Successful treatment of nonunion with teriparatide after failed ankle arthrodesis for Charcot arthropathy
A 25-year-old Japanese woman sustained a right femoral shaft fracture while climbing the stairs in May 2012 (Fig. ). She denied any abuse or accident such as falling down the stairs. She had a history of Type 1 diabetes mellitus, which was poorly controlled with insulin therapy (HbA1c, 16.7 %), and Charcot arthropathy of the ankle due to peripheral nerve disorder. An ankle arthrodesis had been performed at another clinic 15 months ago, but union was not achieved, and therefore, she underwent further surgery 12 months ago to fix her ankle. This treatment also failed resulting in nonunion, and so the woman was instructed to wear a patellar tendon-bearing brace for her ankle instability and pain (Fig. ). Her laboratory data, including serum levels of alkaline phosphate, parathyroid hormone, calcium, and phosphorus, were normal, but her level of 1.25 vitamin D3 was low, and her left femoral bone density was extremely low (0.54 mg/cm2) and 2.0 standard deviations below the normal value for her age (Table ).\nWe treated the femoral shaft fracture with intramedullary nail fixation 29 days after the fracture occurred, because her chronic heart failure was too poor to allow for immediate surgery. We initiated teriparatide (20-μg subcutaneous injection daily) and alfacalcidol (1-μg oral administration daily) immediately after surgery because of severe osteoporosis and in an attempt to accelerate healing of the femoral fracture. There was no immobilization of the femur, but a non-weight-bearing period of 4 weeks was implemented postoperatively. From 2 weeks after the initiation of teriparatide therapy, plain radiography began showing callus formation on the femoral shaft fracture, and after 12 weeks, almost complete healing of the fractured bone was observed (Fig. ). We therefore allowed the woman to walk with full weight bearing. We noticed that her ankle pain disappeared once she had resumed walking. Radiography and computed tomography images revealed that union of the ankle had been achieved (Fig. ). No side effects attributable to the drug were observed during treatment, and her subsequent laboratory findings continued to be normal. At 6 months, the patient could walk without a brace and without any pain. Plain images taken at this time revealed complete healing of the fractured and nonunion sites.