Open subtrochanteric femur fractures: navigating a complex injury through principles, surgical strategies, and a treatment algorithm.

PURPOSE: In the realm of orthopaedic trauma, some fractures challenge our training, and then there are "open-subtrochanteric-femur fractures" that challenge our very limits. They are not just fractures; they are catastrophic events; they hit where biomechanics are at worst, where every muscle conspires to deform, displace and defy reduction. And when the skin is slit open, it becomes treacherous, transforming a surgical table into a battlefield. There are no established guidelines; considering Ganga-Hospital-Open-Injury-Scoring-System(GHOISS), a tool that brings structure to the chaos, we formulated a surgical algorithm designed to guide decision-making in these complex injuries. METHODS: A-retrospective-cohort-study, at level-1 trauma-care-center, where 5112-open-injuries were analysed. 873 of them had open-femur-fracture; however, only 27 of them had open-subtrochanteric-femur-fractures, 2-patients died within 7days-of-admission, and 3-patients were lost-to-follow-up. This study represents the results of the remaining 22-patients, who were followed for at-least 1-year. Radiological and functional outcomes were analysed. RESULTS: Proportion of open-subtrochanteric-femur-fractures was 0.5%. The mortality rate was 7%(2 of 27). The mean age of the study population was 34years(range:8-72), with males outnumbering females (M: F = 21:1). 54% of patients had polytrauma, 35% had multiple fractures. The mean GHOISS was 8. Mean fracture-union-time is 22-weeks, mean Harris-hip-score is 93.8. Delayed-union rate was 9%(2-of-22), infection-rate was 9%(2-of-22), Non-union was seen in 4.5%(1-of-22). CONCLUSION: In patients with hemodynamic stability and GHOISS of less than 9, primary-definitive-fixation can be done. However, in patients who are hemodynamically unstable or have GHOISS of more than 9, the most effective treatment involves proper initial debridement and stable external fixation. Followed by definitive fixation and early soft-tissue cover. In cases where multiple soft tissue procedures are required, either the external-fixator should be continued, or it should be converted to LRS. LEVEL OF EVIDENCE: Level III.