Risk factors for refracture after vertebral augmentation in postmenopausal women with osteoporotic vertebral compression fractures: a systematic review and meta-analysis.

BACKGROUND

Postoperative refracture is a significant complication that may arise after percutaneous vertebral augmentation (PVA). While several studies have explored the risk factors associated with refracture following PVA for osteoporotic vertebral compression fractures (OVCF), there is currently no meta-analysis specifically focusing on postmenopausal women. QUESTIONS/PURPOSES: To assess the risk factors for refracture after PVA in postmenopausal women with OVCF and to explore the underlying mechanisms.

METHODS

We systematically searched Cochrane Library, PubMed, EMBASE, and Web of Science (until September 2024) for trials comparing refracture vs. non-refracture groups in postmenopausal women post-PVA. Study quality was assessed using Newcastle-Ottawa Scale (NOS). Binary variables expressed as Odds Ratio (OR); continuous variables as Standard Mean Difference (SMD) or Mean Difference (MD). Heterogeneity sources evaluated via meta-regression, subgroup analysis, and sensitivity analysis, publication bias testing.

RESULTS

Ten studies (NOS ≥ 7, high quality) were included. Significant refracture associated factors: advanced age [MD = 3.34, 95% CI (2.55, 4.12), p < 0.00001], lower bone mineral density (BMD) [SMD = -0.67, 95% CI (-0.99, -0.34), p < 0.0001], lower paravertebral muscle density (PMD) [MD = -5.91, 95% CI (-7.56, -4.26), p < 0.00001], larger postoperative kyphotic angle [MD = 1.41, 95% CI (0.69, 2.14), p = 0.0001], smoking [OR = 1.57, 95% CI (1.04, 2.36), p = 0.03], steroid use [OR = 1.91, 95% CI (1.28, 2.84), p = 0.001], previous fracture history [OR = 3.14, 95% CI (2.26, 4.36), p < 0.00001], multiple vertebral fractures [OR = 1.83, 95% CI (1.43, 2.34), p < 0.00001], bone cement leakage [OR = 5.78, 95% CI (1.18, 28.39), p = 0.03], anti-osteoporosis treatment (AOT) [OR = 0.56, 95% CI (0.39, 0.81), p = 0.002].

CONCLUSION

As the first meta-analysis in postmenopausal women with OVCF after PVA, our study indicates several key findings: established risk associations include advanced age, steroid use, previous fracture history, and multiple vertebral fractures; risk factors requiring contextual interpretation are bone cement leakage and low BMD due to substantial heterogeneity, as well as low PMD and increased postoperative kyphotic angle due to limited studies; a protective association was found for AOT; and no significant associations were found for BMI, drinking, diabetes, hypertension, or T-L junction fracture. Clinical implications derived from these findings suggest: pre-operative optimization of bone health in patients with advanced age, previous fracture history, or steroid use; intra-operative consideration of techniques to reduce cement leakage, acknowledging the heterogeneity in available evidence; and post-operative implementation of routine anti-osteoporotic therapy and smoking cessation counseling.