pubertal growth spurt (Dunn et al., 2018; Negrini et al., 2018). AIS patients not only endure severe physical and mental suffering but also impose a heavy financial burden on their families (Zhao et al., 2025). Therefore, identifying high-risk populations and developing targeted prevention strategies are essential for the health management of AIS.

Physical fitness refers to the ability to maintain health and perform physical activities, including health- and skill-related physical fitness (Caspersen et al., 1985; Haverkamp et al., 2022). Health-related physical fitness typically includes cardiorespiratory endurance, muscular strength, muscular endurance, flexibility, and body composition, and skill-related physical fitness includes agility, balance, coordination, reaction time, power, and speed (Caspersen et al., 1985). Previous studies have shown that adolescents with AIS exhibit significant differences in physical fitness compared with healthy peers, most commonly impaired pulmonary function, paraspinal muscle dysfunction, reduced lumbar mobility, abnormal posture, and balance (Chan et al., 2024; Kao et al., 2014; Lin et al., 2022; Mallau et al., 2007; Tarrant et al., 2018). Furthermore, studies have shown that exercise therapy aimed at improving physical fitness can reduce the Cobb angle, enhance quality of life, and even promote mental health, and is widely regarded as an economical, effective, safe, and reliable conservative treatment method (Wang et al., 2024; Zhou et al., 2021). Physical fitness can not only reflect current physical condition, but can also predict future health status (Huang et al., 2023). Therefore, as a measurable and modifiable indicator, physical fitness has the potential to support early risk identification and targeted intervention in AIS.

China is one of the countries that places a strong emphasis on the health of children and adolescents. It has incorporated AIS screening and physical fitness tests into routine school physical examination, in accordance with the Screening for Spinal Curvature Abnormality in Children and Adolescents (GB/T 16133-2014) and the Chinese National Student Physical Fitness Standard (CNSPFS; 2014 Revision) (Ministry of Education of the People's Republic of China, 2014; Standardization Administration of China and National Health and Family Planning Commission of the PRC, 2014). However, both physical examinations were conducted separately, and previous studies have mostly focused on the relationship between cross-sectional, single-dimensional physical fitness and AIS, and adolescent physical fitness data have not been fully utilized. The association between physical fitness and AIS remains inconclusive.

This study aimed to (1) use physical fitness testing data based on the CNSPFS from the prior year, systematically evaluate the associations between all-dimensional physical fitness indicators and AIS, and conduct sex-stratified analyses; and (2) provide effective recommendations for early AIS screening and prevention based on physical fitness data.

2. Methods

2.1. Study design and population

This case–control study was based on a large-scale school-based scoliosis screening program conducted in Jincheng, Shanxi Province, northern China in 2025. The program covers students aged 6–18 in primary, junior secondary, and senior secondary schools across the city. Scoliosis screening in strict accordance with the Screening for Spinal Curvature Abnormality in Children and Adolescents (GB/T 16133-2014). Individuals with an angle of trunk rotation (ATR) ≥ 5° were classified as suspected scoliosis cases and referred for standing posteroanterior full-spine radiographs. When a standing posteroanterior full-spine radiograph showed a Cobb angle ≥10°, and congenital, neuromuscular, and syndromic causes were excluded, AIS was diagnosed. In addition, to ensure that exposure preceded outcome and to minimize reverse causation, physical fitness testing data were collected from the prior academic year. However, test items differed by grade in primary school. Therefore, the inclusion criteria for the AIS case group were: (1) aged 13–18 years; (2) diagnosed with AIS through this school-based scoliosis screening; (3) complete prior-year physical fitness test data and the uniform test item; and (4) voluntary participation with signed informed consent. The inclusion criteria for the healthy control group were: (1) ATR < 5° on school-based scoliosis screening; (2) frequency-matched to AIS cases by age and sex; (3) without musculoskeletal disorders or a history of intensive competitive training; (4) complete prior-year physical fitness test data and the uniform test item and (5) voluntary participation with signed informed consent.

