Current Role and Application of Teriparatide in Fracture Healing of Osteoporotic Patients: A Systematic Review

Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review

Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing.

BACKGROUND

Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing.

METHODS

Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT).

RESULTS

Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans.

CONCLUSION

Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.

The Role of Bone Mineral Density in a Successful Lumbar Interbody Fusion: A Narrative Review

BACKGROUND

The incidence of osteoporosis is a prime concern, especially in parts of the world where the population is aging, such as Europe or the US. Many new therapy strategies have been described to enhance bone healing. Lumbar interbody fusion (LIF) is a surgical procedure that aims to stabilize the lumbar spine by fusing two or more vertebrae using an interbody cage. LIF is a standard treatment for various spinal conditions, such as degenerative disc disease, spinal stenosis, and spondylolisthesis. However, successful fusion is challenging for patients with osteoporosis due to their reduced bone mineral density (BMD) and increased risk of cage subsidence, which can lead to implant failure and poor clinical outcomes.

METHODS

 A comprehensive literature search yielded 220 articles, with 16 ultimately included. Keywords included BMD, cage subsidence, osteoporosis, teriparatide, and lumbar interbody fusion.

RESULTS

 This review examines the relationship between BMD and LIF success, emphasizing the importance of adequate bone quality for successful fusion. Preoperative assessment methods for BMD and the impact of low BMD on fusion rates and patient outcomes are discussed. Additionally, techniques to improve fusion success in patients with weakened bone density, such as biological enhancement and BMD-matched interbody cages, are explored. However, consensus on the exact BMD threshold for a successful outcome remains elusive.

CONCLUSION

 While an apparent correlation between BMD and fusion rate in LIF procedures is acknowledged, conclusive evidence regarding the precise BMD threshold indicative of an increased risk of unfavorable outcomes remains elusive. Surgeons are advised to exercise caution in surgical planning and follow-up for patients with lower BMD. Furthermore, future research initiatives, particularly longitudinal studies, are encouraged to prioritize the examination of BMD as a fundamental risk factor, addressing gaps in the literature.

Effects of Teriparatide on Clinical and Radiologic Long-Term Outcomes after Fixation of Pertrochanteric Hip Fractures

Background

Pertrochanteric hip fractures are common and among serious injuries of the old population with considerable mortality and morbidity. The aim of this study was to evaluate long-term effects of recombinant human parathyroid hormone on postoperative clinical and radiologic outcomes in elderly patients with pertrochanteric hip fractures.

Materials and Methods

Between 2016 and 2019, we prospectively assessed 80 patients with pertrochanteric hip fractures who underwent reduction and internal fixation with a dynamic hip screw. Patients were divided randomly into two groups. About 40 patients in the control group who received supplementary calcium (1000 mg/day) and vitamin D (800 UI/day), and 40 others who were treated additionally with 20-28 mg daily teriparatide for three months post-operatively. The functional and radiologic assessment was done using visual analog scale (VAS), Harris hip score (HSS), and standard radiographs of the hip.

Results

At the final follow-up, there was a significant difference between the two groups regarding average HSS (68.38 in the control group versus 74.12 in the treatment group, P-value <0.001). VAS score was also significantly lower in the treatment group (P-value <0.001). Regarding radiographic evidence of union, the results were not statistically different between the two groups.

Conclusions

The current study illustrated that short-term daily administration of teriparatide improves long-term functional outcome after pertrochanteric hip fracture fixation and can reduce the pain but does not affect union and callus formation.

Comparison of Teriparatide and Combination of Cissus Quadrangularis and Dalbergia Sissoo on Bone Healing Against the Control Group in Maxillofacial Fractures: A Randomized Open-label Control Trial

Study Design

Randomized Control Trial.

Objective

A randomized control trial was planned to aim to assess whether subcutaneous Injection of Teriparatide and Tablet Reunion (combination of Cissus Quadrangularis and Dalbergia sissoo) improves maxillofacial fracture healing as compared to the control group.

