A retrospective study of 1,307 patients undergoing elective percutaneous vertebroplasty for osteoporotic vertebral compression fractures found that 136, or 10.4%, had a puncture-site wound event within two weeks of surgery. The composite outcome included erythema or swelling, bleeding or exudate, subcutaneous hematoma, and infection. After adjustment for patient and procedural factors, suture closure was associated with more than twice the risk of the composite outcome, while diabetes, mildly elevated international normalized ratio, and multilevel treatment were also associated with higher risk.

The findings come from consecutive patients treated at Ningde Municipal Hospital in China between January 2022 and June 2026. Patients were excluded if they underwent surgery for a new fracture, had uncontrolled coagulation disorders, received concomitant open spinal surgery, required an intraoperative incision at the puncture site, had malignant tumors or abnormal immune status, or lacked key clinical or follow-up information. The analysis therefore describes elective vertebroplasty performed within one hospital system, rather than all fracture patients or all puncture wounds treated after other forms of spine surgery.

Researchers extracted information from electronic medical records, operative and anesthesia records, laboratory reports, dressing-change notes, wound-clinic assessments, and documented telephone follow-up. All puncture sites were covered with waterproof dressings and assessed within two weeks through inpatient observation, clinical review, or telephone follow-up. A wound event was counted only when explicitly documented in the records. Erythema, swelling, bleeding, exudate, hematoma, and infection were combined into one patient-level outcome, counted once even if a patient experienced several types of event, while individual components were also summarized separately.

Closure was not assigned through a randomized comparison. The operating physician selected nonsuture or suture closure according to intraoperative bleeding, exudation, skin condition, wound tension, and routine practice. Sutured wounds were typically closed with one 3-0 Vicryl Rapide stitch. Among the 1,307 patients, 774 received nonsuture closure and 533 received sutures. An early event was recorded in 53 nonsuture cases, or 6.8%, and in 83 sutured cases, or 15.6%. The crude risk ratio for any event was 2.27, with a 95% confidence interval of 1.64 to 3.15 and a P value below 0.001.

After the researchers adjusted for closure method, diabetes, INR above 1.2, age, sex, body mass index, and multilevel treatment, the association with suturing remained. The adjusted risk ratio was 2.24, with a 95% confidence interval of 1.59 to 3.16 and P below 0.001. Diabetes was associated with an adjusted risk ratio of 1.57, with a 95% confidence interval of 1.11 to 2.21 and P equal to 0.010. An INR above 1.2, defined using the hospital laboratory’s upper reference limit, was associated with an adjusted risk ratio of 1.66, with a 95% confidence interval of 1.08 to 2.57 and P equal to 0.022. Multilevel treatment had an adjusted risk ratio of 1.73, with a 95% confidence interval of 1.03 to 2.89 and P equal to 0.038.

The component findings were concentrated in relatively common superficial manifestations rather than infection. Erythema or swelling occurred in 4.1% of patients with nonsuture closure and 10.9% of those with sutures, producing a crude risk ratio of 2.63, with a 95% confidence interval of 1.73 to 3.99. Bleeding or exudate occurred in 2.7% and 5.8% of the respective groups, with a crude risk ratio of 2.14 and a 95% confidence interval of 1.25 to 3.69. Subcutaneous hematoma was uncommon, affecting two nonsuture cases and three sutured cases, and its wide confidence interval included no difference. Infection was documented in one nonsuture case and no sutured cases, too few events to model infection separately.

Age, sex, and body mass index were not independently associated with the composite outcome in the primary adjusted model. Each additional decade of age had an adjusted risk ratio of 1.15, with a 95% confidence interval of 0.94 to 1.41 and P equal to 0.186. Female sex had an adjusted risk ratio of 0.96, with a 95% confidence interval of 0.66 to 1.39 and P equal to 0.829, while each 1 kg/m² increase in body mass index had an adjusted risk ratio of 1.07, with a 95% confidence interval of 0.99 to 1.17 and P equal to 0.091. These estimates mean that the study did not find clear independent associations for those demographic and anthropometric measures, not that they have no relationship to wound events in every clinical setting.

The suture result is particularly notable because the design cannot establish that suturing caused the additional events. The authors excluded several conditions that could make closure decisions unusual, including uncontrolled coagulation disorders, concomitant open surgery, and wounds requiring an intraoperative incision. Even so, surgeons may have selected sutures for locally difficult wounds, bleeding, exudation, poor skin condition, or excessive tension. Those unrecorded features could confound the comparison, while the fact that sutured patients may have had more wound checks or suture-removal visits could also increase the likelihood that mild redness or exudate was noticed and recorded. The finding should therefore be interpreted as an adjusted observational association rather than proof that sutures themselves produce wound inflammation or other complications.