According to prespecified eligibility criteria, a total of 1221 students were included: 401 cases and 820 controls. All participants and their legal guardians were fully informed of the study objectives, procedures, and potential risks and benefits, and provided written informed consent. To protect privacy, all data were de-identified before analysis. This study was conducted in accordance with the principles of the Declaration of Helsinki and received approval from the Medical Technology Ethics Committee of Jincheng Kangning Hand Surgery Hospital (Approval No. PJ-KL2025-001). The clinical trial has been registered at the Chinese Clinical Trial Registry (ChiCTR2500105030) on 06/27/2025.

2.2. Measures

All physical fitness tests, including the selection of test items, scoring criteria, and weight assignments, were conducted strictly in accordance with the CNSPFS (Ministry of Education of the People's Republic of China, 2014). This national standard, developed based on data from a nationwide student physical fitness survey, provides sex- and grade-specific scoring tables for each test item. Raw performance values for each test were converted to a standardized score (0–100 points) using the official, sex- and grade-specific normative scoring tables. According to the CNSPFS, a composite total score (0–100 points) was then calculated as the weighted sum of the standardized scores from all test items and was classified into the following performance categories: excellent (≥90 points), good (80–89 points), pass (60–79 points), and fail (≤59 points).

Specifically, the test items (with measurement units and their weight in the total score) were: height (cm) and weight (kg) for the calculation of BMI (kg/m²; 15%); vital capacity (mL; 15%); 50 m run (s; 20%); standing long jump (cm; 10%); sit-and-reach (cm; 10%); one-minute sit-ups for females and pull-ups for males (reps; 10%); and 800 m run for females or 1000 m run for males (s; 20%). Detailed descriptions of each test procedure are provided in the Appendix A. According to CNSPFS guidelines, the BMI score was assigned based on BMI category (obesity, OB = 60 points; overweight, OW, and underweight, UW = 80 points; normal weight, NW = 100 points). The BMI score is nonlinear, and this study uses its raw value (continuous variable; kg/m²) for analysis. Other individual fitness test item scores and the composite total score (calculated as the weighted sum of all item scores) were treated as continuous variables. Physical fitness was reclassified into five dimensions based on physical fitness test items is summarized in Table 1 as follows: body composition (BMI); cardiorespiratory endurance (vital capacity and the 1000 m run for males or 800 m run for females); muscular strength and endurance (pull-ups for males or one-minute sit-ups for females); flexibility (sit-and-reach); and explosive power (50 m run and standing long jump), the explosive power was treated as a composite indicator of skill-related physical fitness.

Table 1.

Physical fitness dimensions and corresponding test items of the Chinese National Student Physical Fitness Standard among adolescents in Jincheng, Shanxi Province, China, 2025 (N = 1221).

Physical Fitness Dimensions	Physical Fitness Test Items (weight)
Body Composition	BMI (15%)
Cardiorespiratory Endurance	Vital capacity (15%) Male: 1000 m run or Female: 800 m run (20%)
Muscular Strength & Endurance	Male: pull-ups or Female: one-minute sit-ups (10%)
Flexibility	Sit-and-reach (10%)
Explosive Power	Standing long jump (10%) & 50 m run (20%)
Total Score	Weighted sum of all item scores (100%)

2.3. Statistical analysis

Descriptive statistics were used to describe the demographic characteristics of the AIS case and the healthy control group. Categorical variables were expressed as counts (percentages), and continuous variables as mean ± standard deviation (SD) or median (interquartile range). Categorical variables were compared using the chi-square test. Continuous variables with a normal distribution were compared using the t-test, and those without a normal distribution were compared using the Mann-Whitney U test. Multivariable logistic regression models were used to estimate independent associations between physical fitness and AIS. Results are reported as odds ratios (aORs) with 95% confidence intervals (CIs). Two-sided tests and p < 0.05 are considered statistically significant. All statistical analyses were conducted using SPSS 26.0 (IBM Corp, Armonk, NY, USA).