Methods

24 patients of mandibular fracture with or without concomitant maxillofacial fractures were randomly divided into 3 equal groups (Group 1- Control, Group 2- Tablet Reunion, and Group 3- Injection Teriparatide) and the treatment duration was 4 weeks. Pain, fracture site mobility, bite force, serum markers, and radiographic healing were assessed preoperatively and postoperatively at regular intervals till 12 weeks.

Results

Group 2 showed early pain relief, although it was insignificant. Group 3 showed the highest anterior bite force at all the time points. Change in mean posterior bite force (PBF) showed a statistically significant increase at 8th week and 12th week in intergroup comparison; however, at 12th week, Group 3 was significantly better than Group 1 and reported the highest posterior bite force compared to other groups. Serum calcium and PTH level showed no significant difference, whereas Serum ALP showed a statistically significant increase in Group 3. The radiographic assessment showed no significant difference among the 3 groups.

Conclusions

Both the intervention group drugs showed a promising effect on accelerating the fracture healing and improving bite force restoration with the osteoanabolic action; however, early radiographic healing and increased serum osteogenic markers in Group 3 indicate its possible optimistic role in maxillofacial fracture healing.

Heavy clinical and economic burden of osteoporotic fracture among elderly female Medicare beneficiaries

We comprehensively described elderly Medicare women with an outpatient visit in 2011 and fracture within 2 years before. These women were at very high risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low.

INTRODUCTION

Postmenopausal women with osteoporosis are stratified to high and very-high fracture risk categories, and this categorization drives algorithms for osteoporosis management in osteoporosis treatment guidelines. This study comprehensively describes a very-high-risk cohort.

METHODS

This retrospective cohort study used the Medicare 20% database; elderly women with an outpatient visit in 2011 and fracture within 2 years before the visit were included. Outcomes included fracture risk, all-cause and fracture-related healthcare resource utilization and cost, and osteoporosis medication use in the 5 years after the visit.

RESULTS

Overall, 43,193 patients were included. The 5-year probability was 0.36 for major fracture and 0.11 and 0.17 for hip fracture and vertebral fracture, respectively, much higher than the guidelines' 10-year probability thresholds for very-high-risk (0.3 for major fracture, 0.045 for hip fracture). Rates of hospitalizations, emergency department visits or observation stays, and skilled nursing facility stays in year 1 were 53.7, 57.0, and 18.8 per 100 patient-years, respectively, decreasing slightly in subsequent years. Mean healthcare cost was $23,700 in year 1, decreasing to $18,500 in year 5. About 29.1% of patients received osteoporosis medications in year 1, decreasing to 16.9% by year 5. Rates for all outcomes, especially fractures, were much higher among vertebral and multiple fracture cohorts.

CONCLUSION

Elderly women with a fracture within last 2 years were at very-high-risk for subsequent fracture and high healthcare utilization and cost, especially those with vertebral or multiple fractures. However, rates of fracture prevention treatments were low. More effort is needed to identify and treat patients at very-high-risk for fracture.

The role of intermittent PTH administration in conjunction with allogenic stem cell treatment to stimulate fracture healing

Aims

A growing number of fractures progress to delayed or nonunion, causing significant morbidity and socioeconomic impact. Localized delivery of stem cells and subcutaneous parathyroid hormone (PTH) has been shown individually to accelerate bony regeneration. This study aimed to combine the therapies with the aim of upregulating fracture healing.

Methods

A 1.5 mm femoral osteotomy (delayed union model) was created in 48 female juvenile Wistar rats, aged six to nine months, and stabilized using an external fixator. At day 0, animals were treated with intrafracture injections of 1 × 10⁶ cells/kg bone marrow mesenchymal stem cells (MSCs) suspended in fibrin, daily subcutaneous injections of high (100 μg/kg) or low (25 μg/kg) dose PTH 1-34, or a combination of PTH and MSCs. A group with an empty gap served as a control. Five weeks post-surgery, the femur was excised for radiological, histomorphometric, micro-CT, and mechanical analysis.

