Analysis of Risk Factors for Subsequent Fractures Following Percutaneous Kyphoplasty for Single-Segment Osteoporotic Vertebral Compression Fractures

Analysis of Risk Factors for Subsequent Fractures Following Percutaneous Kyphoplasty for Single-Segment Osteoporotic Vertebral Compression Fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of Risk Factors for Subsequent Fractures Following Percutaneous Kyphoplasty for Single-Segment Osteoporotic Vertebral Compression Fractures Aiqi Zhang, Xun Wang, Yichen Lin, Mingxiang Kong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3414679/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: The purpose of this study was to look into the risk factors for recurrent fractures following percutaneous kyphoplasty (PKP) in patients with single-level osteoporotic vertebral compression fractures (OVCF). Methods: This retrospective cohort study analyzed the clinical data of 289 patients who underwent PKP for single-segment OVCF at our institution from January 2018 to December 2020. The patients were categorized into the refracture group (39 cases) and the non-refracture group (250 cases) based on whether new vertebral fractures occurred postoperatively. Sex, age, body mass index (BMI), hypertension, diabetes, bone mineral density (BMD), osteoporosis treatment, fracture level, bone cement injection volume, bone cement leakage, bone cement distribution, spinal scoliosis, pre-and postoperative Cobb angles, and vertebral height restoration rate were recorded. Univariate analysis was conducted to examine the correlation between variables and subsequent vertebral fractures. Subsequently, multivariable logistic regression analysis was performed to determine independent risk factors.. Nonrestrictive cubic spline functions were employed to explore the correlations between the independent risk factors selected from the multivariate analysis. Results: The univariate analysis revealedthat age, BMI, BMD, postoperative anti-osteoporosis treatment, fracture level, preoperative Cobb angle, and vertebral height restoration rate were significantly correlated with postoperative vertebral refracture after PKP ( P <0.05). The results of the multivariable logistic regression analysis revealed that a BMD less than -2.6 (odds ratio (OR)=0.64, 95% confidence interval (CI)0.45,0.90, P <0.05) and a vertebral height restoration rate greater than 9.8% (OR=1.40, 95% CI 1.17,1.68, P <0.01) were significantly linked to post-PKP recurrent fractures. The results of the nonrestrictive cubic spline function indicated a monotonic relationship between BMD and risk of PKP refracture. The risk of PKP refracture decreased with increased BMD after PKP surgery. The relationship between vertebral height restoration rate and the risk of PKP refracture followed a "U" shaped pattern. After the vertebral height restoration rate exceeded 9.8%, the risk of PKP refracture increased, reaching its highest point at 26.1% and then slightly declining. Conclusions: BMD9.8% are independent risk factors for postoperative vertebral refracture in patients with OVCF following PKP. kyphoplasty osteoporosis spinal fractures risk factors subsequent fracture Figures Figure 1 Figure 2 1 Introduction Osteoporotic vertebral compression fracture (OVCF) can cause back pain and spinal deformity, leading to reduced mobility and compromised pulmonary function ( 1 ). Percutaneous kyphoplasty (PKP) is a minor surgical operation that has gained widespread application in treating OVCF. It effectively alleviates pain and restores vertebral height. This approach is associated with minimal trauma and allows rapid recovery ( 2 ). However, some patients who undergo PKP may experience subsequent vertebral fractures, which is considered one of the most serious complications. This can lead to severe local pain and impose considerable psychological and economic burden on patients ( 3 – 6 ). Post-PKP refractures have garnered the attention of researchers in the field ( 7 , 8 ). According to reports, refractures may be correlated with a variety of factors, including age, degree of osteoporosis, extent of vertebral compression, volume of bone cement injection, distribution of bone cement, and vertebral height restoration rate (VHRR) ( 3 , 5 , 9 ). However, no consensus has been reached on the primary risk factors contributing to refracture. Therefore, the main purpose of this study was to investigate the risk factors for post-PKP refracture and preliminarily explore the relationship between changes in risk factors and refracture occurrence. 2 Materials and Methods 2.1 Study Participants In this retrospective study, we collected the clinical data of 289 patients who underwent PKP for single-segment OVCF at our institution between January 2018 and December 2020. Participants included 50 men and 239 women aged 49–95 (74.7 ± 9.6) years. The distribution of the fracture segments was as follows: T5–T9 in 25 cases, T10–L2 in 209 cases, and L3–L5 in 55 cases. Based on the occurrence of subsequent vertebral refractures after surgery, the patients were categorized into a refracture group (39 cases) and a non-fracture group (250 cases). The following were the inclusion criteria: ( 1 ) PKP performed for single-segment vertebral fractures brought on low-energy injuries (such as falling) resulting in lumbar pain or restricted movement; ( 2 ) X-ray and computed tomography findings indicating vertebral compression fracture, with magnetic resonance imaging showing low T1 and high T2 signals; and ( 3 ) complete medical records. The following were the exclusion criteria: ( 1 ) vertebral fractures brought on tumors, infections, or tuberculosis, ( 2 ) spinal cord compression accompanied neurological symptoms, and ( 3 ) poor cardiac and pulmonary function. The Institutional Ethics Committee of our hospital approved our study, and patients were made aware that their data would be used for clinical research. The need for informed consent by study participants was waived by the Institutional Ethics Committee. 2.2 Surgical Procedure The patient was positioned prone, and an anteroposterior view of a C-arm fluoroscopy machine was utilized to detect and project the spinous processes on both sides of the damaged vertebra. Marking lines were drawn accordingly. Standard disinfection and draping procedures were performed. Local infiltration anesthesia was administered at the puncture sites on both sides of the spinous processes. A small incision was made on the left side at the projected location of the spinous process, and a puncture was performed at approximately the 10 o'clock position under fluoroscopic guidance, focusing on the sagittal angle and medial angulation. Fluoroscopic imaging of the anteroposterior and lateral views confirmed proper needle placement at the center of the pedicle on both sides. A guide wire was then inserted and positioned roughly 0.5 cm anterior to the posterior margin of the vertebral body after the puncture needle was removed. After the guidewire was removed, a working cannula was inserted. Under the appropriate pressure, a contrast agent was injected to inflate the balloon. A guide wire was then inserted and positioned roughly 0.5 cm anterior to the posterior margin of the vertebral body after the puncture needle was removed. Under continuous C-arm fluoroscopic supervision, bone cement was slowly injected to fill the anterior part of the broken vertebral body and form an efficient mechanical column. If cement leakage occurred during the procedure, the injection was immediately ceased. After the bone cement solidified, the cannula was withdrawn, and surgery was concluded. 