What non-surgical interventions can stimulate bone growth at a midfoot nonunion (non-union)?

From the Guidelines

Yes, there are non-surgical interventions that can stimulate bone growth at a midfoot nonunion, with low intensity pulsed ultrasound (LIPUS) being a viable option. According to the 2017 clinical practice guideline published in the BMJ 1, LIPUS has been approved by the US Food and Drug Administration (FDA) for fracture healing and treatment of established non-unions since 1994 and 2000, respectively. The guideline also mentions that the UK National Institute for Health and Care Excellence (NICE) supports the use of LIPUS to reduce fracture healing time and provide clinical benefit, particularly in circumstances of delayed healing and non-union.

Some key points to consider when using LIPUS for bone growth stimulation at a midfoot nonunion include:

• The device is typically used for 20 minutes daily for several months
• LIPUS works by increasing blood flow and stimulating osteoblast activity, which enhances the natural bone healing process
• The effectiveness of LIPUS may vary based on the specific location and severity of the nonunion, and it generally works best for stable nonunions with good alignment rather than displaced fractures
• Other non-surgical interventions, such as extracorporeal shock wave therapy (ESWT) and bone stimulation devices, may also be considered, but LIPUS is a well-established and widely used option, with global revenues of around $250m in the US in 2007, as reported in the study 1.

It is essential to note that the effectiveness of these interventions can vary, and they should be used under the guidance of a healthcare professional, taking into account the individual patient's condition and medical history, as well as the severity and location of the nonunion, as mentioned in the study 1.

From the Research

Non-Surgical Interventions for Midfoot Nonunion

• Teriparatide, a parathyroid hormone (PTH) analogue, has been found to induce union in cases of delayed union and nonunion, including midfoot nonunions 2, 3, 4.
• The use of teriparatide has been reported to be effective in numerous case reports and studies, with a high rate of complete union (95.3%) and no side effects 4.
• The typical dosage of teriparatide used in these studies is 20 μg/day, administered via subcutaneous injection, with a mean duration of treatment ranging from 7.3 weeks to 9.7 months 4.
• While the current evidence is promising, further clinical studies are required to investigate the safety and efficacy of teriparatide for treating midfoot nonunions 2, 3, 4.

Mechanism of Action

• Teriparatide is believed to stimulate bone growth by increasing osteoblast activity and promoting the formation of new bone tissue 2, 3.
• The exact mechanism of action of teriparatide in promoting fracture healing is not fully understood, but it is thought to involve the stimulation of osteogenic cells and the enhancement of bone remodeling 2, 3.

Limitations and Future Directions

• The current evidence for the use of teriparatide in treating midfoot nonunions is limited to case reports and small studies, and further research is needed to fully establish its safety and efficacy 2, 3, 4.
• The use of teriparatide for treating midfoot nonunions is considered "off-label," and informed consent and cost coverage from healthcare insurance must be obtained prior to treatment 3.