Teriparatide for the rapid resolution of delayed healing of atypical fractures associated with long-term bisphosphonate use

Abstract

Bisphosphonates (BPs) are the most widely used drugs to treat osteoporosis. However, recent reports associated to long-term BPs use with atypical low-impact fractures and prodromal pain. It is estimated that 26% of the cases of atypical fractures associated with the long-term use of BPs show delayed healing or nonunion. Teriparatide [PTH1-34] (TPTD) is an anabolic drug shown to be effective in stimulating bone formation. The aim was to describe the course of a right diaphyseal femoral fracture sustained by a patient on long-term BPs treatment. A 57-year-old postmenopausal Caucasian female presented with delayed healing of a right femoral diaphyseal fracture 10 months after the fracture, despite having received orthopedic treatment. The fracture was preceded by progressive, severe, and bilateral thigh pain. Her medical history included osteopenia that was treated with alendronate over 7 years. On presentation at our clinic, the patient ambulated with the aid of a walking cane. The diagnosis was an atypical right femoral fracture associated with long-term alendronate use. The levels of the following parameters were measured: mineral metabolism laboratory: intact parathormone, 40 ng/mL (reference values (rv): 10-65 ng/mL); 25-hydroxyvitamin D, 40 ng/mL (rv: >30 ng/mL); serum Crosslaps, 318 ng/mL (rv: 80-590 ng/mL); and bone-specific alkaline phosphatase, 76UI/L (rv: 31-95UI/L)]. Magnetic resonance imaging of the left femur was performed, which revealed a diaphyseal stress fracture. She was prescribed 20 µg/day of subcutaneous (s.c.) TPTD (PTH1-34, Forteo; Eli Lilly Co., Indianapolis, IN, United States). A computed tomography scan performed 3 months later showed that the fracture had healed; the patient was able to resume her usual activities. Twenty micrograms per day of s.c. TPD accelerated the healing of the atypical fracture associated with long-term alendronate therapy, allowing a fast recovery of ambulation and quality of life.

Surgical outcome of atypical subtrochanteric and femoral fracture related to bisphosphonates use in osteoporotic patients with or without teriparatide treatment

“…Teriparatide treatment was found to refresh bone remodeling after bisphosphonates use and possibly be effective in promoting bone healing [ 14 , 15 ], although the definite mechanism has not been elucidated. Several case reports [ 16 – 20 ] and series studies [ 21 , 22 ] have mentioned the benefits of teriparatide for patients with atypical fracture. Nevertheless, more data on the treatment outcome of atypical fracture is urgently needed to clarify this issue.…”

Endoprosthetic Reconstruction for a Displaced Atypical Femoral Fracture in a Cancer Patient with Poor Prognosis

“…Displaced AFFs also can be treated successfully with IMN and discontinuation of BMAs; however, some earlier reports have indicated that revision was required in 46% (7/17) of patients owing to nonunion/delayed union [ 2 ] and that the mean time to bone union was 11.3 months for displaced AFFs [ 9 ]. Another report demonstrated that teriparatide (TPTD) combined with IMN is advantageous, although TPTD is contraindicated in cancer patients with bone metastasis [ 10 ]. On the other hand, hip arthroplasty after IMN breakage has been reported to provide good results [ 11 ].…”

Teriparatide Prevented Near Atypical Femur Fracture by Reducing Cortical Thickening in a Symptomatic Patient With Prolonged Use of Oral Bisphosphonate: A Case Report

“…Several cases have been reported in the literature where TPP had been used to treat incomplete or complete AFF (Table 2) [3][4][5][6][7][8]; however, none of them showed the effect of TPP on reducing the cortical thickening. We hereby presented a case of preventing near AFF with clinical symptoms; cortical thickness; no obvious radiographic radiolucent line and bone marrow edema by reducing cortical thickness with TPP use.…”

“…Mastgalia et al, 2012 [5] A 57-year-old Argentine woman with a sustained non healing femoral shaft fracture 7 years Her pain improved after 10 days of TPP and healing was complete after 3 months.…”