Proximal Femoral Fractures: Clinical Guidelines

List of Abbreviations

ASA – American Society of Anesthesiologists;

BIS – bispectral index;

DHS – dynamic hip screw (dynamic bone screw***, non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***);

AB – antibiotic (ATC J01 Antibacterials for systemic use);

BP – blood pressure;

AM – antimicrobial;

FE – femur;

VRS – verbal rating scale for pain;

WHO – World Health Organization;

VTE – venous thromboembolism complications;

SSI – surgical site infection;

RCT – clinical trial;

CG – clinical guidelines;

CT – computed tomography;

ICF – International Classification of Functioning, Disability and Health;

MO – medical organization;

NSAIDs – Non-steroidal anti-inflammatory and antirheumatic drugs;

OS – osteosynthesis;

PAP – perioperative antibiotic prophylaxis;

AD – admissions department;

PFF – proximal femur fracture;

RCT – randomized clinical trial;

HIP – hip joint;

TP – thromboprophylaxis;

THA – total hip arthroplasty;

LoE – level of evidence;

GoR – grade of recommendation;

FMSM – functional multichannel stimulation of muscles during walking;

CVP – central venous pressure;

NRS – numerical rating scale for pain;

FN – femoral neck;

THR – total hip replacement.

Terms and Definitions

Proximal femur fractures (PFF) represent a non-classified category combining fractures of the femoral head, femoral neck, pertrochanteric, intertrochanteric, and subtrochanteric fractures of the femur.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Diagnosis and treatment of patients with proximal femur fractures (PFF) represent a non-classified category combining the principles of examination and treatment of patients with femoral head fractures, femoral neck fractures, pertrochanteric, intertrochanteric, and subtrochanteric fractures.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

PFF are subdivided into low-energy and high-energy injuries [202].

Low-energy injuries occur due to minor trauma (e.g., a fall from standing height). The cause of such fractures may be a decrease in bone mass and altered bone quality due to, for example, osteoporosis, metastatic bone lesions, and similar processes accompanied by changes in trabecular microarchitecture, accumulation of microfractures, and increased cortical bone porosity [27], predominantly in patients older than 60 years.

High-energy PFF occur due to the transfer of a large amount of kinetic energy to the tissues, leading to significant soft tissue and bone damage; this type of fracture is more common in younger patients.

1.3 Epidemiology of the Disease or Condition

With the increase in human life expectancy, the proportion of elderly individuals is growing, including those with chronic somatic pathologies; correspondingly, the number of registered PFF is increasing. Low-energy femoral fractures typically occur as a result of a fall from standing height onto the side and are predominantly seen in people over 60 years of age [141]. Globally, approximately 1,700,000 cases of PFF are registered annually [32]. By 2050, assuming current demographic trends persist, the number of PFF is projected to increase to 6,300,000 cases annually [32]. In Russia, according to epidemiological studies of the population over 50 years of age, the incidence of PFF is 174.78 cases per 100,000 population in men and 275.92 in women, and this figure is steadily increasing [8].

The lifetime risk of developing a trochanteric fracture is 6% for men and reaches 18% for women [80]; in Norway in 2015, according to the national PFF registry, the male-to-female ratio was 3 to 7 [143].

The mean age of patients with PFF, which was 81 years in the mid-1990s, increased to 82 years by 2015 [143, 190]. The risk of sustaining a PFF increases with age: at 50 years it is 1.8%, at 60 years – 4%, at 70 years – 18%, and at 90 years – 24% [94]. Furthermore, S. Berry reported [41] that 15% of individuals with a PFF suffer a fracture of the contralateral proximal femur within the subsequent 4 years of life following this injury.

In 2011, in Saint Petersburg, a multicenter study was conducted based on three major municipal multidisciplinary hospitals, dedicated to studying the cohort of patients with PFF, as well as the types, scope, and outcomes of specialized care provided to them. As worldwide, the majority of patients were women (71.7%) versus 28.3% men; a significant proportion belonged to the older age group of 70 years and older (71.4%). The other two large groups consisted of patients aged 60–69 years (11.9%) and 50–59 years (10.2%). Among all patients with PFF, just over half had FN fractures (52.0%), and 41.9% had pertrochanteric fractures. Patients with subtrochanteric fractures were significantly fewer (5.3%), and those with an isolated fracture of the greater trochanter of the femur accounted for less than one percent (0.8%).

Based on calculations, the total average annual demand for emergency surgical treatment for proximal femur fractures in Saint Petersburg amounted to 4,098 surgeries per year, or 1 surgery per 1,000 adult population [4].

In Moscow in 2018, the total average annual demand for emergency surgical treatment for PFF in clinics subordinated to the Moscow Healthcare Department amounted to 9,883 surgeries per year, or 0.93 surgeries per 1,000 adult population [Annual Report on the Traumatology and Orthopedics Specialty of the Moscow Healthcare Department for 2018, unpublished data [6].

Proximal femur fractures in children, especially of the femoral neck, present a complex surgical challenge due to the high prevalence of severe complications such as avascular necrosis of the femoral head, nonunion, lower limb shortening, and premature closure of the proximal epiphyseal plate [204–207].

