Distal femur fractures represent roughly 3 %−6 % of all femur fractures and are expected to rise in incidence with the aging population [[1], [2], [3]]. Locked lateral plating has historically been the treatment of choice for these injuries [[4], [5], [6], [7], [8], [9]]. Advances in plate design have led to robust fixed angular constructs, improved polyaxial fixation with locking capability, and minimally invasive techniques to limit disruption of the local blood supply [[10], [11], [12], [13], [14], [15], [16]]. Despite these improvements, complications rates remain high and include malalignment (secondary to mismatch between the plate and bone), implant failure (particularly in cases with significant medial metaphyseal involvement), and fracture nonunion [17]. As a result, retrograde femoral nailing (RFN) has gained popularity as an alternative treatment option for extra-articular and simple intra-articular distal femur fractures [[18], [19], [20]].

RFN offers advantages including relative stability with decreased soft tissue compromise, ease of implantation, shorter operative time, and earlier weightbearing with a load sharing device [7,9,17]. Advances in nail design have been made to further expand RFN utilization in more complex distal femur fracture patterns. The RFN-Advanced (RFNA) Retrograde Femoral Nailing System (DePuy Synthes, West Chester, PA) is a novel retrograde nail with multiplanar distal interlocking options designed for simple and complex fracture patterns. Unique benefits of this implant include alternative distal sagittal angle options that accommodate for a more posterior starting point in periprosthetic fractures, and an option for a locking attachment washer (LAW) or condylar nuts for supplemental distal fixation [20,21]. Complications associated with this implant have been described, but no direct comparison of outcomes between the RFNA and locked lateral plating has been performed [[22], [23], [24]].

In January 2021, the RFNA became available at our institution, with implant design features that allowed nailing of distal femur fractures that had historically been treated with a plate. The aim of the present study was to compare early outcomes in distal femur fractures managed with the DePuy Synthes RFNA to a historical cohort of similar fractures treated with locked lateral plating.