Several other constraints limit what the study can establish. Follow-up was retrospective and varied among inpatient observation, wound-clinic examination, and telephone reporting, so assessment intensity and recording thresholds were not standardized. Very mild redness or transient bleeding may have been missed, and the records did not consistently capture event duration, patient discomfort, additional care, revisits, or hospitalization. The composite endpoint improved capture of local findings but combined conditions with different causes and severities. Only one infection occurred within two weeks, preventing meaningful analysis of surgical-site infection or later infections. The single-center design and the selected elective population also limit generalizability to open spine surgery, malignant disease, immunosuppression, or puncture sites requiring remedial closure.

Overall, the study identifies four factors associated with the short-term local wound status after elective vertebroplasty: suture closure, diabetes, elevated INR, and multilevel treatment. Its practical signal is that early observation may be especially relevant for patients with these characteristics, although the findings do not establish a clinical rule or a preferred closure technique. Because closure was clinician-selected, follow-up was not standardized, and the endpoint combined mild events with rare infection, the results point to priorities for further prospective research rather than definitive guidance. Within those limits, the observed 15.6% event rate after suturing compared with 6.8% after nonsuture closure provides the clearest signal in the cohort, while the observational design makes the mechanism unresolved.

Subject of Research: Factors associated with early puncture-site wound events after percutaneous vertebroplasty for osteoporotic vertebral compression fractures

Article Title: Factors associated with early puncture-site wound events after percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a retrospective cohort study

Article References: He, X., Huang, C., Zheng, B., Wu, X., Huang, C., Lu, S., Huang, Y., Chen, J., Huang, J., & Li, B. (2026). Factors associated with early puncture-site wound events after percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a retrospective cohort study. Frontiers in Medicine, 13, Article 1988843. https://doi.org/10.3389/fmed.2026.1988843

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1988843

Keywords: Percutaneous vertebroplasty, Osteoporotic fractures, Puncture-site wounds, Suture closure, Diabetes, Coagulation, Multilevel treatment, Retrospective cohort, Postoperative care, Factors, associated, early

Cardiovascular magnetic resonance measurements identified a hemodynamic pattern associated with death or heart-transplant referral or listing in people with Fontan circulation, according to a retrospective study of 182 patients followed at a moderate-altitude center. Patients who later experienced the composite outcome had a lower superior vena cava flow index than those who did not. In time-to-event analysis, each 0.1-liter-per-minute-per-square-meter increase in the indexed flow was associated with a 30% lower hazard of the outcome.

The association remained in an exploratory model that also included ventricular ejection fraction, but the researchers said the estimate requires prospective, multicenter validation before clinical application. The cohort comprised people who had undergone Fontan palliation between 1999 and 2021 at a tertiary institution approximately 5,118 feet above sea level. Fontan circulation passively directs systemic venous blood into the pulmonary arteries without the support of a sub-pulmonary ventricle.

Eligible participants had a clinically indicated CMR examination at least five years after Fontan completion, a threshold selected to match the center’s routine surveillance practice. For patients with multiple examinations, investigators used the last CMR obtained before an outcome or censoring. Most participants, 173 of 182, or 95%, had an extracardiac conduit Fontan circulation, and 76, or 42%, underwent a Damus–Kaye–Stansel anastomosis.

At CMR, the median body surface area was 1.43 square meters, with an interquartile range of 1.16 to 1.69 square meters. The median age at Fontan completion was 3.2 years, and the median interval between surgery and imaging was 10.9 years. Median follow-up after CMR was 4.7 years, while participants’ median home elevation was 5,221 feet above sea level.

Hypoplastic left heart syndrome was the most common underlying diagnosis, accounting for 35% of the cohort, followed by tricuspid atresia at 30%. The systemic ventricle was left-dominant in 53% and right-dominant in 47%. Magnetic resonance examinations were performed on 1.5- or 3.0-tesla scanners, with cine imaging used to assess ventricular function and phase-contrast sequences used to measure blood flow.

The primary endpoint combined death with referral or listing for heart transplantation. Fourteen patients, or 7.7% of the cohort, met that endpoint during follow-up: two died and 12 were referred or listed for transplantation. Among patients who experienced the outcome, the median time from CMR to the first qualifying event was 1.2 years, with an interquartile range of 0.5 to 2.5 years.

The median superior vena cava flow index was 0.54 liters per minute per square meter among patients with the primary outcome, compared with 0.82 liters per minute per square meter among those without it; the difference was statistically significant, with a p-value of 0.011. The superior vena cava-to-ascending-aorta flow ratio was also lower in the event group, with medians of 0.22 and 0.30, respectively. Several other CMR flow measures did not differ significantly between patients with and without the primary outcome.

These included flow indices in the ascending aorta, right pulmonary artery, left pulmonary artery and inferior vena cava, as well as calculated systemic-to-pulmonary collateral flow. Receiver operating characteristic analysis indicated that superior vena cava flow index discriminated between patients who met the endpoint and those who did not with an area under the curve of 0.74 and a 95% confidence interval of 0.56 to 0.92. A data-derived threshold of 0.66 liters per minute per square meter, selected using the Youden index, yielded 70% sensitivity and 75% specificity.