Results

Combination therapy treatment led to increased callus formation compared to controls. In the high-dose combination group there was significantly greater mineralized tissue volume and trabecular parameters compared to controls (p = 0.039). This translated to significantly improved stiffness (and ultimate load to failure (p = 0.049). The high-dose combination therapy group had the most significant improvement in mean modified Radiographic Union Score for Tibia fractures (RUST) compared to controls (13.8 (SD 1.3) vs 5.8 (SD 0.5)). All groups demonstrated significant increases in the radiological scores – RUST and Allen score – histologically compared to controls.

Conclusion

We demonstrate the beneficial effect of localized MSC injections on fracture healing combined with low- or high-dose teriparatide, with efficacy dependent on PTH dose.

Cite this article: Bone Joint Res 2021;10(10):659–667.

Insufficient increase in bone mineral density testing rates and pharmacotherapy after hip and vertebral fracture: analysis of the National Database of Health Insurance Claims and Specific Health Checkups of Japan

Test and treatment rates for osteoporosis in Japan aimed at preventing secondary fragility fractures were insufficient. Those who suffered hip fractures had approximately half the rates of those who suffered vertebral fractures, with such rates being lower among those over 80 years old and males.

PURPOSE

The present study aimed to examine the care gap for secondary fracture prevention in Japan given the few large-scale studies regarding the matter.

METHODS

Changes in bone mineral density testing (test rate) and osteoporosis pharmacotherapy administration (treatment rate) rates before and after hip and vertebral fracture registration were examined using medical insurance data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan issued from April 2012 to March 2019.

RESULTS

The hip fracture group comprised 677,480 women and 264,003 men, the vertebral fracture group comprised 703,247 women and 251,542 men, and the mixed fracture group comprised 3614 women and 1055 men. Test rates were 14.1%, 25.3%, and 17.6% prior to fracture registration (pre-registration) and 22.3%, 43.6%, and 28.1% after fracture registration (post-registration) in the hip, vertebral, and mixed fracture groups, respectively. Moreover, pre-registration treatment rates were 21.2%, 33.5%, and 30.7%, while post-registration rates were 31.6%, 61.7%, and 46.6% in the hip, vertebral, and mixed fracture groups, respectively. All fracture groups showed a tendency for decreased post-registration test and treatment rates among those aged over 80 years old, with men having lower rates. Moreover, 184,180 (19.4% of whom received new treatment) and 707,263 (23.8% of whom received new treatment) patients with and without polypharmacy underwent treatment after registration, respectively.

CONCLUSION

To bridge the care gap following fractures, medical professionals should change their perception regarding osteoporosis treatment in patients with hip fractures, elderly individuals undergoing polypharmacy, and males.

Teriparatide and stress fracture healing in young adults (RETURN - Research on Efficacy of Teriparatide Use in the Return of recruits to Normal duty): study protocol for a randomised controlled trial

Background

Stress fractures are a common and potentially debilitating overuse injury to bone and occur frequently among military recruits and athletes. Recovery from a lower body stress fracture typically requires several weeks of physical rehabilitation. Teriparatide, a recombinant form of the bioactive portion of parathyroid hormone (1–34 amino acids), is used to treat osteoporosis, prevent osteoporotic fractures, and enhance fracture healing due to its net anabolic effect on bone. The study aim is to investigate the effect of teriparatide on stress fracture healing in young, otherwise healthy adults undergoing military training.

