Teriparatide Treatment of a Glucocorticoid-associated Resorbing Nonunion of a Type III Odontoid Process Fracture: A Case Report

Efficacy and Safety of Teriparatide in Improving Fracture Healing and Callus Formation: A Systematic Review

Fracture nonunion remains a great challenge for orthopedic surgeons. Some bone fractures don't heal promptly, resulting in delayed unions and nonunions, and there is a need for an additional surgical procedure. Previous research has shown that teriparatide, a type of synthetic parathyroid hormone, can promote the formation of callus and lead to healing in individuals with delayed or non-healing bone fractures. Limited systematic reviews exist that examine the use of teriparatide in cases of delayed healing or non-healing bone fractures, which have their limitations. In this review, we overcome those limitations by including prospective studies, retrospective studies, case reports, and case series together. A systematic search of the literature was conducted in both PubMed and Google Scholar up to September of the year 2022. The studies included in our research included adult patients (over the age of 16) diagnosed with delayed union or nonunion of any bone in the body (flat bone, long bone, short bone, or irregular bone). The studies were limited to those written in English. The outcomes that were tracked and recorded include the healing of the fracture and any negative side effects or adverse events. The initial search yielded 504 abstracts and titles. After reviewing these, 32 articles were selected for further analysis, which included 19 case reports, five case series, two retrospective studies, and six prospective studies. Studies included daily (20 micrograms) or weekly (56.5 micrograms) subcutaneous administration of teriparatide. The duration of follow-up for these studies varied from three to 24 months. Based on the available research, it appears that administering teriparatide subcutaneously is a safe treatment option for delayed healing and non-healing bone fractures, with very few to no reported negative side effects. Using teriparatide for induction of callus formation and treating delayed and nonunions is highly safe and effective.

Teriparatide as an Effective Nonsurgical Treatment for a Patient with Basicervical Peritrochanteric Fracture Nonunion—A Case Report

The nonunion rate of surgically treated basicervical peritrochanteric fractures has been reported to be as high as 9%. Due to the high 1-year mortality rate following revision surgery, finding an effective nonsurgical treatment option is of interest. Over the last decade, numerous reports have been published that have suggested teriparatide as an effective treatment for certain types of fracture nonunion. However, the literature focused on teriparatide treatment for proximal femoral fracture nonunion is scanty. A 70-year-old man suffering from a left hip basicervical peritrochanteric fracture received cephalomedullary nail fixation. Nine months after the surgery, the patient still complained of left hip pain referring to the medial thigh with an antalgic limping gait. No sign of healing was noted for more than a consecutive 3 months of follow-up. Fracture nonunion was diagnosed and further confirmed by the computed tomography (CT). The patient preferred nonsurgical treatment after thorough discussion. He then received 4 months of subcutaneous teriparatide injections, 20 mcg daily. After less than 4 months of teriparatide treatment, a follow-up CT confirmed fracture union and the patient’s pain subsided. The patient also tolerated independent ambulation afterward. Teriparatide has been reported to be an effective treatment for certain types of fracture nonunion. Our case goes a step further to expand its possible application for basicervical peritrochanteric fracture nonunion. However, further larger scale studies are needed to confirm its efficacy.

Effectiveness of parathyroid hormone (PTH) analogues on fracture healing: a meta-analysis

This meta-analysis evaluated the evidence for the use of parathyroid hormone (PTH) analogues to improve fracture healing. Eligible studies were prospective randomised controlled trials of adults with acute fractures treated with a PTH analogue. PTH improved functional outcomes but did not affect fracture healing rate or reduce pain.

PURPOSE

This meta-analysis evaluated the evidence of parathyroid hormone (PTH) analogues in fracture healing. The use of PTH analogues to prevent osteoporotic fractures is well investigated, and studies are emerging on extended indications. One such indication receiving increasing attention is the effect of PTH in fracture healing; however, the overall degree of efficacy remains inconclusive.

METHODS

A systematic electronic database search of MEDLINE, EMBASE and the Cochrane Library was conducted for relevant articles in August 2019 with no date restrictions. Randomised controlled trials of adults with acute fractures treated with a PTH analogue were included. PTH was compared with a comparator intervention, placebo or no treatment.

RESULTS

PTH analogue treatment improved functional outcomes in a range of fracture types but did not affect the fracture healing rate or reduce pain. Most trials included in this review were in elderly patients with osteoporosis. There was no evidence that PTH treatment caused harm or impeded fracture healing.

CONCLUSIONS

Meta-analysis of published data supports the use of PTH analogues to improve functional outcomes but not fracture healing rate or pain for different fracture types. The evidence for PTH analogue use in fracture healing is less clear in younger, non-osteoporotic patient populations. Trial design was heterogeneous and of limited quality, justifying further original trials.

Scope and Limits of Teriparatide Use in Delayed and Nonunions: A Case Series

Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the “off-label” character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing.

Does Teriparatide Improve Fracture Union?: A Systematic Review

We conducted an updated review of the evidence of teriparatide (TPTD) for fracture healing for the following questions. (1) Does it decrease fracture healing time?; (2) Can it be an alternative treatment for nonunion?; (3) Does it aid the union of atypical femoral fracture (AFF)? We searched PubMed, EMBASE, and Cochrane Library including “Fracture” AND “nonunion” AND “Teriparatide”. In total, 57 publications met our inclusion criteria were summarized. This systemic review of the available literature revealed that TPTD works positively with regard to enhancing fracture healing time and union of AFF. There are also many case studies on the use of TPTD could be a potential new safe treatment for nonunion with no side effects. However, level 1 studies on the evidence of TPTD are still lacking so far. Over the last decade, a growing body of evidence has accumulated suggesting that TPTD can be an adjunct to enhance fracture healing or a therapeutic option to treat nonunion, but greater evidences from large volume prospective trials are needed.

