J Endocrinol Metab

Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc

Journal website http://www.jofem.org

Case Report

Volume 6, Number 6, December 2016, pages 183-186

Teriparatide Prevented Near Atypical Femur Fracture by Reducing Cortical Thickening in a Symptomatic Patient With Prolonged Use of Oral Bisphosphonate: A Case Report

Figure 1. Before: cortical thickening of 12.2 mm before teriparatide use; after: reduction of cortical thickening to 11.3 mm after teriparatide use.

**Table 1.** Timeline Measurement of Vertebral and Femoral Neck Bone Mineral Density (BMD) and T Score
Measurement	Treatment
*Percent change in BMD from the previous year.
Vertebral (L1-L4)
BMD (g/cm²)	0.896	0.88 (-1.34%)*	1.010 (+14.25%)*	0.905 (-10.4%)*	1.118 (+23.54%)*	1.128 (+0.89%)*
T score (SD)	-2.4	-2.3	-1.4	-2.5	-0.5	-0.4
Femoral neck right
BMD (g/cm²)	0.755	0.853 (+12.98%)*	0.840 (-1.52%)*	0.763 (-9.17%)*	0.756 (-0.92%)*	0.749 (-0.93%)*
T score (SD)	-1.6	-1.3	-1.2	-2.0	-2.0	-2.1
Femoral neck left
BMD (g/cm²)	0.795	0.780 (-1.89%)*	0.773 (-0.9%)*	0.848 (+9.7%)*	0.799 (-5.78%)*	0.809 (+1.25%)*
T score (SD)	-1.3	-1.3	-1.7	-1.4	-1.7	-1.6

Table 1. Timeline Measurement of Vertebral and Femoral Neck Bone Mineral Density (BMD) and T Score

Measurement

Treatment

Alendronate

Teriparatide

2002

2007

2010

2013

2014

2015

*Percent change in BMD from the previous year.

Vertebral (L1-L4)

BMD (g/cm²)

0.896

0.88 (-1.34%)*

1.010 (+14.25%)*

0.905 (-10.4%)*

1.118 (+23.54%)*

1.128 (+0.89%)*

T score (SD)

-2.4

-2.3

-1.4

-2.5

-0.5

-0.4

Femoral neck right

BMD (g/cm²)

0.755

0.853 (+12.98%)*

0.840 (-1.52%)*

0.763 (-9.17%)*

0.756 (-0.92%)*

0.749 (-0.93%)*

T score (SD)

-1.6

-1.3

-1.2

-2.0

-2.1

Femoral neck left

BMD (g/cm²)

0.795

0.780 (-1.89%)*

0.773 (-0.9%)*

0.848 (+9.7%)*

0.799 (-5.78%)*

0.809 (+1.25%)*

T score (SD)

-1.3

-1.7

-1.4

-1.7

-1.6

**Table 2.** List of the Cases Where Teriparatide (TPP) Was Used to Treat Complete or Incomplete Atypical Femur Fracture (AFF) Caused by Prolonged Use of Bisphosphonate (BP)
Reference	Case history	BP use	TPP use and results
Gomberg et al, 2011 [3]	A 63-year-old woman with thigh pain and bilateral AFFs	13 years	Complete healing and relief of pain in 21 months
Carvalho et al, 2011 [4]	A 77-year-old woman presented with right subtrochanteric femur fracture	4 years	Closure of the right femur fracture after 1 month
Mastgalia et al, 2012 [5]	A 57-year-old Argentine woman with a sustained non healing femoral shaft fracture	7 years	Her pain improved after 10 days of TPP and healing was complete after 3 months.
Saleh et al, 2012 [6]	A 65-year-old woman with right femur showing a periosteal reaction in the anterior shaft and transverse radiolucent line on higher magnification	14 years	Disappearance of the fracture line with resolution of symptoms after 1 year of TPP treatment.
Tsuchie et al, 2015 [7]	A 77-year-old woman having bilateral thigh pain persisting for 6 months. Plain radiographs of the bilateral femur showed thickening of the outer cortex and a horizontal line resembling an incomplete AFF.	6 years	Treated surgically using locking plates and TPP was continued for 1 year after the operation, and she remained asymptomatic during the follow-up period of 2 years postoperatively.
Tsuchie et al (2015) [7]	A 78-year-old woman with pain of the left thigh persisting for 1 month. Plain radiographs showed some thickening of the femoral cortex and a horizontal line resembling fracture over the outer cortical bone of the left femoral distal diaphysis.	4 years	Treated surgically using locking plates to prevent complete fracture of the femur. TPP was finished 1 year after the operation; and selective estrogen receptor modulator (SERM) intake was started after TPP therapy. She did not have any pain of the left thigh during 3 years follow-up course.
Huang et al, 2012 [8]	A 63-year-old Asian woman revealed a right femoral diaphysis stress fracture.	3 years	After 15 months, fracture line completely disappears with all the symptoms resolution.

Table 2. List of the Cases Where Teriparatide (TPP) Was Used to Treat Complete or Incomplete Atypical Femur Fracture (AFF) Caused by Prolonged Use of Bisphosphonate (BP)

Reference

Case history

BP use

TPP use and results

Gomberg et al, 2011 [3]

A 63-year-old woman with thigh pain and bilateral AFFs

13 years

Complete healing and relief of pain in 21 months

Carvalho et al, 2011 [4]

A 77-year-old woman presented with right subtrochanteric femur fracture

4 years

Closure of the right femur fracture after 1 month

Mastgalia et al, 2012 [5]

A 57-year-old Argentine woman with a sustained non healing femoral shaft fracture

7 years

Her pain improved after 10 days of TPP and healing was complete after 3 months.

Saleh et al, 2012 [6]

A 65-year-old woman with right femur showing a periosteal reaction in the anterior shaft and transverse radiolucent line on higher magnification

14 years

Disappearance of the fracture line with resolution of symptoms after 1 year of TPP treatment.

Tsuchie et al, 2015 [7]

A 77-year-old woman having bilateral thigh pain persisting for 6 months. Plain radiographs of the bilateral femur showed thickening of the outer cortex and a horizontal line resembling an incomplete AFF.

6 years

Treated surgically using locking plates and TPP was continued for 1 year after the operation, and she remained asymptomatic during the follow-up period of 2 years postoperatively.

Tsuchie et al (2015) [7]

A 78-year-old woman with pain of the left thigh persisting for 1 month. Plain radiographs showed some thickening of the femoral cortex and a horizontal line resembling fracture over the outer cortical bone of the left femoral distal diaphysis.

4 years

Treated surgically using locking plates to prevent complete fracture of the femur. TPP was finished 1 year after the operation; and selective estrogen receptor modulator (SERM) intake was started after TPP therapy. She did not have any pain of the left thigh during 3 years follow-up course.

Huang et al, 2012 [8]

A 63-year-old Asian woman revealed a right femoral diaphysis stress fracture.

3 years

After 15 months, fracture line completely disappears with all the symptoms resolution.