Dual vs. single plating in distal femoral fractures: a systematic review and meta-analysis

Distal femoral fractures, comprising 0.4% of all fractures, present significant management challenges due to their complex anatomy and associated complications. While single plating (SP) is commonly used, its biomechanical limitations in complex fractures have prompted interest in dual plating (DP), which may offer superior stability. This systematic review and meta-analysis aimed to compare clinical outcomes between single and dual plating techniques in distal femoral fractures.

A comprehensive literature search was conducted in PubMed, Scopus, and Web of Science up to May 2025, following PRISMA guidelines. Thirteen retrospective studies comparing dual vs. single plating in distal femoral fractures (DFF) involving 1,015 patients (654 SP, 361 DP) met inclusion criteria. Outcomes assessed included union rates, operation time, blood loss, postoperative range of motion (ROM), functional scores, complications, and reoperation rates. Data were analyzed using random-effects models, with heterogeneity assessed via I² statistics.

DP was associated with significantly higher union rates with odds of union approximately five times greater than SP (OR = 5.34, 95% CI: 2.23-12.79; p = 0.0002), shorter union times (MD= -3.08, 95% CI: -5.18, -0.99; p = 0.004), a 73% lower odds of nonunion (OR = 0.27, 95% CI: 0.14, 0.53; p = 0.0002), an 89% lower odds of malunion (OR = 0.11, 95% CI: 0.02, 0.54; p = 0.007), and an 84% lower odds of delayed union (OR = 0.16, 95% CI: 0.04, 0.68; p = 0.01). However, DP resulted in longer operative times (MD = 27.19, 95% CI: 23.11-31.28; p < 0.00001). SP demonstrated superior postoperative knee ROM (p = 0.02). No significant differences were observed between groups in hospital stay, reoperation rates, superficial infections, or overall complications; p < 0.05. Heterogeneity was low for most outcomes, except for blood loss (I² = 84%), flexion contracture (I² = 89%), and union time (I² = 69%), reflecting variability in surgical technique and case complexity.

Dual plating offers superior fracture healing without increasing complication rates, making it preferable for DFF. Single plating may remain advantageous for patients prioritizing postoperative knee mobility.