2.3 Measures The following data were recorded for both groups: sex, age, body mass index (BMI), hypertension, diabetes, bone mineral density (BMD), anti-osteoporosis treatment, fracture segment, volume of bone cement injection, bone cement leakage, distribution of bone cement, scoliosis status, preoperative and postoperative Cobb angles, and VHRR. The associations between these factors and post-PKP refractures were investigated using univariate analysis. To identify independent risk factors for post-PKP refractures, multivariate logistic regression analysis was employed. The relationship between the identified independent risk factors and the occurrence of vertebral refracture was further analyzed. A dual-energy X-ray absorptiometry instrument was used to measure BMD. Spinal scoliosis was defined as a coronal Cobb angle greater than 10°. Bone cement leakage was evaluated on anteroposterior and lateral X-ray images to determine if the bone cement extended beyond the vertebral boundaries, with such an extension classified as cement leakage. Bone cement dispersion was assessed on postoperative anteroposterior X-ray images to ascertain whether the bone cement crossed the midline symmetrically; crossing the midline indicates sufficient distribution, otherwise, it is considered insufficient ( 10 ). The X-ray images were measured to obtain the height of the upper vertebra (HUV) of the fractured segment, height of the lower vertebra (HLV) of the fractured segment, preoperative anterior vertebral height (AVH 1 ) of the fractured vertebra, and postoperative vertebral height (AVH 2 ) of the fractured vertebra. The VHRR of the fractured vertebra was defined as the ratio of the difference between AVH 1 and AVH 2 divided by the average of HUV and HLV. The formula is as follows: VHRR =[2×(AVH 2 - AVH 1 ) / (HUV + HLV)]×100% ( 11 ). 2.4 Postoperative Management As foundational therapy, the anti-osteoporosis treatment regimen included oral calcium supplements and active vitamin D, supplemented with an intravenous infusion of zoledronic acid or subcutaneous denosumab injections. The anabolic agent teriparatide is not the first-choice medication due to its high cost. Some patients who smoke and consume alcohol should also be encouraged to quit smoking and drinking. All patients underwent spinal anteroposterior and lateral X-ray examinations 24 hours after the surgery. Outpatient follow-up visits were scheduled at 1 month, 3 months, 6 months, 1 year, and 2 years after discharge. During these follow-up visits, spinal X-ray examinations were conducted. If a patient experienced symptoms such as lower back pain or restricted mobility, an magnetic resonance imaging examination could be considered. The study endpoint was set at 2 years or the occurrence of a recurrent fracture during outpatient follow-up. 2.5 Diagnosis of PKP Re-fracture The diagnostic criteria for post-PKP fractures are as follows:1. New-onset lower back pain or limited lower back mobility after PKP surgery.2. Spine X-rays and magnetic resonance imaging findings indicating vertebral fractures at a different location from the surgical site. 2.6 Statistical Assessments SPSS 26.0 (IBM Corporation, Armonk, New York, USA) and R (version 4.2.0) were used for statistical analysis. The Kolmogorov–Smirnov test was used to determine the data's normality. The mean and standard deviation of normally distributed continuous variables were provided, and between-group comparisons were made with an independent samples t-test. Non-normally distributed continuous variables were given as medians and interquartile ranges, and the Mann–Whitney U test was used to compare groups. Categorical data were presented as counts and/or percentages, with group comparisons using the chi-squared test. The multivariate logistic regression analysis comprised observed indicators with P < 0.05 in the univariate study. Nonrestrictive cubic spline functions were employed to explore the correlations between the independent risk factors selected from the multivariate analysis. P < 0.05 was considered statistically significant. 3 Results We included 289 patients in the study. Among them, 39 (14%) experienced refractures after PKP, whereas 250 (86%) did not experience refractures. Sixteen cases of proximal vertebral fractures and 23 cases of distal vertebral fractures were discovered. In the refracture group, the mean age was 78.54 (± 7.92) years, with 6 men (15%) and 33 women (85%). In the non-refracture group, the mean age was 74.09 (± 9.67) years, with 44 men (18%) and 206 women (82%) (Table 1 ). Table 1 Clinical features of the refracture group and non-refracture group Variable Refracture Group (n = 39) Non-Refracture Group (n = 250) P Sex, n (%) Men 6 (15.4) 44 (17.6) 0.734 Women 33 (84.6) 206 (82.4) Age, years 78.5 ± 7.9 74.1 ± 9.7 0.003 BMI, kg/m 2 20.9 ± 3.4 22.8 ± 3.7 0.003 History of hypertension, n (%) Yes 15 (38.5) 138 (55.2) 0.051 No 24 (61.5) 112 (44.8) History of diabetes, n (%) Yes 6 (15.4) 44 (17.6) 0.734 No 33 (84.6) 206 (82.4) BMD -3.1 ± 1.3 -2.5 ± 1.3 0.005 Anti-osteoporotic treatment, n (%) Yes 9 (23.1) 116 (46.4) 0.006 No 30 (76.9) 134 (53.6) Fracture segment, n (%) T 5 ཞT 9 9(23.1) 16(6.4) T 10 ཞL 2 27(69.2) 182(72.8) 0.002 L 3 ཞL 5 3(7.7) 52(20.8) Bone cement dosage, mL 4.8(4.0,6.0) 4.9(4.0,6.0) 0.496 Bone cement leakage, n (%) Yes 14 (35.9) 60 (24.0) 0.113 No 25 (64.1) 190 (76.0) Bone cement dispersion, n (%) Yes 33 (84.6) 226 (90.4) 0.414 No 6 (15.4) 24 (9.6) Scoliosis status, n (%) Yes 17 (43.6) 87 (34.8) 0.287 No 22 (56.4) 163 (65.2) Pre-op Cobb angle (°) 17.6(12.0,22.0) 12.1(7.0,16.0) < 0.001 Post-op Cobb angle (°) 10.7(5.0,15.0) 8.4(4.0,12.0) 0.050 VHRR, n (%) 24.2 (18.1, 29.7) 7.9 (3.2, 19.8) < 0.001 Values are expressed as the mean ± SD, number (%). BMI, body mass index; BMD, bone mineral density; VHRR, vertebral height restoration rate. The results of the univariate analysis indicated that age, BMI, BMD, postoperative anti-osteoporosis treatment, fracture segment, preoperative Cobb angle, and VHRR were significantly correlated with post-PKP