Comparative analysis of the safety and efficacy of fenestrated pedicle screw with cement and conventional pedicle screw with cement in the treatment of osteoporotic vertebral fractures: A meta-analysis

Abstract

Purpose: Bone cement-reinforced fenestrated pedicle screws (FPSs) have been widely used in the internal fixation and repair of the spine with osteoporosis in recent years and show significant improvement in fixation strength and stability. However, compared with conventional reinforcement methods, the advantages of bone cement-reinforced FPSs remain undetermined. This article compares the effects of fenestrated and conventional pedicle screws (CPSs) combined with bone cement in the treatment of osteoporosis.

Methods: A clinical control study of FPSs and CPSs combined with bone cement reinforcement in osteoporotic vertebral internal fixation was performed using the database PubMed, Embase, Cochrane Library, CNKI, the Wanfang, and the China Biomedical Literature Service System. Two evaluators screened the relevant literature in strict accordance with the inclusion criteria (diagnosis of participants, type of clinical study, treatment with FPS and CPS, and outcome indicators) and exclusion criteria (duplicate literature and missing or incorrect data) and independently conducted data extraction and quality evaluation. Clinical control studies of direct comparison between FPS and CPS combined with bone cement reinforcement in patients who were definitively diagnosed with thoracolumbar fractures or spinal degenerative diseases were included. Quality evaluation was conducted using the Cochrane risk bias evaluation tool for randomized controlled studies and using the Newcastle-Ottawa scale for retrospective case-control studies. RevMan software (version 5.3) was used for the meta-analysis to compare the clinical efficacy, radiological results, and related complications of the 2 methods.

Results: A total of 13 articles were included, including 7 randomized controlled studies and 6 retrospective case-control studies. There were 909 patients in these studies, 451 in the FPS and polymethyl methacrylate (FPS & PMMA) group and 458 in the CPS and polymethyl methacrylate (CPS & PMMA) group. The results of the meta-analysis showed that there was no significant difference between the 2 groups in operation time, hospital stay, visual analogue score, Japanese orthopaedic association score, Oswestry disability index score, Cobb angle, vertebral body deformation index and fusion rate (p > 0.05). The mean difference of intraoperative bleeding volume was -10.45, (95% confidence intervals (CI) (-16.92, -3.98), p = 0.002), the mean difference of loss height of the anterior edge of the vertebral body after surgery was -0.69 (95% CI (-0.93, -0.44), p < 0.001), and the relative risk (RR) of overall complication rate was 0.43 (95% CI (0.27, 0.68), p < 0.001), including the RR of bone cement leakage rate was 0.57 (95% CI (0.39, 0.85), p = 0.005). The screw loosening rate (RR = 0.26, 95% CI (0.13, 0.54), p < 0.001) of the FPS group was significantly lower than that of the CPS group.

Conclusion: The existing clinical evidence shows that compared with the CPS combined with bone cement, the use of FPS repair in the internal fixation of an osteoporotic vertebral body can reduce the amount of intraoperative bleeding, be more conducive to maintaining the height of the vertebral body, and significantly reduce the incidence of postoperative complications such as bone cement leakage and screw loosening.

Keywords: Bone cement leakage; Bone cement strengthening; Complication; Internal fixation; Meta-analysis; Osteoporosis; Pedicle screw.

Fig. 1

Literature screening process diagram.

Fig. 2

Literature risk assessment chart.

Fig. 3

Forest plot of differences in operation time, intraoperative bleeding, and inpatient time in each group. (A) Forest plot of operation time; (B) Forest plot of intraoperative blood loss; (C) Forest plot of inpatient time. FPS: fenestrated pedicle screw, PMMA: polymethyl methacrylate, CPS: conventional pedicle screw, SD: standard deviation, CI: confidence intervals.

Fig. 4

Forest plot of differences in clinical efficacy of each group. (A) Forest plot of the last follow-up visual analogue scale score; (B) Forest plot of the last follow-up JOA score; (C) Forest plot of the last follow-up ODI. FPS: fenestrated pedicle screw, PMMA: polymethyl methacrylate, CPS: conventional pedicle screw, SD: standard deviation, CI: confidence intervals, JOA: Japanese orthopaedic association, ODI: Oswestry disability index.

Fig. 5

Forest plot of parameter differences of imaging results in each group. (A) Forest plot of the last follow-up Cobb angle; (B) Forest plot of postoperative deformation index of vertebrae; (C) Forest plot of postoperative anterior vertebral height loss; (D) Forest plot of the fusion rate. FPS: fenestrated pedicle screw, PMMA: polymethyl methacrylate, CPS: conventional pedicle screw, SD: standard deviation, CI: confidence intervals.

Fig. 6

Forest plot of difference of postoperative complications in each group. (A) Forest plot of incidence of complications; (B) Forest plot of bone cement leakage; (C) Forest plot of the rate of screw loosening; (D) Forest plot of incidence of cerebrospinal fluid leakage; (E) Forest plot of incidence of incision infection. FPS: fenestrated pedicle screw, PMMA: polymethyl methacrylate, CPS: conventional pedicle screw, SD: standard deviation, CI: confidence intervals.