Methods

In a two-arm, parallel, prospective, randomised controlled, intention-to-treat trial, Army recruits (n = 136 men and women, 18–40 years) with a magnetic resonance imaging (MRI) diagnosed lower body stress fracture (pelvic girdle, sacrum, coccyx, or lower limb) will be randomised to receive either usual Army standard care, or teriparatide and usual Army standard care. Teriparatide will be self-administered by subcutaneous injections (20 μg/day) for 16 weeks, continuing to 24 weeks where a fracture remains unhealed at week 16. The primary outcome will be the improvement in radiological healing by two grades or more, or reduction to grade zero, 8 weeks after randomisation, assessed using Fredericson grading of MRI by radiologists blind to the randomisation. Secondary outcomes will be time to radiological healing, assessed by MRI at 8, 10, 12, 14, 16, 20 and 24 weeks, until healed; time to clinical healing, assessed using a clinical severity score of injury signs and symptoms; time to discharge from Army physical rehabilitation; pain, assessed by visual analogue scale; health-related quality of life, using the Short Form (36) Health Survey; and adverse events. Exploratory outcomes will include blood and urine biochemistry; bone density and morphology assessed using dual-energy X-ray absorptiometry, peripheral quantitative computed tomography (pQCT), and high-resolution pQCT; physical activity measured using accelerometers; and long-term future fracture rate.

Discussion

This study will evaluate whether teriparatide, in addition to standard care, is more effective for stress fracture healing than standard care alone in Army recruits who have sustained a lower body stress fracture.

Trial registration

ClinicalTrials.govNCT04196855. Registered on 12 December 2019.

Site-Specific Fracture Healing: Comparison between Diaphysis and Metaphysis in the Mouse Long Bone

The process of fracture healing varies depending upon internal and external factors, such as the fracture site, mode of injury, and mechanical environment. This review focuses on site-specific fracture healing, particularly diaphyseal and metaphyseal healing in mouse long bones. Diaphyseal fractures heal by forming the periosteal and medullary callus, whereas metaphyseal fractures heal by forming the medullary callus. Bone healing in ovariectomized mice is accompanied by a decrease in the medullary callus formation both in the diaphysis and metaphysis. Administration of estrogen after fracture significantly recovers the decrease in diaphyseal healing but fails to recover the metaphyseal healing. Thus, the two bones show different osteogenic potentials after fracture in ovariectomized mice. This difference may be attributed to the heterogeneity of the skeletal stem cells (SSCs)/osteoblast progenitors of the two bones. The Hox genes that specify the patterning of the mammalian skeleton during embryogenesis are upregulated during the diaphyseal healing. Hox genes positively regulate the differentiation of osteoblasts from SSCs in vitro. During bone grafting, the SSCs in the donor’s bone express Hox with adaptability in the heterologous bone. These novel functions of the Hox genes are discussed herein with reference to the site-specificity of fracture healing.

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.

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.

The Efficacy of Teriparatide in Improving Fracture Healing in Hip Fractures: A Systematic Review and Meta-Analysis

Background

This systematic review and meta-analysis assessed the role of teriparatide in improving hip fracture healing and function to provide a clinical guide.

Methods

The systematic literature review identified randomized controlled trials (RCTs) and controlled studies evaluating teriparatide for elderly hip fractures. A meta-analysis was performed using RevMan version 5.3.

Results

This study included two RCTs and four retrospective studies comprising 607 patients, with 269 and 338 patients in the teriparatide and control groups, respectively. The quality of these six studies was moderate. Compared to the control group, teriparatide reduced the time to union (weighted mean difference (WMD) = −1.95; 95% confidence interval (CI): -3.23–-0.68; P = 0.003) but did not improve the rate of fracture union at 3 months (odds ratio (OR) = 1.46; 95% CI: 0.50–4.24; P = 0.49) or 6 months (OR = 0.89; 95% CI: 0.44–1.81; P = 0.75). In addition, teriparatide did not decrease the complications, need for reoperation, mortality, rate of deformity after fracture healing, and subsequent fracture or improve hip function.

Conclusions

The current limited evidence did not support that teriparatide improves fracture healing in hip fractures, due to study heterogeneity and various sources of biases. Further high-quality, large-sample trials are needed. This trial is registered with PROSPERO with registration number CRD42020152205.

Denosumab, raloxifene, romosozumab and teriparatide to prevent osteoporotic fragility fractures: a systematic review and economic evaluation

BACKGROUND

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness, safety and cost-effectiveness of non-bisphosphonates {denosumab [Prolia®; Amgen Inc., Thousand Oaks, CA, USA], raloxifene [Evista®; Daiichi Sankyo Company, Ltd, Tokyo, Japan], romosozumab [Evenity®; Union Chimique Belge (UCB) S.A. (Brussels, Belgium) and Amgen Inc.] and teriparatide [Forsteo®; Eli Lilly and Company, Indianapolis, IN, USA]}, compared with each other, bisphosphonates or no treatment, for the prevention of fragility fracture.

