Enhanced Callus Formation After Six Weeks of Parathyroid Hormone Treatment in a Man with Multiple Pelvic Fractures and Osteogenesis Imperfecta Type IV A Case Report Roland Kocijan, MD, Judith Haschka, MD, Christian Muschitz, MD, Angela Trubrich, MD, Janina Patsch, MD, and Heinrich Resch, MD Investigation performed at the VINFORCE Study Group, St. Vincent Hospital, Vienna, Austria O steogenesis imperfecta (OI) is a genetic disorder in- volving a defect in collagen synthesis 1-3 . OI is charac- terized by impaired bone formation, low bone mass, and deterioration of bone architecture in adults 4,5 . Typical bone features are a decrease in trabecular thickness and number of trabeculae, as well as thin cortices. As a result, there is increased bone fragility with recurrent fractures, leading frequently to skeletal deformities. Currently, no supportive therapy for fracture-healing is available, although preclinical studies show promise for the use of teriparatide (parathyroid hormone [PTH] 1-34) 6-9 . We present the case of a patient with multiple pelvic fractures and osteogenesis imperfecta type IV who demonstrated enhanced callus formation after treatment with PTH. The patient was informed that data concerning the case would be submitted for publication and he provided consent. Case Report A seventy-eight-year-old man with osteogenesis imperfecta (Sillence type IV) was admitted to the hospital with severe pelvic pain following pelvic fractures in five locations (the superior and inferior pubic rami on both the left and right sides and the sacrum), which had been sustained three months earlier after a fall. The initial office visit had been in a spe- cialized trauma center. The patient had been treated with bis- phosphonate therapy (alendronate followed by ibandronate) for a minimum of ten years. Since the occurrence of the pelvic fractures, the patient had been confined to a wheelchair and had been dependent on analgesics (tramadol hydrochloride, metamizol, diclofenac) for severe, chronic pain. The earlier fracture history had consisted of numerous nonvertebral fractures after minor trauma in the left radius, right malleolus, right thumb, left femoral neck (fol- lowed with total endoprosthesis), ilium, and multiple ribs. The spine had been stabilized from T12 to L2, with posterior lumbar interbody fusion for treatment of a vertebral fracture at L1. The medical history also revealed arterial hypertension and a cere- brovascular insult in the basal ganglia that had occurred fifteen years earlier, with a remaining mild left gluteal hemiparesis. When admitted to the hospital, the patient (body mass index, 30.3; weight, 94 kg; height, 176 cm) was hypertensive. The neurological status revealed reduced strength of the left lower extremity (a result of the prior stroke) and insufficiency of the hip muscles. Radiographs and multislice computed tomography of the pelvis showed displaced fractures of the pubic and ischial rami on both the right and left sides and a fracture of the sacrum, with minimal callus formation at the fracture sites (Figs. 1-a and 1-b). A spine radiograph revealed multiple fractures of the lumbar and thoracic vertebrae as well as the ribs. Bone mineral density measurements (measured by dual- energy x-ray absorptiometry) demonstrated moderately decreased T-scores at the radius (21.9), total hip (22.4), femoral neck (23.3), and calcaneus (23.9), with a decrease of approximately 5% compared with values measured four years earlier. The values at the lumbar spine could not be evaluated because of the prior spinal surgery. Structure analysis with high-resolution peripheral quan- titative computed tomography (SCANCO) showed profound inhomogeneity of the trabecular network and a substantially Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. 1 COPYRIGHT Ó 2012 BY THE J OURNAL OF BONE AND J OINT SURGERY,I NCORPORATED JBJS Case Connect 2012;2:e74 d http://dx.doi.org/10.2106/JBJS.CC.L.00042