refractures ( P < 0.01). In contrast, sex, hypertension, diabetes, bone cement dosage, bone cement leakage, bone cement dispersion, presence of spinal scoliosis, and postoperative Cobb angle revealed no significant correlation with post-PKP refractures ( P > 0.05) (Table 1 ). According to the results of multivariate logistic regression analysis, BMD and VHRR were strongly linked with post-PKP refracture ( P < 0.05) (Table 2 ). Table 2 Clinical features of the normal group and refracture group Variable β SE Wald OR 95% CI P Age, years 0.04 0.02 3.10 1.04 1.00, 1.09 0.078 BMI, kg/m 2 -0.06 0.06 1.10 0.94 0.85, 1.05 0.295 BMD -0.45 0.17 6.70 0.64 0.45, 0.90 0.010 Anti-osteoporotic treatment -0.46 0.42 1.17 0.63 0.28, 1.45 0.279 Augmentation segment -0.61 0.38 2.59 0.54 0.26, 1.14 0.108 Pre-op Cobb angle 0.05 0.03 3.44 1.05 1.00, 1.11 0.064 VHRR 0.34 0.09 13.74 1.40 1.17, 1.68 ༜0.001 BMI, body mass index; BMD, bone mineral density; VHRR, vertebral height restoration rate; OR, odds ratio; CI, confidence interval. Analysis using nonrestrictive cubic spline functions indicated that BMD had a monotonic relationship with the risk of post-PKP refractures. With BMD -2.6, the risk of refractures stabilizes (Fig. 1 ). The relationship between VHRR and the risk of post-PKP refractures follows a "U"-shaped pattern. Beyond a VHRR of 9.8% (OR = 1), the risk of post-PKP refracture increases. At a VHRR of 26.1% (OR = 6.52), the risk reaches its highest and then gradually decreases but remains higher than the levels before 9.8% (Fig. 2 ). 4 Discussion PKP is widely utilized for OVCF treatment because of its advantages, including minimal invasiveness, rapid recovery, swift pain relief, and partial vertebral height restoration ( 12 , 13 ). However, some patients undergoing PKP may experience postoperative refractures, with reported incidence rates ranging from 9.3–34.8% ( 7 , 14 , 15 ). In our study, the probability of recurrent vertebral fractures was determined to be 13.5%, indicating a low incidence rate. Numerous studies have examined the risk factors of post-PKP refracture in patients with OVCF. The results suggest that age, sex, BMD, BMI, distribution of bone cement, and spinal scoliosis may increase the incidence of post-PKP refractures ( 16 – 20 ). However, these studies have primarily focused on analyzing independent risk factors for post-PKP fractures without providing insights into how changes in these risk factors may influence the risk of refractures. VHRR and BMD were found to be independent risk factors for refractures after PKP in this study, which also carried out an initial exploration into the relationship between variables in independent risk factors and the discovered risk of recurrent fractures. Gaining an understanding of the risk factors for recurrent fractures and how changes in these factors influence the variation in risk can greatly assist clinicians in implementing appropriate preventive measures and tailored treatment strategies. This knowledge can also contribute to optimizing the allocation of healthcare resources. Osteoporosis is a systemic bone disease characterized by low bone mass, which leads to microstructural degradation and increased bone tissue fragility. As osteoporosis progresses, the risk of post-PKP refracture may increase ( 21 ). According to other research, for every 1% increase in BMD, the occurrence of vertebral refractures decreases by 3% ( 22 ). This study indicated that the risk of post-PKP refracture decreases with increasing BMD. BMD > -2.6 is a protective factor, while BMD < -2.6 is a risk factor. This association may be attributed to the increased cortical porosity and decreased trabecular density in osteoporotic bone, resulting in reduced resistance to external forces in terms of rigidity and toughness. Additionally, patients with lower BMD may have more bone necrotic tissue after fractures, lower bone turnover markers, and poorer bone healing capacity ( 23 ). The clinical diagnostic criterion for osteoporosis is often defined as BMD < -2.5 and preventive measures should be considered for patients with BMD < -2.5. Strengthening health education, enhancing patient compliance, and increasing the duration of lumbar support device use are crucial. Adherence to standardized anti-osteoporosis treatments can help halt the progression of osteoporosis and reduce the risk of post-PKP refracture ( 24 , 25 ). A viable approach could involve utilizing calcium and vitamin D as foundational medications, supplemented with zoledronic acid or denosumab ( 26 ). The relationship between VHRR and the occurrence of post-PKP refractures has drawn the attention of researchers in the field ( 20 , 27 ). The results of this study indicate that VHRR of less than 9.8% acts as a protective factor. This implies that the partial restoration of vertebral height can help correct vertebral deformities resulting from OVCF, thereby enhancing spinal stability. In contrast, a VHRR exceeding 9.8% is a risk factor. Excessive restoration of the vertebral height may elevate tension in the surrounding soft tissues, potentially leading to an increased load on the fractured vertebra and bone necrosis ( 20 , 28 ). Furthermore, as the restored vertebral height increases, the volume of bone cement required for filling also increases. This can result in increased stiffness and strength of the broken vertebrae, as well as greater stress on the facet joints. These factors may affect spinal stability and raise the likelihood of neighboring vertebral fractures ( 29 ). Excessive restoration of vertebral height can expand the vertebral endplates, disrupting their characteristic slight concavity. This phenomenon may increase the stress load on adjacent vertebrae ( 30 ). Upon reviewing the patient imaging data, we observed that some patients experienced extreme preoperative compression of the vertebral heights, which significantly compromised spinal stability. During the surgical procedure, even a minor restoration of the vertebral height could substantially increase the VHRR and contribute to improved spinal stability. This phenomenon may explain the decreasing risk trend of VHRR exceeding 26.1% observed in the findings of this study. As the primary goal of PKP is to alleviate thoracolumbar pain, vertebral height should be cautiously and appropriately restored without excessive expansion of the fractured vertebrae. This study has several limitations. The relatively small number of cases included might have contributed to the inability to identify factors such as the lack of anti-osteoporosis treatment as independent risk factors. Additionally, being a single-center retrospective analysis primarily based on existing clinical data, further exploration of the potential risk factors for post-PKP refractures would greatly benefit from multicenter randomized controlled trials. In conclusion, BMD − 2.6 and VHRR > 9.8% were found to be independent risk factors for post-PKP refractures. In clinical practice, timely preventive and therapeutic measures should be implemented to reduce the risk of refractures in patients with these risk factors. Abbreviations OCVF, osteoporotic vertebral compression fracture; PKP, percutaneous kyphoplasty; VHRR, vertebral height restoration rate; BMI, body mass index; BMD, bone mineral density; HUV, height of the upper vertebra; HLV, height of the lower vertebra; AVH 1 , preoperative anterior vertebral height; AVH 2 , postoperative vertebral height; OR, odds ratio Declarations Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Author Contributions AZ and MK designed the study. AZ gathered the data and wrote the manuscript. XW and YL designed the figures and provided valuable feedback. 