DATA SOURCES

For the clinical effectiveness review, nine electronic databases (including MEDLINE, EMBASE and the World Health Organization International Clinical Trials Registry Platform) were searched up to July 2018.

REVIEW METHODS

A systematic review and network meta-analysis of fracture and femoral neck bone mineral density were conducted. A review of published economic analyses was undertaken and a model previously used to evaluate bisphosphonates was adapted. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years for a simulated cohort of patients with heterogeneous characteristics. This was done for each non-bisphosphonate treatment, a strategy of no treatment, and the five bisphosphonate treatments previously evaluated. The model was populated with effectiveness evidence from the systematic review and network meta-analysis. All other parameters were estimated from published sources. An NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net monetary benefit was estimated using non-parametric regression. A probabilistic sensitivity analysis and scenario analyses were used to assess uncertainty.

RESULTS

Fifty-two randomised controlled trials of non-bisphosphonates were included in the clinical effectiveness systematic review and an additional 51 randomised controlled trials of bisphosphonates were included in the network meta-analysis. All treatments had beneficial effects compared with placebo for vertebral, non-vertebral and hip fractures, with hazard ratios varying from 0.23 to 0.94, depending on treatment and fracture type. The effects on vertebral fractures and the percentage change in bone mineral density were statistically significant for all treatments. The rate of serious adverse events varied across trials (0-33%), with most between-group differences not being statistically significant for comparisons with placebo/no active treatment, non-bisphosphonates or bisphosphonates. The incremental cost-effectiveness ratios were > £20,000 per quality-adjusted life-year for all non-bisphosphonate interventions compared with no treatment across the range of QFracture and FRAX scores expected in the population eligible for fracture risk assessment. The incremental cost-effectiveness ratio for denosumab may fall below £30,000 per quality-adjusted life-year at very high levels of risk or for high-risk patients with specific characteristics. Raloxifene was dominated by no treatment (resulted in fewer quality-adjusted life-years) in most risk categories.

LIMITATIONS

The incremental cost-effectiveness ratios are uncertain for very high-risk patients.

CONCLUSIONS

Non-bisphosphonates are effective in preventing fragility fractures, but the incremental cost-effectiveness ratios are generally greater than the commonly applied threshold of £20,000-30,000 per quality-adjusted life-year.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107651.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 29. See the NIHR Journals Library website for further project information.

The one-year mortality rate in elderly patients with osteoporotic fractures of the pelvis

Osteoporosis is a common condition for elderly people. The incidence of osteoporotic pelvic fractures has been increasing. Osteoporotic pelvic fractures are associated with increased mortality rates. Based on the aim of our study, we found out that one-year mortality rate after a pelvic fracture is high and depends on the fracture type.

PURPOSE

The aim of this study was to determine the one-year mortality rate in patients aged 65+ with osteoporotic pelvic fractures depending on the type of fracture according to AO/OTA classification.

METHODS

Patients aged 65+ with pelvic insufficiency fractures admitted to a single center between 1 June 2013 and 31 December 2016 were enrolled in the study. The fractures were classified according to AO/OTA classification. The start of the survival time analysis was the date of the injury. The end of the analysis was 31 December 2017 or the date of the patient's death. Mortality rates were assessed with respect to fracture types using Kaplan-Meier curves. The Cox proportional hazards model was applied to assess the dependence of mortality on the fracture type.