Teriparatide for treating delayed union and nonunion: A systematic review

INTRODUCTION

Fracture nonunion remains a great challenge for orthopaedic surgeons. Approximately 5-10% of bone fractures do not heal promptly, and require another surgical procedure. Previously, several small studies have found that teriparatide, a parathyroid hormone (PTH) analogue, has been found to induce union in those with delayed union and nonunion. However, to date, no systematic reviews regarding the use of teriparatide for delayed union and nonunion are available. The present review aims to investigate the safety and efficacy of teriparatide in delayed union and nonunion.

METHODS

Systematic literature search was performed in PubMed, ScienceDirect, and Google Scholar until September 26, 2019. We included studies involving adult patients (age >16 years) diagnosed with delayed union or nonunion fracture regardless of location (long bone, short bone, flat bone or irregular bone). The language was restricted to English and Indonesian. Outcomes that were recorded were fracture union and adverse events.

RESULTS

Initial search found 5416 abstract and titles. Of these, 20 articles consisting of 64 subjects were retrieved. Of these, 15 case reports, 4 case series, and one prospective study were included. All of the studies administered subcutaneous injection of teriparatide 20 μg/day with mean duration of 7.3 ± 1.5 weeks to 9.7 months. Sixty-one (95.3%) of 64 subjects developed complete union. The follow-up ranged from 3 to 24 months. No side effects occurred during the follow-up period.

CONCLUSIONS

Limited evidence demonstrates that daily subcutaneous injection of teriparatide 20 μg is a potential new safe treatment for delayed union and nonunion with no side effects. We highly suggest the use of such drug, as it is highly effective and safe. However, further clinical studies are required to investigate its safety and efficacy.

Low acceptance of osteoanabolic therapy with parathyroid hormone in patients with fragility fracture of the pelvis in routine clinical practice: a retrospective observational cohort study

INTRODUCTION

A recent randomized controlled trial has reported full patient compliance and no adverse events from therapy with parathyroid hormone (PTH) for osteoporosis and accelerated healing of fragility fractures of the pelvis. The purpose of the presented study was to evaluate if similar results can be achieved with comprehensive PTH therapy in routine clinical practice. We hypothesised that patients' burden of PTH therapy is underestimated in the literature.

PATIENTS AND METHODS

Osteoanabolic PTH therapy was recommended to 79 patients suffering from an acute fragility fracture of the pelvis (FFP). Case finding, initiation of therapy and follow-up were performed by a fracture liaison service team. Primary outcome was PTH initiation rate. Secondary outcomes were implementation rate of alternative antiresorptive pharmaceutical therapy for osteoporosis and participation rate in a bone metabolic workup. Adverse events and effects potentially related to the therapy with bone-active drugs were documented as exploratory outcomes.

RESULTS

Osteoanabolic PTH therapy as suggested was accepted by 32%, whereas antiresorptive therapy was implemented in another 14% of the patients. DEXA scans were available in 38% of the patients (+ 27% when compared to baseline). A bone-specific laboratory analysis was done in 18 patients, uncovering 7 pathological findings. Two patients terminated PTH therapy early because of side effects.

CONCLUSION

The experiences with PTH therapy in FFP patients with respect to, implementation rate, frequency of side effects and of pathological findings in laboratory controls as reported from a previous RCT could not be reproduced in routine clinical practice.

Anabolic agents: what is beyond osteoporosis?

Osteoporosis is a common skeletal disorder characterized by low bone mass, which leads to reduced bone strength and an increased risk of fractures. Anabolic agents have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Currently, two anabolic agents are available in the USA: recombinantly produced teriparatide (TPTD), which is the fully active (1-34) amino active sequence of human parathyroid hormone (PTH), and abaloparatide (APTD), a synthetic analog of parathyroid hormone-related peptide (PTHrP). At present, both agents are approved only for treatment of patients with osteoporosis at high risk of fracture. Nonetheless, their anabolic properties have led to off-label application in additional settings which include spine fusion, osteonecrosis of the jaw, arthroplasty, and fracture healing. In this article, we summarize available scientific literature regarding the efficacy, effectiveness, and safety of TPTD in these off-label settings.

Teriparatide treatment of femoral fracture nonunion that autogenous bone grafting failed to heal: a case report

PURPOSE

Management of fracture nonunion is challenging as another surgical intervention for the patient is often a necessity, which has a huge impact on both quality of life and economic burden of the patient. Thus, a less aggressive and better accepted treatment for nonunion is required.

METHODS

We gave teriparatide to a 45-year-old man with femoral fracture nonunion 1 year after he underwent surgery with autogenous bone grafting that failed to heal his initial nonunion. Successful union was obtained after once-daily administration of teriparatide for 9 months.

RESULTS

Our case showed teriparatide could successfully treat a femoral fracture nonunion that autogenous bone grafting failed to heal.

CONCLUSIONS

Teriparatide may provide an alternative treatment for fracture nonunion.