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Med Clin North Am (2021) 105:1117–34. doi: 10.1016/j.mcna.2021.05.016 Zhu S, Su Q, Zhang Y, Sun Z, Yin P, Hai Y. Risk factors of cemented vertebral refracture after percutaneous vertebral augmentation: a systematic review and meta-analysis. Neuroradiology (2020) 62:1353–60. doi: 10.1007/s00234-020-02495-9 Heo DH, Chin DK, Yoon YS, Kuh SU. Recollapse of previous vertebral compression fracture after percutaneous vertebroplasty. Osteoporos Int (2009) 20:473 – 80. doi: 10.1007/s00198-008-0682-3 Mills ES, Hah RJ, Fresquez Z, Mertz K, Buser Z, Alluri RK, et al. Secondary Fracture Rate After Vertebral Osteoporotic Compression Fracture Is Decreased by Anti-Osteoporotic Medication but Not Increased by Cement Augmentation. J Bone Joint Surg Am (2022) 104:2178–85. doi: 10.2106/JBJS.22.00469 Iida K, Kumamaru H, Saito T, Harimaya K. Overcorrection of fractured vertebrae increases the incidence of adjacent fractures after balloon kyphoplasty: A retrospective study. J Orthop (2021) 24:194–200. doi: 10.1016/j.jor.2021.02.035 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3414679","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":238682595,"identity":"f261be26-8fa5-40d2-aa8f-2146f519b9da","order_by":0,"name":"Aiqi Zhang","email":"","orcid":"","institution":"Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aiqi","middleName":"","lastName":"Zhang","suffix":""},{"id":238682596,"identity":"b789ac76-5224-4d14-95a1-b0ec4bc0345d","order_by":1,"name":"Xun Wang","email":"","orcid":"","institution":"Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xun","middleName":"","lastName":"Wang","suffix":""},{"id":238682597,"identity":"6c1141e1-aa9d-4db4-af9b-15019c0d7fee","order_by":2,"name":"Yichen Lin","email":"","orcid":"","institution":"Chinese Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yichen","middleName":"","lastName":"Lin","suffix":""},{"id":238682598,"identity":"f3c444e7-2ea0-4bef-b54f-9fdc90804557","order_by":3,"name":"Mingxiang Kong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBACCTBpAMTMIEbFASRR4rScIVoLDDC2EaFFsr338KsbBXfsNhxnfvbw67w70fwNzAdv8zDY5eHSIs1zLs06x+BZ8sxmNnNj2W3PcmccYEu25mFILsalRU4ix8w4x+BwMj8zg5m05LbDuRsYeMykeRgOJDYQ0sLGzP5NWnIOSAv/N7xapCVyjB8DtdjxM/OYSX5sANvChleLZM8ZM2aglgTJZp4yaYZjh3NnHGYztpxjkIxTi8TxHuPPOX8O2xucP75N8kfN4dz+9uaHN95U2OHUAgRsoFgAK2DmAfHBcWqAWz1IyQcgYQ9iMf7Aq3AUjIJRMApGKgAAFUJVRwZmI5oAAAAASUVORK5CYII=","orcid":"","institution":"Chinese Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mingxiang","middleName":"","lastName":"Kong","suffix":""}],"badges":[],"createdAt":"2023-10-06 01:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3414679/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3414679/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44521613,"identity":"92a7a17d-4f4c-4fb4-bdee-5b55a5258bd5","added_by":"auto","created_at":"2023-10-12 16:33:11","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":153211,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between BMD and risk of refractures\u003c/p\u003e\n\u003cp\u003eThe horizontal dashed line represents an OR of 1, corresponding to a BMD of -2.6. BMD, bone mineral density. BMD, bone mineral density\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3414679/v1/26b1270fefeb66109c52c647.jpeg"},{"id":44521614,"identity":"43d6b556-8dd9-4459-8509-31f17f0b8349","added_by":"auto","created_at":"2023-10-12 16:33:11","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":182101,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between VHRR and risk of refractures\u003c/p\u003e\n\u003cp\u003eThe horizontal dashed line represents an OR of 1, corresponding to a VHRR of 9.8%. The vertical dashed line represents an OR of 6.52, corresponding to a VHRR of 26%. VHRR, vertebral height restoration rate; PKP, percutaneous kyphoplasty.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3414679/v1/be645a6b315cb47d9ef55ff6.jpeg"},{"id":48031995,"identity":"0a7cc690-690a-4eb2-a1a9-7f407bd67eaa","added_by":"auto","created_at":"2023-12-12 06:11:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":380365,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3414679/v1/fd57eed0-5076-4729-8d77-6c3159d48311.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of Risk Factors for Subsequent Fractures Following Percutaneous Kyphoplasty for Single-Segment Osteoporotic Vertebral Compression Fractures","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eOsteoporotic vertebral compression fracture (OVCF) can cause back pain and spinal deformity, leading to reduced mobility and compromised pulmonary function (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Percutaneous kyphoplasty (PKP) is a minor surgical operation that has gained widespread application in treating OVCF. It effectively alleviates pain and restores vertebral height. This approach is associated with minimal trauma and allows rapid recovery (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, some patients who undergo PKP may experience subsequent vertebral fractures, which is considered one of the most serious complications. This can lead to severe local pain and impose considerable psychological and economic burden on patients (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Post-PKP refractures have garnered the attention of researchers in the field (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). According to reports, refractures may be correlated with a variety of factors, including age, degree of osteoporosis, extent of vertebral compression, volume of bone cement injection, distribution of bone cement, and vertebral height restoration rate (VHRR) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, no consensus has been reached on the primary risk factors contributing to refracture. Therefore, the main purpose of this study was to investigate the risk factors for post-PKP refracture and preliminarily explore the relationship between changes in risk factors and refracture occurrence.