Effect of Teriparatide on Fracture Healing in Intertrochanteric Fractures Treated with Proximal Femoral Nailing: A Prospective Comparative Study

Abstract

Introduction: Intertrochanteric fractures are common in the elderly and are associated with significant morbidity and delayed functional recovery. Proximal femoral nailing (PFN) is a standard method of fixation; however, fracture healing may be compromised in osteoporotic bone. Teriparatide, an anabolic agent, has been proposed to enhance fracture healing. Aims & Objectives: To evaluate the effect of adjunctive teriparatide therapy on radiological union and functional outcomes in intertrochanteric fractures treated with PFN. Materials & Methods: A prospective randomized comparative study was conducted on 30 patients with intertrochanteric fractures at a tertiary care hospital over a 24-month period. Patients were allocated into two groups: Group A (PFN with teriparatide, n=15) and Group B (PFN alone, n=15). Group A received subcutaneous teriparatide (20 µg/day) starting on postoperative day 7 for 24 weeks. Functional outcomes were assessed using the Visual Analogue Scale (VAS), Lower Extremity Functional Scale (LEFS), and Harris Hip Score (HHS). Radiological assessment included cortical bridging, tip-apex distance (TAD), femoral offset, and neck-shaft angle (NSA). Results: Group A demonstrated significantly earlier fracture union (mean 11.2 weeks) compared to Group B (13.4 weeks). Patients receiving teriparatide showed better pain relief and functional scores during early follow-up (1–3 months, P < 0.05). However, functional outcomes and radiological parameters (TAD, NSA, and femoral offset) were comparable between groups at 6 months (P > 0.05). Complication rates were similar in both groups. Conclusion: Adjunctive teriparatide therapy accelerates biological fracture healing and improves early functional recovery in osteoporotic intertrochanteric fractures treated with PFN, without affecting final structural outcomes or increasing complications. References Boyd HB, Griffin LL. Classification and treatment of trochanteric fractures. Arch Surg. 1949;58(6):853-866. Cooper C, Campion G, Melton LJ III. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992;2(6):285-289. https://doi.org/10.1007/bf01623184 Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997;7(5):407-413. https://doi.org/10.1007/pl00004148 Kanis JA, Johnell O, Oden A, Sembo I, Redlund-Johnell I, Dawson A, et al. Epidemiology of hip fractures. Bone. 2003;32(5):463-473. https://doi.org/10.1016/s8756-3282(01)00418-5 Cummings SR, Melton LJ. Epidemiology and outcomes of hip fractures. Lancet. 2002;359(9319):1761-7. Parker MJ, Handoll HH. Surgical versus conservative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2006;(4):1-10. https://doi.org/10.1002/14651858.cd000337 Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1973;55(7):1304-1321. https://doi.org/10.2106/00004623-197961020-00009 Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77(7):1058-1064. https://doi.org/10.2106/00004623-199507000-00012 Simmermacher RKJ, Bosch AM, Van der Werken C. The AO/ASIF proximal femoral nail in unstable trochanteric fractures. Injury. 1999;30(5):327-332. https://doi.org/10.1016/s0020-1383(99)00091-1 Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res. 1980;(146):53-61. Strauss E, Frank J, Lee J, Kummer FJ, Koval KJ. Helical blade versus sliding hip screw for internal fixation of unstable intertrochanteric fractures: a biomechanical comparison. J Orthop Trauma. 2006;20(7):433-436. https://doi.org/10.1016/j.injury.2006.06.008 Riggs BL, Melton LJ. Involutional osteoporosis. N Engl J Med. 1986;314(26):1676-86. Eastell R, O'Neill TW, Hofbauer LC, Jagschies B, Reeve J, Vignoni M. Management of male osteoporosis. Lancet. 1998;352(9137):1347-1353. Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001;344(19):1434-1441. https://doi.org/10.1097/00006254-200110000-00018 Aspenberg P, Genant HK, Johansson T, Nino AJ, See K, Krohn K, et al. Teriparatide for acceleration of fracture repair in humans: a prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Miner Res. 2010;25(2):404-414. https://doi.org/10.1359/jbmr.090731 Bhandari M, Jin L, See K, Stegmueller B, Fernandes JC, Jönsson B, et al. Does teriparatide accelerate healing in osteoporotic hip fractures? A mid-term analysis. J Orthop Trauma. 2016;30(3):121-127. Larson CB, et al. Mechanical failure of fixation in intertrochanteric fractures. J Bone Joint Surg Am. 1974;56(3):483-492. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1991;73(1):123-136. https://doi.org/10.2106/00004623-197961020-00009 Jensen JS, Sonne-Holm S, Tøndevold E. Failure of internal fixation of intertrochanteric fractures. Acta Orthop Scand. 1980;51(1-6):803-810. Gardenbroek TJ, Segers MJ, Simmermacher RK, Hammacher ER. The proximal femur nail antirotation: an identifiable improvement in the treatment of unstable pertrochanteric fractures? J Trauma. 2011;71(1):169-174. https://doi.org/10.1097/ta.0b013e3182213c6e Varacallo MA, Fox EJ. Osteoporosis and its complications. Med Clin North Am. 2014;98(4):817-831. Einstein A, et al. Effect of osteoporosis on internal fixation stability. Clin Orthop Relat Res. 1995;(312):19-27. Lou S, Lv H, Wang G, Zhang L, Li M, Li Z, et al. The effect of teriparatide on fracture healing of osteoporotic patients: a meta-analysis of randomized controlled trials. Biomed Res Int. 2016;2016:1-10. https://doi.org/10.1155/2016/6040379 Bukata SV, et al. Systemic anabolic therapy for fracture healing. Clin Orthop Relat Res. 2011;469(8):2178-86. Yu W, et al. Teriparatide improves healing in unstable intertrochanteric fractures treated with PFN. Injury. 2020;51(2):236-243. Singhal S, et al. Role of teriparatide in intertrochanteric fracture healing. Indian J Orthop. 2018;52(5):507-514. Choi YJ, et al. Teriparatide after pertrochanteric fracture fixation. J Orthop Trauma. 2025;39(2):112-119. Wheeless CR III. Closed reduction of intertrochanteric fractures. In: Wheeless' Textbook of Orthopaedics. Durham (NC): Wheeless Online; 2026:1-11. https://doi.org/10.1002/cyto.990110308 Shapira J, Chen SL, Rosinsky PJ, Maldonado DR, Meghpara MB, Lall AC, Domb BG. The effect of postoperative femoral offset on outcomes after hip arthroplasty: a systematic review. J Orthop. 2020;22:5-11. https://doi.org/10.1016/j.jor.2020.03.034