3. Results

3.1. Demographic characteristics

As shown in Table 2, a total of 1221 students were recruited, with a mean age of 15.3 years (SD: 0.6), comprising 401 cases (32.8%) and 820 controls (67.2%). The case group had a mean age of 15.3 years (SD: 0.6), comprising 185 males (46.1%) and 216 females (53.9%). The control group had a mean age of 15.3 years (SD: 0.6), comprising 376 males (45.9%) and 444 females (54.1%). Notably, there were no significant differences between the two groups in age (p = 0.968) or sex (p = 0.975), indicating that the matching procedure achieved satisfactory baseline comparability. Compared with controls, cases had lower mean height (p = 0.025) and mean weight (p < 0.001), a higher prevalence of a family history of scoliosis (p < 0.001), and a higher proportion of mothers with education below a bachelor's degree (p < 0.001). No significant differences between groups in residential mode, ethnicity, or the education level of father (p > 0.05).

Table 2.

Demographic characteristics of adolescents with and without idiopathic scoliosis in Jincheng, Shanxi Province, China, 2025 (N = 1221).

Variable	Total, n (%)	Cases, n (%)	Controls, n (%)	P
Total	1221 (100%)	401 (32.8%)	820 (67.2%)
Age, years (mean ± SD)	15.3 (0.6)	15.3 (0.6)	15.3 (0.6)	0.968
Sex, n (%)				0.975
Male	561 (45.9%)	185 (46.1%)	376 (45.9%)
Female	660 (54.1%)	216 (53.9%)	444 (54.1%)
Height, cm (mean ± SD)	164.03 (8.04)	163.32 (7.41)	164.37 (8.32)	0.025
Weight, kg (mean ± SD)	55.18 (12.90)	52.24 (10.66)	56.62 (13.64)	<0.001
Family history of scoliosis, n (%)				<0.001
Yes	105 (8.6%)	61 (15.2%)	44 (5.4%)
No	1116 (91.4%)	340 (84.8%)	776 (94.6%)
Residential mode, n (%)				0.506
Boarding	394 (32.3%)	135 (33.7%)	259 (31.6%)
Commuting	827 (67.7%)	266 (66.3%)	561 (68.4%)
Ethnicity, n (%)				0.474
Han	1166 (95.5%)	380 (94.8%)	786 (95.9%)
Minority	55 (4.5%)	21 (5.2%)	34 (4.1%)
Education level of father, n (%)				0.413
Below a bachelor's degree	587 (48.1%)	200 (49.9%)	387 (47.2%)
Bachelor's degree or above	634 (51.9%)	201 (50.1%)	433 (52.8%)
Education level of mother, n (%)				<0.001
Below a bachelor's degree	594 (48.6%)	227 (56.6%)	367 (44.8%)
Bachelor's degree or above	627 (51.4%)	174 (43.4%)	453 (55.2%)

Note: Data are presented as mean ± standard deviation or n (%). P-values were derived from independent t-tests for continuous variables and chi-square tests for categorical variables.

3.2. Physical fitness test scores between AIS cases and healthy controls

As shown in Table 3, in the overall sample, cases had a significantly lower median BMI (p < 0.001), lower median vital capacity score (p < 0.001), lower median 50 m run score (p < 0.001), lower median standing long jump score (p = 0.007), and lower median sit-and-reach score (p < 0.001) compared to controls. No significant differences were found for the remaining indicators or the total score (p > 0.05).

Table 3.

Comparison of prior-year physical fitness scores between adolescents with and without idiopathic scoliosis in Jincheng, Shanxi Province, China, 2025 (N = 1221).

