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OBJECTIVE Comparing outcomes of periprosthetic distal femur fractures treated with open reduction internal fixation (ORIF) versus distal femoral replacement (DFR). SETTING Three major academic hospitals within one metropolitan area. DESIGN Retrospective. PATIENTS/PARTICIPANTS 370 patients >64 years old with periprosthetic distal femur fractures were identified and 115 were included (65 ORIF vs 50 DFR). INTERVENTION ORIF with locked plating versus DFR. MAIN OUTCOME MEASUREMENT One-year mortality, ambulatory status at 1 year, reoperations, and hospital readmissions. RESULTS No differences were seen between ORIF and DFR cohorts with respect to demographics or medical history, including Charleston Comorbidity Index. DFR was associated with longer hospital stay (6.09 days ORIF vs 9.08 days DFR, p<0.001) and more frequent blood transfusion (12.3% ORIF vs 44.0% DFR, p<0.001). Logistic regression analysis using propensity score matching (PSM) demonstrated no statistically significant difference in reoperation, hospital readmission, ambulatory status at 1-year, or 1-year mortality between the two cohorts. Lastly, applying Bayesian model averaging using PSM to identify risk factors for 1-year mortality demonstrated that increasing age, length of index hospital stay, and 90-day hospital readmission were significantly associated with 1-year mortality, regardless of type of surgical treatment. CONCLUSION Rehospitalization, reoperation, ambulatory status and 1-year mortality are no different between ORIF and DFR in the treatment of geriatric periprosthetic distal femur fractures when PSM is applied to mitigate selection bias. Further study is warranted to elucidate functional outcomes, long-term sequelae, and costs of care related to these treatment options to better guide treatment planning. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.