RESULTS

A total of 105 patients with 95 (90.5%) being female were enrolled in this prospective study. The average age was 80.3 years (95% CI 78.8-81.7). Mean follow-up time was 23.5 months (95% CI 20.7-26.4). According to AO/OTA classification, 30 (28.6%) patients had a type A pelvic fracture, 73 (69.5%) patients-type B fracture, and 2 (1.9%)-type C fracture. Overall, the one-year mortality rate was 23.8% (95% CI 16.8-33.2%). For patients with type A fracture, the one-year mortality rate was 13.3% (95% CI 5.2-31.7%) compared with 27.4% (95% CI 18.6-39.2%) in the group with type B fracture, and this difference was statistically significant (p < 0.001).

CONCLUSIONS

We found that within a year after an osteoporotic pelvic fracture, the number of deaths in the patients having type B pelvic fracture was twice higher than in the patients with type A fracture.

The role of teriparatide in tuberosity healing after reverse shoulder arthroplasty in complex proximal humeral fragility fracture

INTRODUCTION

Tuberosity healing is known to be one of the factors that increase functional outcome in Reverse Total Shoulder Arthroplasty (rTSA). In fragility fractures, tuberosity healing is difficult to be achieved. The fragment stability and bone-forming agent application become strategies to overcome this problem. The purpose of this study was to evaluate the benefit of teriparatide application to promote tuberosity union in rTSA on four-part proximal humeral fractures to achieve better functional outcome.

METHODS

A retrospective study of a prospectively collected shoulder arthroplasty medical record was performed. Eleven patients were included in this analysis and consisted of two groups, teriparatide and no-teriparatide groups. Patients were evaluated on the range of motions and clinical outcome using the American Shoulder Elbow Surgeon (ASES) Shoulder Score and X-ray to determine tuberosity union. The group differences were analyzed by t-test or Mann-Whitney U test with SPSS version 20.0 for Windows.

RESULTS

The statistical analysis revealed no significant differences in mean age in both the groups. There were significant differences between teriparatide and no-teriparatide groups in external rotation (29.5° vs. 7.5°; p = 0.004), external rotation in 90° abduction (55° vs. 12.5°; p < 0.020), forward flexion (120° vs. 105°; p = 0.002) range of motions, and ASES (84.5 vs. 74.6; p = 0.019). We found clinical difference between teriparatide and no-teriparatide groups in time to achieve the initial callus (33 ± 18.3 days vs. 150 ± 42.4 days) and tuberosity consolidation (165.8 ± 70.3 days vs. 315 ± 106.1 days).

CONCLUSIONS

Teriparatide administration supports tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after rTSA in acute complex proximal humeral fractures.

[Influence of specific osteoporosis drugs on fracture healing]

BACKGROUND

For the treatment of disturbed fracture healing, drugs could be given in addition to surgical procedures. Specific osteoporosis drugs affect the bone metabolism and are used to treat osteoporosis, particularly after a fragility fracture has occurred. Therefore, their use would be conceivable to improve a disturbed fracture healing.

OBJECTIVE

This article presents the available and upcoming specific osteoporosis drugs and investigates whether these substances affect fracture healing in the context of osteoporosis. Furthermore, it is discussed whether disturbed fracture healing can be improved by the use of these substances.

MATERIAL AND METHODS

A literature search (PubMed) was conducted using key terms. Preclinical studies, clinical studies, reviews and meta-analyses were considered in order to present the current knowledge in a clinically relevant context.

RESULTS

Preclinical and clinical studies show that specific osteoporosis drugs have no relevant negative impact on the healing of fragility fractures. A tendency to improve a disturbed fracture healing was attributed to bone anabolic substances; however, studies are inconsistent and there is no approval for this application.

CONCLUSION

Following a fragility fracture, osteoporosis should be diagnosed according to the guidelines and, if necessary, treated with specific osteoporosis drugs, since in principle they do not impair fracture healing but significantly reduce the risk of subsequent fractures. Approval to improve fracture healing requires further investigations.

Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues

Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.