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Participants\u003c/h2\u003e \u003cp\u003eIn this retrospective study, we collected the clinical data of 289 patients who underwent PKP for single-segment OVCF at our institution between January 2018 and December 2020. Participants included 50 men and 239 women aged 49\u0026ndash;95 (74.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6) years. The distribution of the fracture segments was as follows: T5\u0026ndash;T9 in 25 cases, T10\u0026ndash;L2 in 209 cases, and L3\u0026ndash;L5 in 55 cases. Based on the occurrence of subsequent vertebral refractures after surgery, the patients were categorized into a refracture group (39 cases) and a non-fracture group (250 cases).\u003c/p\u003e \u003cp\u003eThe following were the inclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) PKP performed for single-segment vertebral fractures brought on low-energy injuries (such as falling) resulting in lumbar pain or restricted movement; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) X-ray and computed tomography findings indicating vertebral compression fracture, with magnetic resonance imaging showing low T1 and high T2 signals; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) complete medical records.\u003c/p\u003e \u003cp\u003eThe following were the exclusion criteria: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) vertebral fractures brought on tumors, infections, or tuberculosis, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) spinal cord compression accompanied neurological symptoms, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) poor cardiac and pulmonary function.\u003c/p\u003e \u003cp\u003e The Institutional Ethics Committee of our hospital approved our study, and patients were made aware that their data would be used for clinical research. The need for informed consent by study participants was waived by the Institutional Ethics Committee.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Surgical Procedure\u003c/h2\u003e \u003cp\u003eThe patient was positioned prone, and an anteroposterior view of a C-arm fluoroscopy machine was utilized to detect and project the spinous processes on both sides of the damaged vertebra. Marking lines were drawn accordingly. Standard disinfection and draping procedures were performed. Local infiltration anesthesia was administered at the puncture sites on both sides of the spinous processes. A small incision was made on the left side at the projected location of the spinous process, and a puncture was performed at approximately the 10 o'clock position under fluoroscopic guidance, focusing on the sagittal angle and medial angulation. Fluoroscopic imaging of the anteroposterior and lateral views confirmed proper needle placement at the center of the pedicle on both sides. A guide wire was then inserted and positioned roughly 0.5 cm anterior to the posterior margin of the vertebral body after the puncture needle was removed. After the guidewire was removed, a working cannula was inserted. Under the appropriate pressure, a contrast agent was injected to inflate the balloon. A guide wire was then inserted and positioned roughly 0.5 cm anterior to the posterior margin of the vertebral body after the puncture needle was removed. Under continuous C-arm fluoroscopic supervision, bone cement was slowly injected to fill the anterior part of the broken vertebral body and form an efficient mechanical column. If cement leakage occurred during the procedure, the injection was immediately ceased. After the bone cement solidified, the cannula was withdrawn, and surgery was concluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Measures\u003c/h2\u003e \u003cp\u003eThe following data were recorded for both groups: sex, age, body mass index (BMI), hypertension, diabetes, bone mineral density (BMD), anti-osteoporosis treatment, fracture segment, volume of bone cement injection, bone cement leakage, distribution of bone cement, scoliosis status, preoperative and postoperative Cobb angles, and VHRR. The associations between these factors and post-PKP refractures were investigated using univariate analysis. To identify independent risk factors for post-PKP refractures, multivariate logistic regression analysis was employed. The relationship between the identified independent risk factors and the occurrence of vertebral refracture was further analyzed.\u003c/p\u003e \u003cp\u003eA dual-energy X-ray absorptiometry instrument was used to measure BMD. Spinal scoliosis was defined as a coronal Cobb angle greater than 10\u0026deg;. Bone cement leakage was evaluated on anteroposterior and lateral X-ray images to determine if the bone cement extended beyond the vertebral boundaries, with such an extension classified as cement leakage. Bone cement dispersion was assessed on postoperative anteroposterior X-ray images to ascertain whether the bone cement crossed the midline symmetrically; crossing the midline indicates sufficient distribution, otherwise, it is considered insufficient (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The X-ray images were measured to obtain the height of the upper vertebra (HUV) of the fractured segment, height of the lower vertebra (HLV) of the fractured segment, preoperative anterior vertebral height (AVH\u003csub\u003e1\u003c/sub\u003e) of the fractured vertebra, and postoperative vertebral height (AVH\u003csub\u003e2\u003c/sub\u003e) of the fractured vertebra. The VHRR of the fractured vertebra was defined as the ratio of the difference between AVH\u003csub\u003e1\u003c/sub\u003e and AVH\u003csub\u003e2\u003c/sub\u003e divided by the average of HUV and HLV. The formula is as follows: VHRR =[2\u0026times;(AVH\u003csub\u003e2\u003c/sub\u003e - AVH\u003csub\u003e1\u003c/sub\u003e) / (HUV\u0026thinsp;+\u0026thinsp;HLV)]\u0026times;100% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Postoperative Management\u003c/h2\u003e \u003cp\u003eAs foundational therapy, the anti-osteoporosis treatment regimen included oral calcium supplements and active vitamin D, supplemented with an intravenous infusion of zoledronic acid or subcutaneous denosumab injections. The anabolic agent teriparatide is not the first-choice medication due to its high cost. Some patients who smoke and consume alcohol should also be encouraged to quit smoking and drinking. All patients underwent spinal anteroposterior and lateral X-ray examinations 24 hours after the surgery. Outpatient follow-up visits were scheduled at 1 month, 3 months, 6 months, 1 year, and 2 years after discharge. During these follow-up visits, spinal X-ray examinations were conducted. If a patient experienced symptoms such as lower back pain or restricted mobility, an magnetic resonance imaging examination could be considered. The study endpoint was set at 2 years or the occurrence of a recurrent fracture during outpatient follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Diagnosis of PKP Re-fracture\u003c/h2\u003e \u003cp\u003eThe diagnostic criteria for post-PKP fractures are as follows:1. New-onset lower back pain or limited lower back mobility after PKP surgery.2. Spine X-rays and magnetic resonance imaging findings indicating vertebral fractures at a different location from the surgical site.