Teriparatide in fracture healing: Case series and review of literature

Teriparatide (TPTD) (recombinant Parathyroid Hormone 1-34) is one of the pioneer osteo-anabolic agents approved for management of osteoporosis. Being an anabolic agent, it increases bone mineral density by inducing formation of new bone by the action on osteoblasts. As new bone formation is an important aspect of fracture healing as well, Teriparatide has long been a product of interest with respect to its effect on the process of fracture healing. Though fracture healing is not an approved indication for Teriparatide, there is quite a substantial amount of published data related to its effectiveness in fracture healing. With an intent to better understand the role of teriparatide in fracture, we share few case reports of successful fracture healing after giving Teriparatide and also review the published evidences of union taking place in difficult delayed union and non-union cases secondary to mechanical instability, inadequate fixation support or other reasons. This article thus, intended to summarize the accumulating preclinical and clinical evidence for role of TPTD in accelerating fracture healing in various conditions like conservative management of fractures, vertebral fractures, non-unions, delayed unions and atypical femoral fractures.

A Novel Mouse Model to Study Fracture Healing of Tibia

Background Delayed union of most tibial fractures due to their special anatomical structures.So an effective animal model is very important to study the mechanism and method of fracture healing.However, due to the small tibia of mice, the operation is difficult, and the surgical model requires high surgical skills. The construction of the fixation model of intramedullary nail for this fracture has improved and simplified the traditional fixation model of intramedullary nail, which not only achieves the purpose of constructing the fracture model, but also makes it more simple and effective.Therefore, the aim of the current study was to develop a new mouse model to study fracture healing of tibia. Methods We chose a combination between an open osteotomy and intramedullary stabilization. The 22G needle was inserted into the fracture end in a closed manner by using an open approach for osteotomy at the middle and lower 1/3 level of the tibia.Fractured tibia were analyzed using microcomputed tomography and histology at days 7,14,21and 28after surgery. All animals displayed normal limb loading and a physio-logical gait pattern within the first three days after fracture. No animals were lost due to surgery or anesthesia. Results X-ray confirmed that the fracture types obtained by the fracture modeling method were transverse fractures. X-ray, Micro-CT, immunohistochemistry, histological staining and Real-time PCR showed that the fracture healing of mice was typical endochondral ossification, with high repeatability. Conclusion The mouse tibial fracture model established by intramedullary nailing is safe, rapid and simple. Its fracture healing is a typical intrachondral ossification with high repeatability, which can be better used for the study of molecular mechanism and clinical transformation of fracture healing and bone metabolism.

Editorial Comment on the Article by P.A. Ivanov et al. “A New Method of Intraoperative Reposition and Holding of Bone Fragments with Ty-Raps”

In the editorial comment on the article A New Method of Intraoperative Reposition and Holding of Bone Fragments with Ty-Raps the advantages and disadvantages of the authors method are discussed. The advantages include availability, low cost, convenience and reliability. At the same time, it may lead to excessive devascularization of bone fragments with the risk of delayed union or even non-union. Only a comparative study on a large number of patients can confirm or refute these concerns. The comment also contains a brief review of articles on this issue.

Anterior inferior plating versus superior plating for middle 1/3rd clavicle fracture: a prospective comparative study

<p class="abstract"><strong>Background: </strong>Fractures of the clavicle are common injuries that may result from direct blow or transmitted forces. Deformities are shortening and depression of lateral fragments. Various techniques are performed out of which superior and anteroinferior plating are widely used with each having its own merits and drawbacks. Our study compares the outcome between above mentioned techniques.</p><p class="abstract"><strong>Methods: </strong>We conducted a prospective comparative study of 60 patients who has met inclusion criteria and out of which 30 patients were treated with anteroinferior technique and 30 patients were treated with superior plating technique. Outcome measure were assessed through constant and murley score.</p><p class="abstract"><strong>Results: </strong>The demographic analysis of our study showed that the incidence of fracture is predominant among males (63.3%) with RTA being the most common mode of injury. AO/OTA classification which was used in our study revealed A1 as the most frequently involved group. Each group had 2 patients with infection post operatively which was managed with appropriate antibiotics. Increased incidence of delayed union was found in anterioinferior group (13.3%) with decreased hardware prominence in comparison with superior plating.</p><p class="abstract"><strong>Conclusions:</strong> There were no significant differences in functional outcome between both the groups except the fact that superior plating had higher chances of plate prominence. So either of the surgical technique can be employed depending upon the feasibility of surgeon.</p>