Among all proximal femur fractures in children, femoral neck (FN) fractures are the most common, accounting for 0.3 to 1% per year of all fractures in pediatric age [208]. The peak incidence of FN fractures occurs between 11 and 12 years of age [209]. Boys sustain injuries 1.3 to 1.7 times more frequently than girls [210]. Unlike osteoporotic fractures in the elderly, in individuals under 18 years of age, 80% of proximal femur fractures are caused by high-energy impact (motor vehicle accidents, falls from height) [211, 212].

1.4 Features of Coding the Disease or Condition

S72.0 Fracture of neck of femur

Fracture of hip region NOS

S72.1 Pertrochanteric fracture

Intertrochanteric fracture

Trochanteric fracture

S72.2 Subtrochanteric fracture

T93.1 Sequelae of fracture of femur

1.5 Classification of the disease or condition

Metaphyseal fractures are divided into intra-articular, when the fracture line extends to the joint surface, and extra-articular – fractures that separate the joint from the bone diaphysis but do not extend to the joint surface (may be intracapsular) [129].

PFF are subdivided into those extending to the articular surface (femoral head fractures) and those not extending to the articular surface (fractures of the FN and trochanteric region of the femur) [129]. Depending on the localization of the fracture line relative to the attachment line of the hip joint capsule, extra-articular fractures are divided into intracapsular (FN fractures) and extracapsular fractures (fractures of the trochanteric region of the femur) [169].

In children, slipped capital femoral epiphysis (epiphysiolysis), transcervical, intertrochanteric, and pertrochanteric fractures, fractures (apophysiolysis) of the greater and lesser trochanters, including avulsion fractures, are distinguished [238, 243, 245].

Traumatic proximal epiphysiolyses occur in children of any age, while being an extremely rare injury [243].

Avulsion fractures of the greater and lesser trochanter occur mainly in adolescent athletes [241, 245].

Classification of femoral head fractures

To systematize femoral head fractures, according to literature data, the Pipkin classification [156] is most frequently used, according to which 4 types of fractures are distinguished (Fig. 1):

• Type I – femoral head fractures distal to the fovea capitis femoris

• Type II – femoral head fractures proximal to the fovea capitis femoris

• Type III – femoral head fractures combined with a femoral neck fracture

• Type IV – femoral head fractures combined with an acetabular fracture

Fig. 1 Pipkin classification of femoral head fractures.

Classification of femoral neck fractures

To systematize femoral neck fractures in literature, the Garden [77] and Pauwels [152] classifications are most widely used; depending on the fracture type, they allow determining treatment tactics and predicting its outcomes.

Garden classification of femoral neck fractures

The Garden classification of femoral neck fractures is based on the degree and nature of fragment displacement (Fig. 2).

• Type I – incomplete, impacted, valgus fractures

• Type II – valgus, complete, stable fractures

• Type III – varus fractures with minimal displacement

• Type IV – varus fractures with significant displacement

Fig. 2. Garden classification of femoral neck fractures [77]

Pauwels classification of femoral neck fractures

Another popular classification of femoral neck fractures, the Pauwels classification, is based on the direction or angle of the fracture line relative to the horizontal plane (Fig. 3):

• Type I – fracture line angle with the horizontal up to 30°

• Type II – fracture line angle with the horizontal up to 50°

• Type III – fracture line angle with the horizontal up to 70°

Fig. 3 Pauwels classification of femoral neck fractures [152].

Type I or II fractures according to the Garden classification (valgus or impacted undisplaced), or Type I according to the Pauwels classification, are characterized by a high degree of stability and minimal impairment of the femoral head blood supply, which is favorable for fracture union prognosis and justifies osteosynthesis as the method of choice when determining surgical treatment tactics [64]. Garden type III–IV and Pauwels type II–III fractures are unstable in nature, and the blood supply to the proximal fragment is usually completely disrupted [166].

AO/OTA classification of femoral neck fractures

According to literature data, the AO/OTA classification is used less frequently than the Garden and Pauwels classifications [64, 88, 189].

According to the AO/OTA classification, femoral neck fractures are coded as 31B and divided into 3 types — B1, B2, B3, which, in turn, are subdivided into 3 subgroups depending on the severity of the fracture (Fig. 4) [129].

• Type B1 – subcapital fracture

• Type B2 – transcervical fracture

• Type B3 – basicervical fracture

* For type B2 fracture classification, an additional parameter characterizing the angle between the fracture line and the horizontal plane is used:

p - Pauwels 1 (fracture line angle with the horizontal <30°); q - Pauwels 2 (fracture line angle with the horizontal 30–70°); r - Pauwels 3 (fracture line angle with the horizontal >70°)

Fig. 4. AO/OTA classification of femoral neck fractures [129].

Classification of trochanteric femoral fractures

Extracapsular fractures include intertrochanteric, basilar neck, and subtrochanteric fractures. According to the AO/OTA classification [129], intertrochanteric fractures are coded as 31A and divided into 3 types (A1, A2, A3), which are further subdivided into 3 subgroups depending on the severity of the fracture (Fig. 5).

* n – fracture of the greater trochanter; o – fracture of the lesser trochanter

Fig. 5. AO/OTA classification of trochanteric fractures [129].

Type 31A1 fractures are simple (non-comminuted) intertrochanteric fractures.

31A1.1n – isolated fracture of the greater trochanter;

31A1.1o – isolated fracture of the lesser trochanter.

