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. 2a, b). 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 1). Fig. 1 Radiographs of the femur. see more a 3D computed tomography images revealed an oblique fracture of the proximal shaft of

the femur. b Plain film taken 2 weeks after surgery. Callus formation is visible around the fracture site. c Plain film taken 12 weeks after surgery. Large callus and consolidation are visible Fig. 2 Radiographs of the femur. a Plain film of the ankle with Charcot arthropathy before arthrodesis. b Plain film taken before teriparatide therapy was initiated showing atrophic PD0332991 in vitro nonunion of the ankle. c Plain film and sagittal CT images showing atrophic nonunion of the ankle after multiple arthrodesis operations. d Plain film and sagittal CT image taken after 12 weeks of teriparatide therapy showing complete healing of nonunion Dimethyl sulfoxide Table 1 Laboratory data before and after teriparatide therapy   Reference Range, Age-adjusted Pretreatment After 3 months Protein (g/dl) Total 6.7–8.3 7.5 7.2 Albumin 3.9–4.9 3.1 3.5 ALP (IU/l) 104–338 281 1033 BUN (mg/dl) 8.0–20.0 21.7 19.1 Cre (mg/dl) 0.36–1.06 0.67 0.61 Na (mEq/l) 136–147 136 134 K (mEq/l) 3.6–5.0 4.6 4.9 Cl (mEq/l) 98–109 94 99 Ca (mEq/l) 8.8–10.2

9.8 9.1 IP (mEq/l) 2.5–4.5 4.1 3.6 Mg (mEq/l) 1.8–2.4 2 1.9 HbA1c (%) 4.6–6.2 13.5 13.2 ACTH (pg/ml) 7.2–63.3 22.4   Intact-PTH (pg/ml) 10–65 31   Calcitonin (pg/ml) 15–86 35   1.25-Vit D3 (pg/ml) 20–60 12 72 NTx (nmol BCE/mmol・Cr) 8–70 189 327 D-Pyr (nM/mM・Cr) 2.8–7.6 31.8 21.6 We Z-IETD-FMK in vitro 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. 1b, c).