Complications of first tarsometatarsal joint arthrodesis

Objective: First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is a surgical procedure used to treat severe hallux valgus, associated hypermobility of the first ray, and/or osteoarthritis of the first TMTJ. Despite the high satisfaction rate and high corrective power, this technique is not without complications. This study aimed to report the complications of first TMTJ arthrodesis. Methods: This is a case series of 16 patients treated with first TMTJ arthrodesis. Patients were evaluated based on foot radiographs, clinical alignment of the hallux, and signs and symptoms. Results: Eight patients had either major or minor complications. Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (1 with associated nonunion), and 1 had wound dehiscence. Conclusion: First TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to minimize complications as much as possible. We believe that data are still scarce to provide a concrete basis. Level of Evidence IV; Therapeutic Studies; Case Series.

Treatment of FRI after intramedullary nailing of tibia fractures: assessment of nail retention and nail removal

Objectives: Fracture related infection (FRI) is a severe, potentially limb-threatening complication after fracture fixation. Dilemma exists with regard to removing or retaining implants while treating the infection. The purpose of this study was to compare primary bone union and infection clearance in patients who had an infection following intramedullary nailing of the tibia treated either by retaining the implant or by removing the implant. Methods: Patients from two level-I trauma centers were identified through billing registries and retrospectively reviewed between January 2013 and December 2020. We identified 44 patients who had a diagnosis of FRI within 90 days of their initial fixation and returned to the OR for operative treatment of the infection. The incidences of both primary union and infection clearance were calculated for both groups and multiple parameters that may be associated with success or failure were assessed. Results: Four patients did not have complete records and were excluded. Of the remaining patients, 20 (50%) achieved infection clearance. Twenty-three (59%) patients achieved primary union whereas 16 (41%) had a primary outcome of either delayed union, nonunion, or amputation (one additional patient excluded as healing status unknown). Further analysis showed no significant difference (X2 (39) = 1.13, p < .29) in infection clearance between patients treated with nail retention (64%) versus nail removal (68%). No significant difference was seen in primary bone union (X2 (39) = 3.24, p < .07) with 36% of patients treated with nail retention and 68% of patients treated with nail removal reaching primary union; however, this does trend toward an association. Fewer surgeries performed for infection and complication after initial fixation was positively associated with infection clearance (p < .04, M=4.6, SD=2.13, df=39) and primary union (p < .001, M=4, SD=2, df=38). Conclusion: Infection clearance seems similarly possible with both nail retention and nail removal strategies, with fewer number of surgeries performed for infection and complication improving the likelihood of infection clearance and bone union. This may suggest that more severe FRI’s are less likely to unite and clear infection. Nail removal may play a role in increasing primary bone union; however, a larger sample size is needed for more definitive assessment.

Predicting the Outcome of Open Type IIIC Tibial Fractures Regarding Union, Osteomyelitis, and Amputation

Backgrounds: This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures.Methods: Patients who presented to our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, timing, numbers, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. Results: Fifty-eight patients were enrolled and grouped by fracture type; eight union on time (13.8%); 27 late union (46.6%); eight delayed union (13.8%); three nonunion (5.2%); and 12 amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with Injury Severity Score (ISS) ≥ 16 points, and increased length of bone defect. Additionally, a bone gap > 50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within two years was stratified based on this score. Conclusions: IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥ 16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation.