31A1.2 – two-part intertrochanteric fracture. The fracture plane in this case may begin anywhere on the greater trochanter and end either above or below the lesser trochanter. These fractures always present with only two bone fragments, and the medial cortical surface exhibits only a single fracture line. The lesser trochanter, or the so-called medial buttress, remains intact. The key feature of this fracture type is that they are all initially stable or become stable following reduction and fixation of the bone fragments [182].

Fracture 31A1.3 – simple (non-comminuted) intertrochanteric fracture with an intact lateral wall (d > 20.5 mm) [129].

The height (thickness) of the lateral wall (d) is measured in mm as the length of a line extending upward at an angle of 135° to the fracture line from a point located 3 cm distal to the innominate tubercle of the greater trochanter (Fig. 6).

Fig. 6 Determination of the height (thickness) of the lateral wall [129].

31A1.3 and 31A2.2-3 are unstable intertrochanteric fractures where the fracture plane begins laterally at the greater trochanter and terminates on the medial cortical surface of the femur, forming two or more fracture lines, along with a fracture in the region of the lesser trochanter. The loss of posteromedial support, combined with multi-fragmentary comminution in the lateral wall zone, makes the management of these fractures a challenging task [182].

Fracture 31A3 – intertrochanteric fracture, both simple and comminuted. The fracture plane passes between the two trochanters and above the lesser trochanter. Both the lateral and medial cortical surfaces are injured in these fractures. Fractures of subgroup A3.1 are termed reverse obliquity fractures due to the orientation of the fracture plane and typical displacement of bone fragments associated with the attachment of the hip abductor muscles. Very often, this fracture type involves splitting of the proximal third of the femoral diaphysis, which may not be visible on standard radiographs. Fractures of subgroups A3.2 and A3.3 are predominantly transverse with two or more fragments. All type A3 fractures are unstable.

Subtrochanteric fractures are defined as those localized in the region between the lesser trochanter and a line located 5 cm distal to the lesser trochanter; they are coded according to the AO/OTA classification as 32A/B/C (1-3).1 [129].

1.6 Clinical presentation of the disease or condition

The clinical presentation of proximal femoral fractures is characterized by pain in the groin and/or upper thigh, and tenderness upon palpation of the hip joint. Lying supine, the patient is unable to raise the straightened lower extremity, partly due to pain (positive «stuck heel» sign); shortening of the injured limb, adduction, and/or external rotation may also be observed.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria

The diagnostic criterion is the presence of radiographic signs of fracture on a standard anteroposterior plane radiograph or fracture signs identified via computed tomography of the lower extremity/joint, or magnetic resonance imaging of the bone tissue (single region).

2.1 Complaints and Anamnesis

Proximal femoral fractures are characterized by the onset of pain at the fracture site, deformity, and impaired limb function following low- or high-energy impact to the hip joint region.

In suspected cases of proximal femoral fractures, all patients must be evacuated to a medical facility for diagnosis confirmation, barring any absolute contraindications to transportation.

2.2 Physical Examination

• To assess the severity of soft tissue injury, it is recommended to perform a visual and palpation assessment of the local status [11].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: proximal femoral fractures are characterized by the following symptoms: inability of the supine patient to raise the straightened lower extremity – a positive «stuck heel» sign, limb shortening, adduction, and/or external rotation;

To determine the patient's general condition, it is required to assess the somatic status and the following parameters no later than 1 hour after admission to the inpatient facility, with mandatory recording of the results in the medical chart:

√ Measurement of blood pressure on peripheral arteries;

√General thermometry;

√ Assessment of pain intensity using the Numerical Rating Scale (Appendix G4) or Verbal Rating Scale for pain assessment (Appendix G5);

√ Assessment of venous thrombosis risk and pulmonary embolism risk using the Caprini risk assessment model (Appendix G3) [121].

2.3 Laboratory Diagnostics

• All patients diagnosed with a proximal femoral fracture are recommended to undergo a complete blood count to determine the degree of anemia and rule out infectious diseases [52, 133, 136].

GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

• All patients diagnosed with a proximal femoral fracture are recommended to undergo a blood creatinine test to assess renal function [133, 136].

GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

• All patients diagnosed with a proximal femoral fracture, recommended blood glucose testing to rule out diabetes mellitus [122, 136].

GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

2.4 Instrumental Diagnostics

• All adult patients with suspected proximal femur fractures (PFF) are recommended to undergo standard pelvic radiography, radiography of the proximal femur (radiography of the femoral head and neck), and anteroposterior radiography of the hip joint on the affected side within the first 45 minutes of hospital admission in order to establish a diagnosis. Most PFFs can be accurately diagnosed using standard radiography due to the high (90%–98%) sensitivity of this method [139, 151].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: instrumental examination of a patient with suspected PFF begins with radiological imaging—standard pelvic radiography, as well as radiography of the proximal femur (radiography of the femoral head and neck) and anteroposterior radiography of the hip joint on the affected side.

Nevertheless, the absence of fracture signs on a radiogram does not rule out the presence of a fracture; in cases where there are doubts regarding the instrumental examination results (e.g., when there are no signs of fracture on a radiogram evaluated by a specialist radiologist), but the medical history is characteristic of low-energy trauma (a fall from standing height onto the side followed by pain syndrome) even in the absence of corresponding symptoms (the patient lying supine is unable to raise the straightened lower limb—positive heel-pad sign, limb shortening, adduction, and/or external rotation), alternative imaging methods should be used. The incidence of radiolucent femoral neck fractures is 2–10% [139, 151].