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Statistical Assessments\u003c/h2\u003e \u003cp\u003eSPSS 26.0 (IBM Corporation, Armonk, New York, USA) and R (version 4.2.0) were used for statistical analysis. The Kolmogorov\u0026ndash;Smirnov test was used to determine the data's normality. The mean and standard deviation of normally distributed continuous variables were provided, and between-group comparisons were made with an independent samples t-test. Non-normally distributed continuous variables were given as medians and interquartile ranges, and the Mann\u0026ndash;Whitney U test was used to compare groups. Categorical data were presented as counts and/or percentages, with group comparisons using the chi-squared test. The multivariate logistic regression analysis comprised observed indicators with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in the univariate study. Nonrestrictive cubic spline functions were employed to explore the correlations between the independent risk factors selected from the multivariate analysis. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eWe included 289 patients in the study. Among them, 39 (14%) experienced refractures after PKP, whereas 250 (86%) did not experience refractures. Sixteen cases of proximal vertebral fractures and 23 cases of distal vertebral fractures were discovered. In the refracture group, the mean age was 78.54 (\u0026plusmn;\u0026thinsp;7.92) years, with 6 men (15%) and 33 women (85%). In the non-refracture group, the mean age was 74.09 (\u0026plusmn;\u0026thinsp;9.67) years, with 44 men (18%) and 206 women (82%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical features of the refracture group and non-refracture group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefracture Group (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-Refracture Group (n\u0026thinsp;=\u0026thinsp;250)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e206 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of hypertension, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138 (55.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (44.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of diabetes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.734\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e206 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnti-osteoporotic treatment, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116 (46.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134 (53.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture segment, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT\u003csub\u003e5\u003c/sub\u003eཞT\u003csub\u003e9\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9(23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16(6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT\u003csub\u003e10\u003c/sub\u003eཞL\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27(69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e182(72.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL\u003csub\u003e3\u003c/sub\u003eཞL\u003csub\u003e5\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52(20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cement dosage, mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.8(4.0,6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.9(4.0,6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cement leakage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e190 (76.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBone cement dispersion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e226 (90.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScoliosis status, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e163 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-op Cobb angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.6(12.0,22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.1(7.0,16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op Cobb angle (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.7(5.0,15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.4(4.0,12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVHRR, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.2 (18.1, 29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.9 (3.2, 19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, number (%). BMI, body mass index; BMD, bone mineral density; VHRR, vertebral height restoration rate.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of the univariate analysis indicated that age, BMI, BMD, postoperative anti-osteoporosis treatment, fracture segment, preoperative Cobb angle, and VHRR were significantly correlated with post-PKP refractures (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In contrast, sex, hypertension, diabetes, bone cement dosage, bone cement leakage, bone cement dispersion, presence of spinal scoliosis, and postoperative Cobb angle revealed no significant correlation with post-PKP refractures (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). According to the results of multivariate logistic regression analysis, BMD and VHRR were strongly linked with post-PKP refracture (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical features of the normal group and refracture group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eWald\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%\u003cem\u003eCI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.00, 1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.85, 1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.45, 0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnti-osteoporotic treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.28, 1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAugmentation segment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.26, 1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-op Cobb angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.00, 1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.064\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVHRR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.17, 1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e༜0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMI, body mass index; BMD, bone mineral density; VHRR, vertebral height restoration rate; OR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnalysis