Teriparatide for treating delayed union and nonunion: A systematic review

Introduction: Fracture nonunion remains a great challenge for orthopaedic surgeons.Approximately 5 e10% 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 mg/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 mg 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.