Background: The long-term clinical outcomes after open reduction and internal fixation (ORIF) for distal femoral fractures, both native and peri-prosthetic, are not yet well established in the literature.

Methods: We used the clinically validated Western Ontario and McMaster Universities Arthritis Index (WOMAC) score to make the functional outcomes after ORIF comparable with the well-characterized results achieved after total knee arthroplasty (TKA) for osteoarthritis. After long-term clinical follow-up and prospectively collected WOMAC scores were obtained, pain, stiffness, and function were evaluated for 68 elderly patients with distal femur fractures (34 periprosthetic, 34 native; median follow-up time, 2.43 years).

Results: Although pain and stiffness scores were significantly lower than those achieved after TKA, functional and total WOMAC scores were similar. Pain and function continued to improve with greater time to follow-up. Although 32% (22/68) of patients had a return to the operating room (3 for infection, 11 for nonunion, and 7 for implant prominence), total WOMAC scores at long-term follow-up were not different for the patients who returned to the operating room. Although stiffness may persist for some patients, the functional outcomes after this procedure are similar to outcomes for patients after primary TKA. The rate of fracture-related re-operations was 32%, but was not associated with poor clinical outcomes.

Conclusions: The 91% rate of good to excellent outcomes seen in our cohort suggests ORIF is likely to provide a favorable result for distal femur fractures, both native and periprosthetic, among elderly patients. [Orthopedics. 2025;48(3):e124-e130.].