Abstract

Teriparatide is an osteoanabolic agent comprising the recombinant human parathyroid hormone (PTH) fragment PTH(1–34) and has attracted interest as a pharmacological adjunct to fracture healing. This narrative review examines its use in acute fractures, delayed union, and nonunion by summarizing the biological rationale, preclinical evidence, clinical findings, and safety considerations. Intermittent administration of teriparatide activates PTH type 1 receptor signaling in osteoblast-lineage cells and osteocytes, promoting osteoblast differentiation and survival, suppressing sclerostin, and enhancing Wnt/β-catenin signaling to support bone matrix formation, mineralization, callus maturation, and remodeling. Preclinical studies, including those using experimental models of impaired fracture healing, have consistently demonstrated enhanced callus formation and mineralization and improved biomechanical recovery. Clinical evidence, however, is less consistent. Recent randomized studies and pooled analyses suggest that teriparatide may shorten the radiographic time to union in some fracture populations, particularly those with osteoporotic hip and pertrochanteric fractures. However, consistent benefits in terms of final union rate, pain, functional recovery, or revision surgery have not been demonstrated. Favorable radiographic and symptomatic outcomes have been reported in delayed union and nonunion, but the evidence comes mainly from case reports, small case series, and uncontrolled observational studies in which surgical or other supportive interventions frequently accompanied teriparatide treatment. Teriparatide should therefore not be regarded as a routine treatment for all fractures or as a replacement for adequate reduction, stable fixation, and infection control. It may have a role as an adjunct in selected clinical contexts involving reduced osteogenic capacity or an increased risk of impaired healing, although the optimal candidate population has not been established. Future prospective comparative studies should standardize patient selection, treatment initiation and duration, and the assessment of clinically relevant structural and functional outcomes.

• Keywords: Teriparatide; Fracture healing; Parathyroid hormone; Ununited fracture; Osteogenesis