Daily subcutaneous Teriparatide injection increased bone mineral density of newly formed bone after tibia distraction osteogenesis, a randomized study

Long bone defects are often treated by bone segment transport with the Ilizarov method requiring months spent with fixator mounted until bony consolidation of the newly formed bone. Shortening of consolidation would allow earlier fixator removal and earlier return to work. In pre-clinical studies parathyroid hormone, increased bone mineral density and mechanical properties of regenerate bone formed during distraction osteogenesis. Clinical studies showed that Teriparatide accelerated fracture healing in patients with osteoporotic fracture of the pelvis, hip, wrist and shoulder. We hypothesized that rhPTH(1-34) (Teriparatide) administered to patients who had undergone distraction osteogenesis, would increase mineralization of the regenerate formed during the consolidation phase. Sixteen patients with tibial defects after infection, underwent bone segment transport and at the time of docking the transport segment, were randomized to 8 weeks treatment with daily subcutaneous 0.20-μg Teriparatide injection followed by 8 weeks with no treatment, or to 8 weeks with no treatment followed by 8 weeks with daily subcutaneous 0.20 μg Teriparatide injection. Bone mineral density (BMD) of the regenerate was measured at the time of docking, 8 weeks after docking and 16 weeks after docking with DEXA. Functional evaluation was performed after one year. The design was a cross-over study. Overall BMD increased 0.14 g/cm² in 8 weeks without treatment and 0.33 g/cm² under Teriparatide treatment. After adjustment for a potential phase difference, 8 weeks of Teriparatide treatment led to an additional 0.19 g/cm² BMD increase (95%-CI:[0.11,0.28], p < 0.001). The ratio of the BMD increase between the two treatments was 0.33/0.14 = 2.43 (CI: [1.21,3.65]). Teriparatide treatment during the consolidation phase of distraction osteogenesis doubled the mineralization rate of the regenerate when compared to no treatment.

Dysfunctional stem and progenitor cells impair fracture healing with age

Successful fracture healing requires the simultaneous regeneration of both the bone and vasculature; mesenchymal stem cells (MSCs) are directed to replace the bone tissue, while endothelial progenitor cells (EPCs) form the new vasculature that supplies blood to the fracture site. In the elderly, the healing process is slowed, partly due to decreased regenerative function of these stem and progenitor cells. MSCs from older individuals are impaired with regard to cell number, proliferative capacity, ability to migrate, and osteochondrogenic differentiation potential. The proliferation, migration and function of EPCs are also compromised with advanced age. Although the reasons for cellular dysfunction with age are complex and multidimensional, reduced expression of growth factors, accumulation of oxidative damage from reactive oxygen species, and altered signaling of the Sirtuin-1 pathway are contributing factors to aging at the cellular level of both MSCs and EPCs. Because of these geriatric-specific issues, effective treatment for fracture repair may require new therapeutic techniques to restore cellular function. Some suggested directions for potential treatments include cellular therapies, pharmacological agents, treatments targeting age-related molecular mechanisms, and physical therapeutics. Advanced age is the primary risk factor for a fracture, due to the low bone mass and inferior bone quality associated with aging; a better understanding of the dysfunctional behavior of the aging cell will provide a foundation for new treatments to decrease healing time and reduce the development of complications during the extended recovery from fracture healing in the elderly.

Is Teriparatide Beneficial to Spinal Fusion Surgery in the Older Patient?: A Narrative Review

Since FDA approval in 2002, teriparatide has gained popularity as an anabolic therapy for the treatment of osteoporosis. Animal studies have suggested a role for teriparatide in spine surgery. Several recent studies have demonstrated adjunctive use of teriparatide in osteoporotic patients undergoing spine fusions improves fusion rates, decreases time to union, and decreases osteoporosis-related complications such as proximal junctional kyphosis. On the basis of the available literature, we outline an algorithm for the use of teriparatide in spine surgery.

Successful treatment of pathologic femoral shaft fracture associated with large arteriovenous malformations using a 3-dimensional external fixator and teriparatide: a case report

Background

Arteriovenous malformations (AVMs) are rare congenital vascular lesions associated with early quiescence, late expansion, and, ultimately, infiltration and destruction of local soft tissue and bone. The extremities are a common location. Incidence of bony involvement by AVM has been reported as high as 31%. However, there are few reports on management of pathologic fracture associated with AVM. Teriparatide is a recombinant parathyroid hormone (PTH) analogue consisting of the 1–34 fragment of PTH. Recently, some reports have shown the ability of teriparatide to improve fracture healing. Here, we present a case of pathologic femoral shaft fracture associated with large AVMs that was treated successfully by external fixation and teriparatide.