• In all patients with a discrepancy between clinical and radiological data, in order to verify the diagnosis and determine treatment tactics, it is recommended to perform computed tomography (CT) of the hip joint or magnetic resonance imaging (MRI) of bone tissue (one region), the findings of which are characterized by high sensitivity and specificity for PFF [79, 146, 197, 240, 241, 242, 243].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

• In cases of suspected femoral head fracture, to establish a diagnosis and determine treatment tactics, all adult patients are recommended to undergo computed tomography (CT) of the hip joint or magnetic resonance imaging (MRI) of the joints (one joint) [74, 87].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: to reduce the time required to establish a diagnosis and for the patient's stay in the emergency department, it is advisable to perform radiography of the proximal femur (radiography of the femoral head and neck, radiography of the femoral shaft) and anteroposterior radiography of the hip joint on the affected side within 45 minutes of hospital admission.

Once PFF has been confirmed by diagnostic imaging, the patient must be hospitalized.

If a patient refuses inpatient treatment, the reason for refusal must be documented in the emergency department medical record and signed personally by the patient, the child's legal representative, or the patient's legal guardians (in cases of legally established incapacity).

• All adult patients are recommended to undergo electrocardiography (ECG) to rule out acute coronary syndrome, cardiac rhythm and conduction disorders, as well as all individuals with risk factors or established cardiovascular disease, regardless of age, if surgical treatment is planned [34, 86, 167].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Information regarding the necessity of performing an ECG in children with PFF is absent and remains at the discretion of the attending physician.

• Routine prescription of echocardiography for adult patients is not recommended. Echocardiography is recommended only in the presence of acute cardiovascular pathology (unexplained dyspnea at rest; hypotension refractory to fluid therapy requiring adrenergic and dopaminergic agents; myocardial blood supply disorders according to electrocardiography; suspected pulmonary embolism) to determine treatment tactics that allow for the earliest possible surgical intervention [86, 163, 167].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: echocardiography is performed only as prescribed by a general practitioner and/or cardiologist. The indication for echocardiography must be documented in the medical record.

• Duplex scanning of the lower extremity veins is recommended for adult patients within 48 hours of admission to the hospital with a PFF, except in cases where lower extremity venous ultrasound is mandatory upon admission: injury dating back more than 48 hours prior to admission, ⩾12 points on the Caprini score (Appendix H3) — high risk of pulmonary embolism [121], to prevent thromboembolic complications. Information regarding the necessity of performing lower extremity venous ultrasound in children with PFF is absent and remains at the discretion of the attending physician.

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

2.5 Other Procedures

Emergency specialist consultations in the preoperative period.

1. Initial visit (examination, consultation) by a general practitioner or pediatrician for patients under 18 years of age.

2. Initial examination (consultation) by an anesthesiologist-intensivist.

3. Initial visit (examination, consultation) by a neurologist — in the presence of neurological disorders (altered consciousness, speech impairment, limb paresis or plegia).

Initial visit (examination, consultation) by a cardiovascular surgeon — upon detection of lower extremity vascular thrombosis or signs of arterial insufficiency.

Diagnosis of proximal femur fractures in children

A distinctive feature of the clinical examination is that the child experiences fear of any passive movement and is unable to move actively.

• All pediatric patients with suspected PFF are recommended to undergo radiography of the proximal femur (radiography of the femoral head and neck) and anteroposterior radiography of the hip joints on both the affected and healthy sides to establish a diagnosis [139, 151, 240], which allows for an accurate diagnosis in the majority of cases, except for femoral neck stress fractures, which are extremely rare and require differential diagnosis with conditions such as transient or infectious synovitis, Legg-Calvé-Perthes disease, hip dysplasia, and malignant neoplasms [247].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• In children with a satisfactory range of motion in the injured limb that allows for additional radiographs, it is recommended to perform an axial projection to facilitate differential diagnosis with various hip joint pathologies [139, 240].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: instrumental examination of a patient with suspected PFF in the presence of severe pain syndrome and restricted movement of the injured limb begins with radiological imaging—radiography of the proximal femur (radiography of the femoral head and neck) and anteroposterior radiography of the hip joint on both the affected and healthy sides. Meanwhile, in children with an uncertain medical history, mild pain syndrome, and a satisfactory range of motion in the injured segment, a radiograph in the axial projection (Lauenstein projection) is performed for differential diagnosis.

Nevertheless, the absence of fracture signs on a radiogram does not rule out the presence of a fracture; in cases where doubts arise regarding the instrumental examination results (e.g., when there are no signs of fracture on a radiogram evaluated by a specialist radiologist), but there is a characteristic medical history and clinical presentation, alternative imaging methods must be used.