Indicator	Cases median (interquartile range)	Controls median (interquartile range)	P
BMI
Overall	18.9 (17.1–21.5)	20.2 (17.9–23.0)	<0.001
Male	19.7 (17.5–22.5)	21.0 (18.5–24.8)	<0.001
Female	18.6 (16.9–20.8)	19.5 (17.6–21.9)	0.002
Vital capacity
Overall	80 (68–95)	85 (74–95)	<0.001
Male	74 (68–85)	80 (74–95)	<0.001
Female	80 (68–95)	90 (74–95)	0.009
50 m run
Overall	74 (68–80)	78 (72–85)	<0.001
Male	72 (66–85)	80 (72–90)	<0.001
Female	74 (70–80)	76 (72–80)	0.147
Standing long jump
Overall	68 (60–76)	72 (62–80)	0.007
Male	70 (60–80)	72 (62–80)	0.753
Female	66 (60–76)	72 (62–80)	0.002
Sit-and-reach
Overall	80 (72–95)	85 (78–95)	<0.001
Male	74 (68–85)	85 (76–95)	<0.001
Female	85 (76–100)	85 (78–95)	0.725
Male: 1000 m run/Female: 800 m run
Overall	80 (72–95)	80 (72–95)	0.611
Male	78 (68–95)	80 (66–95)	0.850
Female	85 (74–95)	85 (76–95)	0.669
Male: pull-ups/Female: one-minute sit-ups
Overall	68 (30–76)	68 (30–78)	0.611
Male	20 (10–40)	20 (10–40)	0.749
Female	74 (68–80)	76 (70–80)	0.121
Total score
Overall	77.8 (71.1–83.6)	79.5 (72.6–85.3)	0.131
Male	73.3 (67.5–80.9)	75.5 (67.4–83.0)	0.216
Female	80.3 (75.1–86.2)	81.8 (76.4–86.3)	0.158

Note: Data are presented as median (interquartile range). P-values were derived from Mann-Whitney U tests.

In the male subgroup, cases had a significantly lower median BMI (p < 0.001), lower median vital capacity score (p < 0.001), lower median 50 m run score (p < 0.001), and lower median sit-and-reach score (p < 0.001) than controls. No significant differences were found for the remaining indicators or the total score (p > 0.05).

In the female subgroup, cases had a significantly lower median BMI (p = 0.002), lower median vital capacity score (p = 0.009), and lower median standing long jump score (p = 0.002) than controls. No significant differences were found for the remaining indicators or the total score (p > 0.05).

3.3. Multivariable logistic regression

Multivariable logistic regression was used to evaluate the independent associations between seven physical fitness indicators (raw BMI values and other individual physical fitness test scores) and AIS status. The models were adjusted for the matching variables (age and sex) and for other demographic characteristics that showed significant differences between the case and control groups. For interpretability, aORs (95% CIs) are reported per 1 kg/m² increase for BMI and per 10-point increase for the other physical fitness indicators. This is simply a scale transformation and does not affect p-values. As shown in Table 4, in the overall sample, each 1 kg/m² increase in BMI was associated with an 9.0% decrease in the odds of AIS; each 10-point increase in vital capacity score was associated with an 13.6% decrease in the odds of AIS; each 10-point increase in sit-and-reach score was associated with a 9.5% decrease in the odds of AIS. All remaining indicators were not statistically significant (p > 0.05).

Table 4.

Associations between physical fitness and idiopathic scoliosis in adolescents: multivariable logistic regression analysis stratified by sex in Jincheng, Shanxi Province, China, 2025 (N = 1221).