Case presentation

A 68-year-old Japanese woman, previously diagnosed as having large AVMs, sustained a right femoral shaft fracture due to a fall. At the time of admission, she presented with massive swelling and venous varicosities of the right thigh. Plain radiography of the right thigh revealed femoral shaft fracture with bony erosion and calcification of soft tissue. We planned closed reduction and intramedullary nailing with a unilateral external fixator following embolization of the feeding artery. However, closed reduction using the fracture table was difficult. When we attempted open reduction, massive bleeding (1000 mL) after incision of subcutaneous tissue occurred. Finally, we carefully applied a Taylor Spatial Frame. Fracture displacement was corrected successfully and bony union was obtained with administration of teriparatide 15 months after the initial surgery. The patient is able to walk using 1 cane.

Conclusion

We present the first report of pathologic fracture associated with large AVMs that achieved bony union using a 3-dimensional external fixator and teriparatide.

Clinical Management of Osteoporotic Fractures

PURPOSE OF REVIEW

This review examines recent literature regarding the clinical management of fragility fractures, provides insight into new practice patterns, and discusses controversies in current management.

RECENT FINDINGS

There are declining rates of osteoporosis management following initial fragility fracture. Management of osteoporotic fractures via a multidisciplinary team reduces secondary fracture incidence and improves overall osteoporotic care. Anabolic agents (abaloparatide and teriparatide) are effective adjuvants to fracture repair, and have shown positive results in cases of re-fracture in spite of medical management (i.e., bisphosphonates). For AO 31-A1 and A2 intertrochanteric hip fractures (non-reverse obliquity), no clinical advantage of intramedullary fixation over the sliding hip screw (SHS) has been proven; SHS is more cost-effective. As fragility fracture incidence continues to rise, orthopedic surgeons must play a more central role in the care of osteoporotic patients. Initiation of pharmacologic intervention is key to preventing subsequent fragility fractures, and may play a supportive role in initial fracture healing. While the media bombards patients with complications of medical therapy (atypical femur fractures, osteonecrosis of jaw, myocardial infarction), providers need to understand and communicate the low incidence of these complications compared with consequences of not initiating medical therapy.

The Effects of Systemic Therapy of PEGylated NEL-Like Protein 1 (NELL-1) on Fracture Healing in Mice

Fractures are common, with an incidence of 13.7 per 1000 adults annually. Systemic agents have been widely used for enhancing bone regeneration; however, the efficacy of these therapeutics for the management and prevention of fracture remains unclear. NEL-like protein 1 (NELL-1) is a potent pro-osteogenic cytokine that has been modified with polyethylene glycol (PEG)ylation [PEGylated NELL-1 (NELL-PEG)] to enhance its pharmacokinetics for systemic therapy. Our aim was to investigate the effects of systemic administration of NELL-PEG on fracture healing in mice and on overall bone properties in uninjured bones. Ten-week-old CD-1 mice were subjected to an open osteotomy of bilateral radii and treated with weekly injections of NELL-PEG or PEG phosphate-buffered saline as control. Systemic injection of NELL-PEG resulted in improved bone mineral density of the fracture site and accelerated callus union. After 4 weeks of treatment, mice treated with NELL-PEG exhibited substantially enhanced callus volume, callus mineralization, and biomechanical properties. NELL-PEG injection significantly augmented bone regeneration, as confirmed by high expression of bone turnover rate, bone formation rate, and mineral apposition rate. Consistently, the immunohistochemistry results also confirmed a high bone remodeling activity in the NELL-PEG-treated group. Our findings suggest that weekly injection of NELL-PEG may have the clinical potential to accelerate fracture union and enhance overall bone properties, which may help prevent subsequent fractures.