Comparative Outcomes of Locking Plate Fixation versus Intramedullary Nailing in Distal Femur Fractures: A Systematic Review and Meta-Analysis

Dr. Vedavathi H; Sachin N C; Tejal.VV

doi:10.51168/xfrpsf42

Authors

Dr. Vedavathi H Professor and Head, Department of Pharmacology, Shimoga Institute of Medical Sciences, Shimoga 577201, Karnataka, India
Dr. Sachin N C Senior Registar, Apollo Hospital, Bannerghatta Road , Bangalore -560076, Karnataka, India
Dr. Tejal.VV Resident, Indira Maternity and Skin Laser Center, Station Road, Tumkur- 572102 Karnataka, India

DOI:

https://doi.org/10.51168/xfrpsf42

Keywords:

distal femur fracture, locking plate, retrograde intramedullary nail, fracture union, nonunion, infection, meta-analysis

Abstract

Background: Locking plate fixation and retrograde intramedullary nailing are established treatments for distal femur fractures, but implant selection remains influenced by fracture morphology, bone quality and surgeon preference. Evidence published after the search cut-off of a major 2022 review required a transparent update through November 2025.

Objective: To synthesise comparative studies published after the search cut-off of a major 2022 review and to estimate contemporary effects for nonunion, while summarising infection, fracture healing and functional outcomes.

Methods: A sequential update strategy was used. PubMed/MEDLINE, PubMed Central, publisher repositories and citation links were searched for comparative adult studies published from 26 February 2022 to 30 November 2025. Randomised and non-randomised studies directly comparing retrograde intramedullary nailing with locking plate fixation were eligible. Risk ratios (RRs) were pooled using inverse-variance random-effects models with a modified Hartung-Knapp confidence interval when at least three compatible studies were available. Heterogeneity was assessed with I² and τ². Risk of bias was appraised using RoB 2 or ROBINS-I principles, and certainty was judged with GRADE.

Results: Three retrospective comparative studies enrolled 345 patients. All three studies contributed nonunion data. Nonunion occurred in 17 of 173 patients treated with nailing and 29 of 172 treated with plating; the pooled estimate favoured nailing but remained statistically uncertain (RR 0.54, 95% CI 0.17–1.69; p=0.145; I²=0%). Two studies involving 152 participants reported postoperative infection, with 2 events among 80 nailing patients and 4 among 72 plating patients; the evidence was too sparse for pooling. Healing time was numerically shorter after nailing in all three studies, whereas functional findings were inconsistent.

Conclusion: Comparative evidence available through November 2025 does not establish universal superiority of either implant. Nailing may reduce nonunion and accelerate healing, but the estimate remains imprecise, while infection and functional data are insufficient for a dependable conclusion.

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