• In children with suspected nondisplaced slipped capital femoral epiphysis (SCFE) (or osteoepiphysiolysis) and greater or lesser trochanter fractures, to verify the diagnosis and determine treatment tactics, it is recommended to perform comparative radiographs of the injured and healthy limbs in the anteroposterior projection, as even minor widening of the growth plate can be observed on the radiographs [240].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

• In cases of suspected slipped capital femoral epiphysis (SCFE) (osteoepiphysiolysis), greater or lesser trochanter fractures (including avulsion fractures), as well as when interpretation of proximal femur radiographs is difficult or clinical and radiological data are discordant, to verify the diagnosis and determine treatment tactics, it is recommended to perform computed tomography (CT) of the hip joint or magnetic resonance imaging (MRI) of bone tissue (one region), the findings of which are characterized by high sensitivity and specificity for PFF [79, 146, 240, 241, 242, 243].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

• In cases of suspected femoral head fracture, to establish a diagnosis and determine treatment tactics, all adult patients are recommended to undergo computed tomography (CT) of the hip joint or magnetic resonance imaging (MRI) of the joints (one joint) [74, 87, 215].

Furthermore, in children, magnetic resonance imaging is recommended to diagnose femoral neck stress fractures [215, 216].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• In newborns, ultrasound examination is recommended in the differential diagnosis of proximal femur fractures [240].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Classifications of proximal femur fractures in children

• In children, in order to assess prognosis and optimize the choice of treatment strategy, it is recommended to use one of the following classifications:

  ᴑ AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) [244], which describes the localization and morphology of fractures, and also takes into account their severity, divided into two categories: simple and multifragmentary. Proximal metaphyseal fractures of the femur can be divided into three types, indicated by an additional code (I–III) reflecting the location of the fracture in the proximal metaphysis:

Mid-cervical (Type I)

Basilar (Type II)

Transtrochanteric (Type III)

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

ᴑ M.P. Delbet classification modified by PC Colonna is used to determine the fracture type and the prognosis of avascular necrosis of the femoral head [213].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Conservative management

3.2. Emergency medical care in the emergency department

• All patients with suspected proximal femur fractures are recommended to receive the following minimum scope of care in the emergency department:

  • Ensuring thermal comfort for the patient.

  • Adequate analgesia to ensure psycho-emotional comfort and the possibility of repositioning and transporting the patient (see Section 3.1.4 Analgesia).

  • Correction of volume and electrolyte disturbances (if this correction cannot be performed in the emergency department, it is carried out in the traumatology department or in the intensive care unit) [175, 246].

  • Children are recommended to undergo temporary immobilization using wire ladder splints. For children under 10 years of age, a single wire ladder splint extending from the foot (inclusive) to the lumbar region may be used, while in children older than 10 years, an additional U-shaped wire ladder splint is applied from the upper third of the inner surface of the thigh to the outer surface of the torso at the lumbar level [248].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

3.3. Transfer of the patient to the traumatology department or intensive care unit

• All patients with proximal femur fractures are recommended to receive timely and sequential medical care in the emergency department in order to reduce the risk of patient destabilization and the onset of subcompensation of concomitant diseases [107, 177].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: following examination in the emergency department, mandatory specialist consultations, and examination (consultation) by an anesthesiologist-resuscitologist, the patient is brought to the operating room for surgical intervention. If there is a need for additional preoperative preparation, patients must be transferred to the traumatology department or, if intensive preoperative preparation is necessary, to the intensive care unit no later than 2 hours from the moment of admission to the emergency department.

3.4. Preoperative immobilization

Skeletal traction

• Skeletal traction is not recommended for patients over 50 years of age with proximal femur fractures (subtrochanteric fractures (32A/B/C.1 AO/OTA) are an exception) in order to reduce the risk of delirium, hypostatic and hypodynamic complications [162, 168, 173, 201].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: a number of randomized clinical trials [162, 168, 173, 202], which compared the treatment outcomes of patients over 50 years of age with proximal femur fractures with and without preoperative skeletal traction, showed no difference in pain intensity and no benefit of skeletal traction in patients over 50 years of age with proximal femur fractures.

It is important to note that skeletal traction provokes the development of delirium syndrome in elderly patients [162].

External fixation

• If definitive fixation of a subtrochanteric fracture cannot be performed within 12 hours of hospital admission, adult patients younger than 50 years are recommended to undergo external fixation with a pin fixator of the pelvic bones and femur to stabilize bone fragments [72].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

3.5. Pain management

• In the presence of pain syndrome, to reduce its severity and lower the risk of delirium, all patients with proximal femoral fractures are recommended to receive prompt and full analgesia as early as possible after hospital admission, and no later than 30 minutes after admission [132, 139].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: pain is one of the leading components of the symptom complex developing after a proximal femoral fracture. In addition, pain plays a major role in the pathogenesis of delirium syndrome [57, 181]. Prompt stable fixation of bone fragments or arthroplasty significantly reduces trauma-related pain. Furthermore, drug-based analgesia must be administered throughout the perioperative period, taking into account the severity of the pain.

• To measure pain intensity in patients with proximal femoral fractures, it is recommended to use the Numerical Rating Scale (Appendix G4) and the Verbal Rating Scale (Appendix G5) [104, 175].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

• Elderly patients with proximal femoral fractures may find it difficult to determine pain intensity using the NRS. In such cases, it is recommended to use the Verbal Rating Scale (VRS) [114].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• Assessing pain intensity in adult patients with cognitive impairment, acute delirium syndrome, or neurological pathology is most difficult, but this does not mean that these patients do not need analgesia. Such patients are recommended to receive preemptive analgesia via parenteral administration of paracetamol** [68].

GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)

Comments: the pain intensity score on the NRS or VRS must be indicated in the medical history.

The ** symbol designates medications included in the list of vital and essential drugs for medical use in accordance with Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard form of clinical guidelines, and requirements for their structure, composition, and scientific validity of the information included in clinical guidelines" [16].

Pain assessment scales in children

In infants under one year of age, the Neonatal Infant Pain Scale (NIPS) is used (Appendix G7). For children under three years of age – the FLACC (Face, Legs, Activity, Cry, Consolability) behavioral scale (Appendix G8). To assess pain in children aged three to seven years, the Wong-Baker FACES Pain Rating Scale is used (Face scale) (Appendix G9). In children older than three years, the Hand scale may also be used (Appendix G10). For children older than 7 years, the Visual Analog Scale (VAS) is used (Appendix G11) [249, 250].

• Pain intensity assessment is recommended to be performed:

  - upon admission;

  - 30 minutes after initial analgesic interventions [139, 158].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

• Adequate analgesia is recommended to be provided to every patient with suspected proximal femoral fracture before any painful manipulations, such as transferring the patient from a stretcher to a stretcher or from a stretcher to the X-ray table. Before diagnostic procedures, one should ensure that the analgesic effect is sufficient (for example, pain-free passive external rotation of the injured lower extremity) [132, 139].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: when deciding on the need for pain relief, one must be guided by the criteria for the maximum allowable pain intensity (intervention thresholds). In particular, the maximum allowable pain intensity at rest is 3 points on the NRS (mild pain on the VRS).

The step-by-step analgesic therapy principle (the pain management approach recommended by WHO) consists of prescribing paracetamol** [69], NSAIDs [132] for mild pain; opioids for moderate pain (e.g., tramadol** (tramadol** is contraindicated in patients under 1 year of age); for severe pain not relieved by other medications — morphine** 10 mg subcutaneously, maximum daily dose 50 mg (in children, the maximum daily dose is 15 mg) [36, 139].

• All patients admitted to the hospital are recommended to receive paracetamol** [68, 249].

GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)

or NSAIDs for analgesia in proximal femoral fractures [132, 249].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: Currently, the most widely used method of analgesia for proximal femoral fractures is parenteral administration of paracetamol** [36, 68, 139]. In pediatric patients, the use of paracetamol** in the form of an infusion solution is contraindicated in the neonatal period (up to 1 month); rectal suppositories and oral suspension are used from 3 months of age.

• NSAIDs are recommended to be used with caution in adult patients, especially elderly patients [36].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: in addition to NSAIDs, centrally acting opioids with moderate analgesic activity (compared to morphine**), such as tramadol**, may be used, but their use is limited in elderly patients with cognitive impairment due to their depressing effect on the nervous system.

It should be noted that the use of opioids for analgesia may have unpredictable consequences in patients with proximal femoral fractures due to the exacerbation of premorbid vascular pathology and cognitive deficit. Opioid use can lead to respiratory depression, intestinal paresis, constipation, and, more rarely, severe nausea and vomiting combined with neurological pathology, which in some cases can lead to aspiration pneumonia [132].

If pain persists after the administration of NSAIDs in adult patients, it is recommended to use tyrosyl-D-arginyl-phenylalanyl-glycine amide as an effective analgesic, taking into account the risks of using opioid analgesics in elderly patients. Tyrosyl-D-arginyl-phenylalanyl-glycine amide has a pronounced analgesic effect and is effective for pain relief after surgical interventions of various scopes and trauma severity. The use of this drug is associated with a low incidence of adverse reactions and the absence of respiratory depression among the side effects characteristic of opioids [9, 10].

Prescription of opioids is possible only if paracetamol** or NSAIDs are ineffective.

Based on all the above, the following preoperative analgesia regimen can be recommended for patients with proximal femoral fractures in hospitals of the Russian Federation:

1–3 points on the Numerical Rating Scale (mild pain on the Visual Analog Scale) — analgesia is not required.

4 points on the Numerical Rating Scale (moderate pain on the Visual Analog Scale) — paracetamol** [68] 1 g intravenous infusion over 15 min 2–3 times a day.

5–6 points on the Numerical Rating Scale (severe pain on the Visual Analog Scale) — paracetamol** [68] 1 g intravenous infusion over 15 min 3–4 times a day, and for severe pain not relieved by other drugs, opioids: tramadol** 100 mg intramuscularly or intravenously 2–3 times a day, or trimeperidine** 20 mg 2 times a day intramuscularly [35]. In pediatric patients, tramadol** injection solution is prescribed at a single dose based on 1–2 mg/kg of the child's body weight. The minimum effective dose must be selected. The total daily dose of tramadol** should not exceed 8 mg/kg of the child's body weight or no more than 400 mg per day, calculated using the lowest value. Trimeperidine** is contraindicated in patients under 2 years of age; in pediatric patients over 2 years of age, the single dose is 3–10 mg.

7 or more points on the Numerical Rating Scale (very severe and excruciating pain on the Visual Analog Scale) — for severe pain not relieved by other drugs, morphine** 10 mg subcutaneously can be used, with a maximum daily dose of 50 mg (in children, the maximum daily dose is 15 mg) [35].

Pain management in the hospital is carried out taking into account the analgesia performed by the emergency medical service.

