Plate Versus Nail Fixation in Periprosthetic Distal Femur Fractures: An Updated Systematic Review and Meta-Analysis

Periprosthetic distal femur fractures (PDFFs) are increasing in frequency with the rise in primary total knee arthroplasty in an aging global population. Optimal surgical fixation remains controversial, with both plate and nail constructs widely utilized.

We sought to compare clinical and radiographic outcomes between plate and intramedullary nail fixation for PDFFs.

A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines comparing plate versus nail constructs for PDFFs. We searched PubMed, Embase, Scopus, Cochrane CENTRAL, and Web of Science with search terms including "periprosthetic distal femur fracture," "distal femoral fracture," "retrograde intramedullary nail," "locking plate," and "total knee arthroplasty." We included clinical studies that compared lateral plate fixation (PF) versus intramedullary nailing (IMN) fixation for PDFFs. Only single implant constructs were included. Only studies published in English with data on human patients were considered. We excluded cadaveric studies, biomechanical studies, technical notes, and case series without a comparison group. Outcomes analyzed included all cause revision surgery, nonunion, delayed union, time to union, implant failure, fracture alignment, infection, medical complications, mortality, Knee Society Scores (KSS), and postoperative range of motion (ROM). Risk ratios or mean differences were calculated using fixed-effects models.

We included 13 studies (all retrospective cohort studies, Level III) published between 2012 and 2024, that included a total of 1011 patients with PDFFs, 674 treated with PF, and 337 treated with IMN fixation. We found no significant differences between plate and nail fixation in all-cause revision, nonunion, time to union, medical complications, mortality, KSS, ROM, or time to ambulation. Nail fixation was associated with a significantly lower risk of delayed union, implant failure, and wound infection. However, nail fixation had significantly greater risk of coronal and sagittal fracture malalignment.

The findings of this systematic review and meta-analysis of Level-III studies suggest that plate and nail fixation offer comparable outcomes for most clinical parameters in PDFFs. Nail fixation was associated with lower risks of infection, delayed union, and implant failure, but with higher rates of radiographic malalignment.

Level III: systematic review and meta-analysis of Level-III studies.