using nonrestrictive cubic spline functions indicated that BMD had a monotonic relationship with the risk of post-PKP refractures. With BMD \u0026lt; -2.6, the risk of post-PKP refractures decreases as BMD increases. At BMD = -2.6, the odds ratio (OR) is 1. For BMD \u0026gt; -2.6, the risk of refractures stabilizes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe relationship between VHRR and the risk of post-PKP refractures follows a \"U\"-shaped pattern. Beyond a VHRR of 9.8% (OR\u0026thinsp;=\u0026thinsp;1), the risk of post-PKP refracture increases. At a VHRR of 26.1% (OR\u0026thinsp;=\u0026thinsp;6.52), the risk reaches its highest and then gradually decreases but remains higher than the levels before 9.8% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003ePKP is widely utilized for OVCF treatment because of its advantages, including minimal invasiveness, rapid recovery, swift pain relief, and partial vertebral height restoration (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, some patients undergoing PKP may experience postoperative refractures, with reported incidence rates ranging from 9.3\u0026ndash;34.8% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In our study, the probability of recurrent vertebral fractures was determined to be 13.5%, indicating a low incidence rate. Numerous studies have examined the risk factors of post-PKP refracture in patients with OVCF. The results suggest that age, sex, BMD, BMI, distribution of bone cement, and spinal scoliosis may increase the incidence of post-PKP refractures (\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, these studies have primarily focused on analyzing independent risk factors for post-PKP fractures without providing insights into how changes in these risk factors may influence the risk of refractures. VHRR and BMD were found to be independent risk factors for refractures after PKP in this study, which also carried out an initial exploration into the relationship between variables in independent risk factors and the discovered risk of recurrent fractures. Gaining an understanding of the risk factors for recurrent fractures and how changes in these factors influence the variation in risk can greatly assist clinicians in implementing appropriate preventive measures and tailored treatment strategies. This knowledge can also contribute to optimizing the allocation of healthcare resources.\u003c/p\u003e \u003cp\u003eOsteoporosis is a systemic bone disease characterized by low bone mass, which leads to microstructural degradation and increased bone tissue fragility. As osteoporosis progresses, the risk of post-PKP refracture may increase (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). According to other research, for every 1% increase in BMD, the occurrence of vertebral refractures decreases by 3% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This study indicated that the risk of post-PKP refracture decreases with increasing BMD. BMD \u0026gt; -2.6 is a protective factor, while BMD \u0026lt; -2.6 is a risk factor. This association may be attributed to the increased cortical porosity and decreased trabecular density in osteoporotic bone, resulting in reduced resistance to external forces in terms of rigidity and toughness. Additionally, patients with lower BMD may have more bone necrotic tissue after fractures, lower bone turnover markers, and poorer bone healing capacity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The clinical diagnostic criterion for osteoporosis is often defined as BMD \u0026lt; -2.5 and preventive measures should be considered for patients with BMD \u0026lt; -2.5. Strengthening health education, enhancing patient compliance, and increasing the duration of lumbar support device use are crucial. Adherence to standardized anti-osteoporosis treatments can help halt the progression of osteoporosis and reduce the risk of post-PKP refracture (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A viable approach could involve utilizing calcium and vitamin D as foundational medications, supplemented with zoledronic acid or denosumab (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe relationship between VHRR and the occurrence of post-PKP refractures has drawn the attention of researchers in the field (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The results of this study indicate that VHRR of less than 9.8% acts as a protective factor. This implies that the partial restoration of vertebral height can help correct vertebral deformities resulting from OVCF, thereby enhancing spinal stability. In contrast, a VHRR exceeding 9.8% is a risk factor. Excessive restoration of the vertebral height may elevate tension in the surrounding soft tissues, potentially leading to an increased load on the fractured vertebra and bone necrosis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Furthermore, as the restored vertebral height increases, the volume of bone cement required for filling also increases. This can result in increased stiffness and strength of the broken vertebrae, as well as greater stress on the facet joints. These factors may affect spinal stability and raise the likelihood of neighboring vertebral fractures (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Excessive restoration of vertebral height can expand the vertebral endplates, disrupting their characteristic slight concavity. This phenomenon may increase the stress load on adjacent vertebrae (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Upon reviewing the patient imaging data, we observed that some patients experienced extreme preoperative compression of the vertebral heights, which significantly compromised spinal stability. During the surgical procedure, even a minor restoration of the vertebral height could substantially increase the VHRR and contribute to improved spinal stability. This phenomenon may explain the decreasing risk trend of VHRR exceeding 26.1% observed in the findings of this study. As the primary goal of PKP is to alleviate thoracolumbar pain, vertebral height should be cautiously and appropriately restored without excessive expansion of the fractured vertebrae.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The relatively small number of cases included might have contributed to the inability to identify factors such as the lack of anti-osteoporosis treatment as independent risk factors. Additionally, being a single-center retrospective analysis primarily based on existing clinical data, further exploration of the potential risk factors for post-PKP refractures would greatly benefit from multicenter randomized controlled trials.