Tertiary Care Orthopedic Hospital Experience to Find Effect of Dynamisation in Delayed Union Tibia Shaft Fracture

Objective: Our study was designed to evaluate the effect of dynamisation in delayed union tibia shaft fractures. Methodology: This prospective study was conducted at the Orthopedic Department, Shaheed Mohtarma Benazir Bhutto Medical College, from March 2020 to March 2021. During this timeframe total of 20 patients who underwent dynamisation for reamed intramedullary nailing were recruited. After two successive visits, those patients whose fracture failed to show progressive signs of callus formation underwent dynamisation. We removed the single static screw from the longer fracture segment to perform the dynamisation procedure. We inserted a poller screw slightly medial to the nail from anterior to posterior to provide additional stability to the proximal fragment. Statistical analysis was performed by using SPSS 23.0. For evaluating the success of dynamisation Chi-square test was used. Results: The mean age of recruited patients was reported as 35.92 years ranging from 16 years to 63 years old. Out of these twenty cases, 17 were male (85%). The mean time duration of nailing was reported as 35.4 hours. Total fourteen patients were immediately treated with nailing within 20 hours of injury, while the rest six underwent delayed nailing. Total four cases of tibial fracture were turned out as failure because the patient failed to achieve union after dynamisation and underwent augmentation plating with bone grafting for the complete union. Conclusion: Delayed dynamisation is a convenient and cost-effective technique to achieve union in femoral shaft fractures. Overall, our study reported an 80% success rate but failed to achieve early dynamisation in comminuted fractures.

A STUDY ON FRACTURE OF FEMUR SHAFT TREATMENT WITH INTRAMEDULLARY INTERLOCKING NAILING

Background: Rigid interlocking nailing for femoral shaft fracture is ideal for use in adolescents in terms of stability of the fracture and convenience for the patient. Closed reduction and intramedullary interlocking nailing is the surgical treatment of choice for the closed shaft fractures of femur. Present study conducted to study the principles of intramedullary interlocking nailing and to assess the outcome of the patient. Methods: The present study comprises of 30 cases of fracture shaft of the femur in adults about >20 years old. All the fractures, which were included in the study were traumatic in origin, most of them are due to road traffic accidents. Results: The delayed union rate in our series was 6.67%. There were no non-unions. Conclusions: It is concluded that closed intramedullary interlocking nailing method given good result in treatment of shaft fractures of femur. Keywords: Intramedullary nailing, Femur, Diaphysis fractures, Interlocking

Comparison of the rate of delayed/nonunion in fifth metatarsal fractures receiving anti-inflammatory medications

Purpose Controversy exists regarding the acute effect of non-steroidal anti-inflammatory drugs (NSAIDs) on early fracture healing. The purpose of this study was to analyze the rate of nonunion or delayed union in patients with fifth metatarsal (5th MT) fractures. We hypothesize that the use of NSAIDs would increase the rate of nonunion/delayed union in 5th MT fractures. Methods Using PearlDiver, a national insurance database was analyzed. ICD codes were used to identify patients diagnosed with 5th MT fracture from 2007-2018. Patients were grouped by initial management (nonoperative vs. open reduction and internal fixation (ORIF) or non/malunion repair within 60 days) and sub-grouped by whether they had been prescribed at least one pre-defined NSAID. Subsequent ORIF or nonunion/malunion repair operative intervention was used as a surrogate for fracture nonunion/delayed union. Results Of the 10,991 subjects with a diagnosis of 5th MT, 10,626 (96.7%) underwent initial nonoperative treatment, 1,409 of which (13.3%) received prescription NSAIDS within 60 days of diagnosis. 16/1,409 (1.14%) subjects who received anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis while 46/9,217 (0.50%; P=0.003483) subjects who did not receive anti-inflammatory prescriptions underwent ORIF or repair of non/malunion at least 60 days after diagnosis. In the 365 subjects who underwent early repair/ORIF (within 60 days), there was no significant difference in the rate of nonunion/delayed union. Conclusion The rate of nonunion/delayed union of 5th MT fractures was significantly higher in subjects receiving NSAIDs within 60 days of initial diagnosis in patients managed non-operatively. Level of evidence Level III