Distal Femur Fractures: Nail, Plate or Both? A Systematic Review

Background: Distal femur fractures remain among the most challenging injuries in orthopedic trauma, particularly in elderly or osteoporotic patients and in cases involving periprosthetic or highly comminuted distal femur fracture patterns. Modern fixation strategies include retrograde intramedullary nails, locking plates, and, more recently, combined nail–plate constructs (NPC). However, the optimal fixation method remains debated, and high-quality comparative evidence is limited. This systematic review evaluates clinical outcomes, union rates, and complications associated with single versus combined fixation constructs in distal femur fractures. Materials and Methods: A systematic review was performed according to PRISMA guidelines using PubMed/MEDLINE, EMBASE, and the Cochrane Database up to June 2025. Original studies reporting surgical management of distal femur fractures, including periprosthetic distal femur fractures, with postoperative outcomes were included. Ten retrospective studies met the inclusion criteria, comprising 397 patients. Methodological quality was assessed using the Modified Coleman Methodology Score (mean: 56.5). Data collected included patient demographics, fracture type, surgical technique, union rates, complications, and follow-up duration. Descriptive statistics were used to summarize trends due to study heterogeneity. Results: Among the included fractures, 304 involved the distal femur and 55 were periprosthetic. Combined nail–plate fixation was used in 203 patients, while 185 received single-implant fixation. Across studies, union rates were consistently higher in the NPC group, with several reporting 100% union, compared with more variable results in single-construct cohorts (72–96.7%). The most frequent complication in the NPC group was infection (12 cases), whereas delayed union predominated in single-implant constructs (19 cases). Patient comorbidities, such as diabetes or smoking, were inconsistently reported but may have influenced complication patterns. Follow-up periods ranged from 5.15 to 20 months, and operative details were included in several studies. Due to heterogeneity and retrospective design, no meta-analysis was performed, but descriptive trends were consistently observed. Conclusions: Nail–plate constructs appear to offer mechanical advantages in complex or high-risk distal femur fractures, achieving superior union rates compared with single implants. However, this benefit is counterbalanced by a higher incidence of postoperative infections, likely related to greater surgical invasiveness. Single constructs remain appropriate for simpler fracture configurations or better-quality bone. High-quality prospective research with standardized radiographic and functional outcomes is needed to clarify indications and optimize fixation strategies for distal femur fractures.