\u003c/p\u003e \u003cp\u003eIn conclusion, BMD \u0026minus;\u0026thinsp;2.6 and VHRR\u0026thinsp;\u0026gt;\u0026thinsp;9.8% were found to be independent risk factors for post-PKP refractures. In clinical practice, timely preventive and therapeutic measures should be implemented to reduce the risk of refractures in patients with these risk factors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOCVF, osteoporotic vertebral compression fracture; PKP, percutaneous\u0026nbsp;kyphoplasty; VHRR, vertebral height restoration rate; BMI,\u0026nbsp;body mass index; BMD, bone mineral density; HUV,\u0026nbsp;height of the upper vertebra; HLV, height of the lower vertebra; AVH\u003csub\u003e1\u003c/sub\u003e, preoperative anterior vertebral height; AVH\u003csub\u003e2\u003c/sub\u003e, postoperative vertebral height; OR, odds ratio\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eConflict of Interest\u003c/h3\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003ch3\u003eAuthor Contributions\u003c/h3\u003e\n\u003cp\u003eAZ and MK designed the study. AZ gathered the data and wrote the manuscript. XW and YL designed the figures and provided valuable feedback. AZ and MK revised the manuscript. All authors agreed on the final manuscript. The article was composed by all of the authors, and the final version was approved by all of them.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch3\u003e\u0026nbsp;Acknowledgments\u003c/h3\u003e\n\u003ch3\u003eData Availability Statement\u003c/h3\u003e\n\u003cp\u003eThe raw data supporting the conclusion of this article will be made available without restriction by the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e \u003cli\u003e\u003cspan\u003eSchlaich C, Minne HW, Bruckner T, et al. Reduced pulmonary function in patients with spinal osteoporotic fractures. Osteoporos Int. 1998. 8(3): 261\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFehlings MG. The safety of percutaneous vertebroplasty and kyphoplasty. J Neurosurg Spine. 2009. 11(5): 605-6; discussion 606.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi YX, Guo DQ, Zhang SC, et al. Risk factor analysis for re-collapse of cemented vertebrae after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). Int Orthop. 2018. 42(9): 2131\u0026ndash;2139.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao W, Chen Y, Wang X, Liu G, Cui K, Guo J, et al. Establishment and Verification of a Predictive Nomogram for New Vertebral Compression Fracture Occurring after Bone Cement Injection in Middle-Aged and Elderly Patients with Vertebral Compression Fracture. 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J Bone Joint Surg Am (2022) 104:2178\u0026ndash;85. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.22.00469\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.22.00469\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIida K, Kumamaru H, Saito T, Harimaya K. Overcorrection of fractured vertebrae increases the incidence of adjacent fractures after balloon kyphoplasty: A retrospective study. J Orthop (2021) 24:194\u0026ndash;200. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jor.2021.02.035\u003c/span\u003e\u003cspan address=\"10.1016/j.jor.2021.02.035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"kyphoplasty, osteoporosis, spinal fractures, risk factors, subsequent fracture","lastPublishedDoi":"10.21203/rs.3.rs-3414679/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3414679/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e The purpose of this study was to look into the risk factors for recurrent fractures following percutaneous kyphoplasty (PKP) in patients with single-level osteoporotic vertebral compression fractures (OVCF).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective cohort study analyzed the clinical data of 289 patients who underwent PKP for single-segment OVCF at our institution from January 2018 to December 2020. The patients were categorized into the refracture group (39 cases) and the non-refracture group (250 cases) based on whether new vertebral fractures occurred postoperatively. Sex, age, body mass index (BMI), hypertension, diabetes, bone mineral density (BMD), osteoporosis treatment, fracture level, bone cement injection volume, bone cement leakage, bone cement distribution, spinal scoliosis, pre-and postoperative Cobb angles, and vertebral height restoration rate were recorded. Univariate analysis was conducted to examine the correlation between variables and subsequent vertebral fractures. Subsequently, multivariable logistic regression analysis was performed to determine independent risk factors.. Nonrestrictive cubic spline functions were employed to explore the correlations between the independent risk factors selected from the multivariate analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe univariate analysis revealedthat age, BMI, BMD, postoperative anti-osteoporosis treatment, fracture level, preoperative Cobb angle, and vertebral height restoration rate were significantly correlated with postoperative vertebral refracture after PKP (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). The results of the multivariable logistic regression analysis revealed that a BMD less than -2.6 (odds ratio (OR)=0.64, 95% confidence interval (CI)0.45,0.90, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05) and a vertebral height restoration rate greater than 9.8% (OR=1.40, 95% CI 1.17,1.68, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.01) were significantly linked to post-PKP recurrent fractures. The results of the nonrestrictive cubic spline function indicated a monotonic relationship between BMD and risk of PKP refracture. The risk of PKP refracture decreased with increased BMD after PKP surgery. The relationship between vertebral height restoration rate and the risk of PKP refracture followed a \"U\" shaped pattern. After the vertebral height restoration rate exceeded 9.8%, the risk of PKP refracture increased, reaching its highest point at 26.1% and then slightly declining.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eBMD\u0026lt;-2.6 and a vertebral height restoration rate\u0026gt;9.8% are independent risk factors for postoperative vertebral refracture in patients with OVCF following PKP.\u003c/p\u003e","manuscriptTitle":"Analysis of Risk Factors for Subsequent Fractures Following Percutaneous Kyphoplasty for Single-Segment Osteoporotic Vertebral Compression Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-12 16:33:06","doi":"10.21203/rs.3.rs-3414679/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a4e07d5-85a9-4ebb-8d25-a21be4236adb","owner":[],"postedDate":"October 12th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-12T05:59:37+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-12 16:33:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3414679","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3414679","identity":"rs-3414679","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}