Retrograde Nails No Better for Distal Femoral Fractures

A well-designed RCT found locked lateral plates worked just as well

What’s the Claim

Patients with extra-articular or simple articular split distal femoral fractures did as well with retrograde nailing as did patients treated with locked lateral plates in a well-designed multicenter randomized trial that had excellent follow-up. Patients in both groups remained noticeably impaired a year after surgery, with no between-group differences, and there were no differences between the groups in terms of the proportion of patients with malalignment of >5° in any plane or in adverse outcomes of any sort. We note that this was not a study of frail, elderly patients; the average age of patients in this clinical trial was 51.

How’s It Stack Up?

This one cuts against the grain a bit. CORRelations’ Fractures & Trauma advisor shared “this is evidence that our prevailing beliefs that nails are better than plates for these fractures may not totally be true. Many folks have already changed practice to using nails and shake their heads at plates . . . or feel that if they have to plate a periprosthetic, they’re doing something suboptimal.” This study provides good evidence that this is not the case. We’re not aware of another randomized trial comparing these two approaches to this common fracture, and this one was particularly good — multicenter, clear inclusion criteria, and little loss to follow-up in either group at a year.

What’s Our Take?

The authors pointed to a few “trends” in the data that did not pass their statistical tests. We're skeptical of those. They tend to get made when authors expect one thing and find another (or find no difference). For the moment, let’s call this one as the authors’ data would suggest: It’s a no-difference trial on all the important endpoints. While sometimes that doesn’t give us much to chew on, in this case it does. Surgeons can look at the fracture and the patient and pick the approach that feels right, without feeling that they're making a compromise if that feeling pushes those surgeons toward plates over nails. Counseling patients early about the protracted recovery they should expect after this operation is worthwhile to avoid disappointment later, and emphasizing terminal extension in rehab also is worthwhile, as some of these patients developed flexion contractures.


Dunbar RP, Egol KA, Jones CB, et al. Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial. J Orthop Trauma. 2023;37:70-76.