Kaplan–Meier curves showed significantly poorer event-free survival among patients below that threshold. Because the threshold and discrimination measures came from the same cohort, they are exploratory rather than externally validated clinical cutoffs. Univariable Cox proportional hazards regression found a hazard ratio of 0.70 for each 0.1-liter-per-minute-per-square-meter increase in superior vena cava flow index, with a 95% confidence interval of 0.50 to 0.92 and a p-value of 0.008.

Right-dominant ventricular morphology was also associated with a higher hazard than left-ventricular dominance, with a hazard ratio of 3.21, a 95% confidence interval of 1.00 to 10.29 and a p-value of 0.049. The investigators constructed a two-variable Cox model containing superior vena cava flow index and ejection fraction. Each one-percentage-point increase in ejection fraction was associated with an adjusted hazard ratio of 0.92, with a 95% confidence interval of 0.86 to 0.97.

Because only 14 primary events occurred, the multivariable analysis was deliberately restricted and was intended to test whether the flow association persisted beyond ventricular function rather than develop a full prediction model. Internal bootstrap analysis using 2,500 resamples produced a median hazard ratio of 0.71 for superior vena cava flow index and 0.92 for ejection fraction, close to the original adjusted estimates. Collinearity between the two variables was negligible, with a Spearman absolute correlation below 0.1, an R-squared value of 0.008 and a variance inflation factor of 1.01.

Tests did not indicate violation of the proportional-hazards assumption. Ventricular measures also differed according to morphology: in the right-dominant subgroup, patients with events had larger indexed ventricular volumes and lower ejection fraction than those without events, whereas comparable differences were not statistically significant in the smaller left-dominant event subgroup. The study does not establish why lower superior vena cava flow was associated with poorer outcomes.

One proposed explanation is that chronic hypobaric exposure at moderate altitude promotes pulmonary vasoconstriction and raises pulmonary vascular resistance, potentially restricting passive flow through the Fontan pathway. However, pulmonary vascular resistance was not directly measured, and the cohort included no sea-level comparator, so the study cannot determine whether altitude caused the observed hemodynamic pattern. Other possible contributors include anatomical differences in the superior vena cava, systemic venovenous collateral vessels that divert blood around the pulmonary vascular bed, and differences in preload or single-ventricle filling.

The findings therefore associate reduced indexed flow with an unfavorable hemodynamic state rather than demonstrate a specific underlying mechanism. Important limitations constrain the results. The retrospective, single-center design creates the possibility of selection bias, and clinically performed CMR examinations were not acquired at standardized surveillance intervals.

Selecting the last scan before an outcome or censoring may introduce reverse-causation bias because patients approaching clinical deterioration could have been imaged nearer the event. Clinically relevant potential confounders—including functional class, cardiopulmonary exercise capacity, resting oxygen saturation, natriuretic peptide levels, catheterization-derived Fontan pressure and pulmonary vascular resistance, pulmonary vasodilator therapy, arrhythmia burden and the severity of liver disease—were unavailable or not incorporated. The small number of events also leaves the multivariable estimates vulnerable to overfitting despite the deliberately parsimonious model and bootstrap resampling.

Furthermore, the predominance of fenestrated extracardiac conduit Fontan circulation limits generalizability to other surgical configurations. The results position superior vena cava flow index as a candidate prognostic marker that may complement ventricular size and ejection fraction in longitudinal assessment of Fontan circulation, but they do not establish a clinical measurement rule or treatment strategy. Prospective, multicenter studies comparing cohorts across elevations would be needed to test the temporal relationship, determine whether altitude modifies the association, and establish external validity.

The authors also identified four-dimensional flow CMR as a possible tool for characterizing three-dimensional flow patterns and energy loss within the Fontan pathway. Further work could compare imaging signatures with exercise physiology, biomarkers of end-organ dysfunction and pulmonary vascular imaging. Until those studies are completed, the association between reduced superior vena cava flow and adverse outcomes should be regarded as an exploratory finding that requires independent validation.

Subject of Research: Association between CMR-derived blood flow and adverse outcomes in people with Fontan circulation

Article Title: Cardiovascular magnetic resonance–derived hemodynamics predict adverse outcomes after Fontan palliation

Article References: Platnick, C., Frank, B., Romanowicz, J., Gonzalez De Alba, C., Chase, M., Umer, A., Chaudhuri, N. R., Awori, J., Chauhan, D., Mascio, C. E., Udassi, J. P., & Hedjazi Moghari, M. (2026). Cardiovascular magnetic resonance–derived hemodynamics predict adverse outcomes after Fontan palliation. Frontiers in Cardiovascular Medicine, 13, Article 1937933. https://doi.org/10.3389/fcvm.2026.1937933

Image Credits: AI Generated

DOI: 10.3389/fcvm.2026.1937933

Keywords: Fontan circulation, cardiovascular magnetic resonance, superior vena cava flow, heart transplantation, congenital heart disease, risk stratification, ventricular function, moderate altitude, flow quantification, retrospective cohort, Cardiovascular, magnetic