Consensus-based guidelines on subtrochanteric femur fractures: Bridging evidence and experience on 11 key clinical dilemmas

Background: Subtrochanteric femur fractures present complex biomechanical and biological challenges with considerable variability in management approaches. Despite a structured approach to operative fixation using the intramedullary nail being accepted as the gold standard for most subtrochanteric fractures, a number of high-impact clinical dilemmas lack clarity and consensus on management approaches due to limited high-level clinical and published evidence. Methodology: We identified 11 key controversies through a comprehensive literature review of the PubMed, Scopus, and Cochrane databases from 2011 to 2024. Expert input through direct conversations with high-volume trauma surgeons further reinforced the selection of these problem statements. A modified Delphi consensus process was used to engage with 64 experienced Indian orthopedic surgeons. A four-phase methodology was employed, beginning with the pre-definition of 11 key controversies through literature review. PubMed/Scopus/Cochrane: 2000–2024 and expert input. Phase I description: Before initiating the consensus process, a steering committee systematically reviewed existing literature to predefine and shortlist 11 high-impact, unresolved clinical dilemmas. This ensured all subsequent phases of evidence synthesis and voting were focused on these predefined domains. Results: Eleven evidence-supported consensus statements were ratified, addressing implant selection, reduction techniques, technical nuances, and complex scenarios. All statements included clinical rationale, consensus strength (10 Strong, 1 Moderate), and evidence level (I–III). Key outputs of the meeting were the formulation of a standardized treatment algorithm and a decision-making framework for ambiguous clinical situations. Conclusion: This consensus provides practical, expert-endorsed guidance to resolve recurring controversies in subtrochanteric fracture management. By bridging evidence gaps with collective surgical experience, it aims to standardize care, reduce unwarranted variation, and improve patient outcomes.