Journal of Orthopaedic Trauma · May 27, 2026

Comparative Analysis of Nail Plate Combination Over Alternative Fixation Constructs in Low-Energy Distal Femur Fractures: Recovery of Ambulatory Status and Outcomes

By Pereira DE, Rust B, Barton D et al.

OBJECTIVES: To compare ambulatory status, union, mortality, and operative complications in patients with distal femur fracture treated with the nail plate combination (NPC) and alternative fixation constructs. DESIGN: Retrospective Cohort Study. SETTING: Single Level 1, tertiary referral Academic center. PATIENT SELECTION CRITERIA: This study included adults with a low-energy distal femur fracture (OTA/AO33A/C and Su 1-3) that received ORIF within 2018-2024. Exclusions were pathologic fractures, antegrade intramedullary devices, and baseline nonambulators (from ambulatory status evaluation only). OUTCOME MEASURES AND COMPARISONS: The primary outcome was ambulatory status at postoperative intervals using Koval-Walking-Score. Secondary outcomes included radiographic union, mortality, and reoperation. RESULTS: A total of 404 patients with a low-energy distal femur fracture were included, with 342 included for mobility analysis. Fixation constructs included 189 NPC (mean age 75.0 ± 10.2, 83.1% female), 118 lateral locking plate (LLP) (mean age 73.4 ± 10.2; 76.3% female), 79 retrograde intramedullary nail (rIMN) (mean age 73.7 ± 11.1, 74.7% female), and 18 dual plate combination (mean age 74.6 ± 10.9, 83.3% female) (age P = 0.567, sex P = 0.701). NPC was more frequently selected for Su 2 (56.2%) and Su 3 (65.9%) ( P = 0.001). NPC demonstrated lower average ambulatory impairment score over LLP: 3 weeks (-0.8; P = 0.002), 6 weeks (-1.1; P < 0.001), and both LLP and rIMN at 3 months (-0.9/-0.8; P = 0.049/0.013) and 6 months (-0.9/-0.8; P = 0.043/0.021). After Bonferroni correction to account for multiple testing, post hoc pairwise comparisons showed that NPC ambulation scores remained lower at 3 and 6 weeks (-0.8, P = 0.024; -1.1, P < 0.001). Six-month mortality was lower in NPC than rIMN (9% vs. 19%; P = 0.04). Dual plate combination showed higher infection (22.2%; P = 0.012), wound dehiscence (11.1%; P = 0.013), and drainage (5.6%; P < 0.001); although sample size limited analysis. Radiographic union was comparable (36.3% vs. 52.9% vs. 39.6% vs. 54.5%, P = 0.104). CONCLUSIONS: In this study, NPC was associated with superior ambulatory recovery rates to preinjury status over single-implant constructs and improved mortality rates over rIMN. Thus, NPC represented a reliable construct for early ambulation and recovery in these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

doi.org/10.1097/bot.0000000000003230PubMed 42200564Interventions