• In patients with severe cognitive impairment, in the absence of contraindications, it is recommended to administer paracetamol** or NSAIDs at a standard dosage upon admission to the receiving department [139].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

• In patients with proximal femoral fractures in the perioperative period, it is recommended to perform peripheral nerve blocks (administration of medicinal products into the area of a peripheral nerve) as a component of a multimodal pain management strategy [32, 83, 119, 134, 199, 232].

Level of Recommendation ALevel of Evidence 1Level of recommendation A (level of evidence – 1) – for adults

Level of Recommendation CLevel of Evidence 4Level of recommendation C (level of evidence – 4) – for children

Comments: the advantages of regional blocks (administration of medicinal products into the area of a peripheral nerve) include reduced pain intensity, lower risk of delirium, lower risk of respiratory infections, and shorter immobilization time. Large studies confirm a reduced length of hospital stay without an increase in complications associated with regional analgesia. There is currently a large body of evidence supporting the use of any of the three main peripheral blocks (femoral nerve block (FB); fascia iliaca block (FIB); pericapsular nerve group block (PENG block)).

The choice of a particular method should depend on the presence or absence of contraindications, as well as the features of postoperative rehabilitation. For example, the patient's required motor activity potential in the early postoperative period, as well as the technical aspects of performing blocks (administration of medicinal products into the area of a peripheral nerve), such as the experience of the anesthesiologist-resuscitologist or the availability of ultrasound equipment to ensure the safety of the puncture.

Peripheral nerve and fascial plane blocks in superficial and compressible locations are considered low risk for complications and do not require discontinuation of the patient's anticoagulant therapy prior to the block. Ultrasound guidance is recommended to reduce the risk of inadvertent vascular puncture and increase analgesic efficacy. A Cochrane review including more than 3,000 patients in 49 RCTs reported only one case of nerve injury following a block [83].

Table 1. Comparison of common regional blocks for proximal femur fractures

3.6. Surgical treatment

3.6.1. Preoperative period

• The duration of the preoperative period is recommended to be minimized (for patients with a trauma duration of less than 24 hours, the most optimal is 6–8 hours from hospital admission), but should not exceed 48 hours. It should be taken into account that performing arthroplasty at night leads to an increased number of complications; therefore, arthroplasty surgeries are recommended to be performed only during daytime hours by trained teams [107, 177].

GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)

Comments: any delay in surgical treatment leads to a worsening of the patient's somatic condition and an increase in the risk of intra- and postoperative complications, as well as an increase in in-hospital mortality and mortality within the first year after injury [144]. Thus, the coordinated actions of the staff of the receiving department, the hospital trauma and orthopedics department, the intensive care unit, and consultant physicians should be aimed at correcting the patient's existing somatic pathology and performing emergency surgical treatment as soon as possible after the injury. Furthermore, extending the preoperative hospital stay increases the total and postoperative hospital stay, as well as the 30-day readmission rate [144].

Virtually all patients over 60 years of age with proximal femoral fractures have comorbid conditions of varying degrees of compensation; thus, up to 70% of elderly patients with proximal femoral fractures may have an ASA physical status of 3–4 [155], which is why patients requiring intensive preoperative preparation should be hospitalized in the intensive care unit.

It must be borne in mind that surgery performed as soon as possible after admission reduces the number of critical complications and significantly increases survival in this cohort of patients. According to Jean-Pierre et al., surgery performed in the first few hours after injury reduces mortality by 70–80% [98]. The main task of the anesthesiologist-resuscitologist in treating patients with proximal femoral fractures is to assess the risk of surgery and prevent cardiac, infectious, and fatal complications using the results of a minimal patient examination.

• Anesthesia is recommended to be administered to all patients no earlier than 6 hours after a meal and 2 hours after consuming clear liquids (all colored liquids are classified as food) in order to prevent aspiration of gastric contents [159].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: during the history taking, it is necessary to ascertain the circumstances of the injury (if the patient reports that the fall resulted from a loss of consciousness, acute neurological or cardiovascular pathology must be ruled out). Attention should be paid to the allergy history and long-term medication use; special attention must be given to the continuous use of antithrombotic agents, as this may delay surgery or influence the choice of anesthesia method.

Special attention in elderly patients is warranted for the assessment of protein-energy malnutrition (which requires evaluation of total blood protein concentration and body mass index), necessitating increased vigilance toward this patient group in the perioperative period [38].

Based on the examination, the anesthesiologist-resuscitologist makes a conclusion regarding the feasibility of performing surgical intervention.

The degree of anesthetic and surgical risk is determined using the ASA classification (Appendix G2), with mandatory indication in the medical record.

To determine the treatment tactics for patients presenting with the following conditions, the indicated actions are required:

- Acute coronary syndrome (unstable angina, acute myocardial infarction) [23] – initial consultation (examination) by a cardiologist.

- Severe cardiac rhythm and conduction disorders (type II-III AV block, tachy-form atrial fibrillation over 120 bpm) – transfer to the intensive care unit for stabilization.

- Decompensated diabetes mellitus (glucosuria, ketonuria) – transfer to the intensive care unit, initial consultation (examination) by an endocrinologist.

- Senile psychoses (aggression toward others, loss of self-care skills, hallucinosis, delusional disorders) – initial consultation (examination) by a psychiatrist.

