Refracture and Mortality Following Surgical Management of Osteoporotic Vertebral Fractures: A Systematic Review and Meta-Analysis with Patient-Level Survival Modeling

Background/Objectives: Osteoporotic vertebral fractures (OVFs) are a growing global health burden, often managed surgically with vertebroplasty or kyphoplasty. However, long-term outcomes such as refracture and mortality remain poorly characterized across heterogeneous studies. The study aims to determine the pooled rates of refracture and mortality following surgical treatment of OVFs, and to identify clinical and procedural predictors of these outcomes using meta-regression and reconstructed survival analysis. Methods: This systematic review and meta-analysis adhered to PRISMA 2020 guidelines. PubMed, Scopus, and Web of Science were searched up to 15 April 2025. Studies reporting refracture or mortality outcomes after surgical intervention for OVFs in adults were included. Data synthesis used random-effects meta-analysis. Subgroup and meta-regression analyses explored heterogeneity. Individual patient-level data (IPD) were reconstructed from Kaplan–Meier curves to generate survival estimates and Cox proportional hazards models. Results: Eighty-two studies (n = 1,174,092 patients) were included. The pooled refracture rate was 18% (95% CI: 15–21%), with significantly higher rates associated with cement leakage (p = 0.006). Meta-regression found no significant associations with BMD, age, or prior fracture history. Time-to-event analysis revealed a steep increase in refracture within the first 12–24 months. Patients receiving percutaneous vertebroplasty (PVP) had a significantly lower hazard of refracture compared to kyphoplasty (HR = 0.036, 95% CI: 0.033–0.040; p < 0.0001). The pooled postoperative mortality rate was 15% (95% CI: 9–22%). Diabetes was positively associated with mortality risk (p = 0.001), while prior fracture history showed a significant effect. Survival probability was significantly higher in patients treated with kyphoplasty compared to vertebroplasty (HR = 4.64, 95% CI: 3.55–6.07; p < 0.0001). Conclusions: Surgical treatment for OVFs is associated with substantial refracture and mortality risk, particularly within the first two years postoperatively. Cement leakage and diabetes significantly influence outcomes. Vertebroplasty appears protective against refracture, whereas kyphoplasty may confer a survival advantage; however, these associations should be interpreted as exploratory and hypothesis-generating due to high heterogeneity and methodological limitations.