Indicator	aOR	95% CI
BMI
Overall	0.910	(0.874, 0.946)
Male	0.918	(0.869, 0.970)
Female	0.908	(0.856, 0.963)
Vital capacity
Overall	0.864	(0.788, 0.948)
Male	0.856	(0.739, 0.992)
Female	0.873	(0.772, 0.987)
50 m run
Overall	0.917	(0.840, 1.002)
Male	0.837	(0.742, 0.945)
Female	1.029	(0.897, 1.181)
Standing long jump
Overall	0.984	(0.926, 1.046)
Male	1.100	(0.995, 1.216)
Female	0.904	(0.834, 0.980)
Sit-and-reach
Overall	0.905	(0.825, 0.993)
Male	0.762	(0.657, 0.882)
Female	1.051	(0.921, 1.198)
Male: 1000 m run/Female: 800 m run
Overall	1.020	(0.939, 1.107)
Male	1.048	(0.931, 1.180)
Female	0.979	(0.867, 1.104)
Male: pull-up/Female: one-minute sit-up
Overall	0.987	(0.926, 1.053)
Male	0.987	(0.916, 1.064)
Female	1.010	(0.875, 1.165)

Note: Results are presented as adjusted odds ratios with 95% confidence.

In the male subgroup, each 1 kg/m² increase in BMI was associated with a 8.2% decrease in the odds of AIS; each 10-point increase in vital capacity score was associated with a 14.4% decrease in the odds of AIS; each 10-point increase in 50 m run score was associated with an 16.3% decrease in the odds of AIS; each 10-point increase in sit-and-reach score was associated with a 23.8% decrease in the odds of AIS. All remaining indicators were not statistically significant (p > 0.05).

In the female subgroup, each 1 kg/m² increase in BMI was associated with an 9.2% decrease in the odds of AIS; each 10-point increase in vital capacity score was associated with a 12.7% decrease in the odds of AIS; each 10-point increase in standing long jump score was associated with a 9.6% decrease in the odds of AIS. All remaining indicators were not statistically significant (p > 0.05).

4. Discussion

This study examined associations between prior-year physical fitness scores and idiopathic scoliosis in Chinese adolescents aged 13–18, stratified by sex. While total fitness scores did not differ significantly between groups, several sex-specific differences emerged in individual items. Multivariable logistic regression revealed that AIS was negatively associated with BMI, vital capacity, and sit-and-reach in the overall sample. In males, negative associations were found with BMI, vital capacity, 50 m run, and sit-and-reach; in females, with BMI, vital capacity, and standing long jump.

Human activity depends on the coordinated interaction of bones, muscles, ligaments, and joints within the musculoskeletal system (Lu and Chang, 2012). Unfavorable body composition, including low bone mineral density, BMI, reduced muscle mass, and excess adiposity, may disrupt the spine's tension-compression balance and compromise postural stability (Mendy et al., 2014; Migliaccio et al., 2024; Scott et al., 2018). Insufficient cardiorespiratory endurance may accelerate fatigue in trunk-stabilizing muscles, leading to uneven load distribution (Lin et al., 2019a; Lin et al., 2019b). Reduced lower-limb explosive power and weakness of the hip abductors may impair dynamic lumbopelvic stability and may increase asymmetric loading (Prior et al., 2014; Smith et al., 2014). Limited spinal flexibility can reduce segmental mobility, leading to compensatory and uneven pressure distribution (Wang et al., 2025). Inadequate core and paraspinal strength, along with poorer neuromuscular coordination, may result in suboptimal trunk activation and support (Farahpour et al., 2015; Nguyen et al., 2025). Together, these factors may impair postural control and asymmetric spinal loading, potentially increasing the risk of malalignment and progression of curvature.

Our findings are supported by most of the previous research. Regarding body composition (BMI), a cohort study involving populations aged 20 years old reported that each 1 kg/m² increase in BMI was associated with approximately a 12% decrease in the odds of AIS (Ng et al., 2024). Regarding cardiorespiratory endurance (vital capacity, the 1000 m run for males or the 800 m run for females), a cross-sectional controlled study reported impaired static and dynamic pulmonary function in AIS patients compared to controls (Sperandio et al., 2014). Regarding explosive power (50 m run and standing long jump), although there is almost no research on explosive power in AIS patients, a cross-sectional study reported that, compared with the control group, AIS patients exhibited lower limb alignment abnormalities, reduced muscle strength, and abnormal foot features. Regarding flexibility (sit-and-reach), a cross-sectional study reported that greater lumbar curve severity in AIS is associated with reduced spinal range of motion, particularly in axial rotation and lateral bending (Eyvazov et al., 2017). Nevertheless, some studies do not support our results. One cross-sectional study reported that the detection rate of AIS among obese individuals was nearly twice that of those with normal BMI, suggesting that a higher BMI may not necessarily confer protection and could even increase AIS risk (Catanzariti et al., 2023). In particular, regarding muscle strength and endurance, there is evidence that AIS patients demonstrated significantly imbalanced bilateral paraspinal muscle activation and markedly lower endurance in both abdominal and back extensor muscles compared to age-matched healthy controls (Farahpour et al., 2015). These differences may primarily result from variations in study design, sample composition, measurement tools, and assessment precision. However, this study was conducted within a school-based health surveillance setting, using standardized physical fitness assessments. Therefore, this approach may be limited in its ability to assess localized spinal function and internal mechanical loading, which could influence the observed associations between certain physical fitness indicators and AIS.

Nevertheless, our findings still have important implications for the early identification, prevention, and health management of AIS. First, relying solely on the total physical fitness score to assess spinal health risk may mask deficiencies, especially when patients are underweight (80 points) or perform well on a single physical fitness indicator. Particular attention should be directed toward sex-stratified indicators. The results suggest that female students require close monitoring of BMI, vital capacity, and standing long jump performance; male students should be monitored for BMI, vital capacity, sit-and-reach, and 50 m run performance. Secondly, students should be encouraged to increase their awareness of spinal health, regularly monitor their physical condition, and engage in targeted training for areas of weakness. Thirdly, Local education and health departments should collaborate to establish regional adolescent health management platforms integrating school physical assessments with scoliosis screening data. Using data-driven approaches for early risk identification, precise intervention, and policy support, a coordinated “family–school–community” system can be developed to improve AIS screening and intervention.

This study has several strengths. First, this approach not only broadens the perspective on risk identification in population screening but also highlights the potential value of routine physical fitness testing in the early detection of AIS. Second, sex-stratified analyses were conducted, which helped uncover sex-stratified associations between physical fitness and AIS. Finally, the findings offer important practical implications and may provide a scientific basis for developing low-cost, feasible AIS screening and intervention strategies in school settings.

This study also has some limitations. First, the case-control design cannot establish a causal relationship. Second, the physical fitness data have limitations in assessing localized spinal function. Finally, despite adjustments for certain covariates, residual confounding from other potential factors cannot be completely excluded.

5. Conclusions

In conclusion, the study found that physical fitness indicators from the preceding year are significantly associated with AIS and with sex-stratified differences. These findings support the inclusion of physical fitness monitoring in scoliosis screening systems and the development of prevention strategies centered on promoting physical health. Future research should emphasize prospective and interventional studies to validate and refine sex-stratified thresholds and intervention outcomes.

CRediT authorship contribution statement

Fangwen Zhang: Writing – review & editing, Writing – original draft, Software, Methodology, Formal analysis, Data curation, Conceptualization. Wei Peng: Supervision, Methodology, Investigation. Zikang Zhang: Supervision, Methodology, Investigation. Shaoming Sun: Writing – review & editing, Supervision, Methodology, Investigation. Xiang Zhang: Writing – review & editing, Resources, Investigation, Funding acquisition.

Consent for publication

Not applicable.

Ethics approval

This study was conducted in accordance with the principles of the Declaration of Helsinki and received approval from the Medical Technology Ethics Committee of Jincheng Kangning Hand Surgery Hospital (Approval No. PJ-KL2025-001). The clinical trial has been registered at the Chinese Clinical Trial Registry (ChiCTR2500105030) on 06/27/2025.

Funding

This study was funded by Anhui Provincial Higher Education Science Research Project (Project No.: 2024AH051616).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

The datasets generated and/or analyzed during this study are available from the corresponding author upon reasonable request.