- Presence of acute surgical pathology – initial consultation (examination) by a surgeon.

- Venous thrombosis with an episode of pulmonary embolism – initial consultation (examination) by a cardiovascular surgeon.

- Chronic renal failure requiring extracorporeal detoxification – initial consultation (examination) by a nephrologist to perform surgery during the interdialytic period (no earlier than 6 hours after the last procedure).

- Acute anemia accompanied by a drop in hemoglobin levels below 70–80 g/L – transfer to the intensive care unit, transfusion of red blood cell components. In chronic anemia, red blood cell transfusions are prescribed solely to correct respiratory and/or cardiovascular failure caused by anemia that does not respond to primary pathogenetic therapy [Order of the Russian Ministry of Health No. 183n dated April 2, 2013].

Conservative treatment is performed if the patient refuses surgery or, in cases of legally established incapacity, if their legal guardians refuse.

In cases of ASA physical status class IV–V, given the severity of comorbidities and the high probability of decompensation of the patient's cardiovascular and respiratory systems if surgery is postponed or delayed, a decision is made to perform life-saving surgery. The decision to perform life-saving surgery is made by a medical board consisting of three specialists: an orthopedic trauma surgeon, an anesthesiologist-resuscitologist, and a general physician (internist).

Contraindications to surgery or the necessity of postponing the surgical intervention must be determined by a medical board consisting of three specialists: an orthopedic trauma surgeon, an anesthesiologist-resuscitologist, and a general physician (internist), with a clear and detailed record in the medical history of the reasons for convening the board. A history of acute myocardial infarction, including one sustained in the days immediately preceding the injury following angiography with stenting and angioplasty, is not a contraindication to urgent surgical treatment. If a patient with a proximal femoral fracture has an acute cerebrovascular accident, the decision on surgery is made by the board based on the stroke prognosis and the patient's current status.

3.6.2. Anesthesia

• Adult patients with proximal femoral fractures are recommended to receive spinal anesthesia, as this method of pain control reduces intraoperative blood loss, avoids the administration of opioids, and facilitates early mobilization of the patient [54, 127, 164, 193].

GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

Comments: analysis of the use of intrathecal techniques demonstrated a reduction in the incidence of not only thromboembolic, but also respiratory complications and postoperative mortality [140, 164].

Special attention is paid to patients on chronic antithrombotic therapy, as this may influence the choice of anesthesia method (see Appendix A3.3). If there are contraindications to spinal anesthesia, general anesthesia is performed.

• Adult patients in whom spinal anesthesia cannot be performed are recommended to receive combined endotracheal anesthesia or total intravenous anesthesia for anesthetic management of the surgery. The choice of anesthesia technique does not affect two-month patient survival [84, 110, 127, 193].

GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)

Comments: intraoperative monitoring must be performed [58].

Table 2. Intraoperative monitoring in patients with proximal femoral fractures.

During the surgical procedure, urinary bladder catheterization and evaluation of urine output rate are mandatory. Electrolyte balance disorders must be taken into account when formulating the fluid management program. Strict correction of hemodynamic instability episodes is necessary.

Determination of total blood hemoglobin levels and its correction if HGB ≤70 g/L is mandatory.

3.6.3. Techniques used in the surgical treatment of adult patients.

Surgical treatment of patients older than 60 years is performed to restore the weight-bearing capacity of the limb as early as the postoperative period and to enable the earliest possible mobilization and rehabilitation; for this purpose, either implants providing dynamic fixation of bone fragments (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***, dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***) or total hip replacement (arthroplasty)*** are used.

The goal of surgical treatment in patients younger than 60 years is to enable early mobilization and rehabilitation with full restoration of the anthropometric characteristics of the limb; for this purpose, static fixation and delayed weight-bearing are used for trochanteric fractures, and dynamic fixation is used for femoral neck fractures.

With dynamic fixation, mobility of the structural elements inserted into the femoral head and neck fragment relative to the nail (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) or bone plate (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***) is preserved, which allows for full weight-bearing immediately after surgery (this option must be used for intertrochanteric fractures, for femoral neck fractures in patients older than 60 years, and for femoral neck fractures in patients younger than 60 years).

With static fixation, the neck element(s) is locked and becomes immobile relative to the intramedullary nail (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) or dynamic hip screw (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***), while weight-bearing must be delayed for at least 8-10 weeks (this option must be used in patients younger than 60 years with unstable intertrochanteric fractures).

Pipkin I-IV femoral head fractures

• In patients younger than 60 years with femoral head fractures, it is recommended to use the following treatment methods:

For fractures of the head distal to the fovea capitis femoris (Pipkin I) - excision of the head fragment, including arthroscopic excision. The surgery to excise the head fragment may be performed electively.

For fractures proximal to the fovea capitis femoris (Pipkin II) – osteosynthesis of the head fragments using cannulated compression screws (non-absorbable non-sterile orthopedic bone screw***, non-absorbable sterile orthopedic bone screw***) with the possibility of subchondral sinking.

For head fractures combined with femoral neck fractures (Pipkin III) – primary total hip arthroplasty***.

• For femoral head fractures combined with acetabular fractures (Pipkin IV), the choice of treatment method is determined by the type of femoral head fracture. For head fractures distal to the fovea capitis, excision of the head fragment and osteosynthesis of the acetabular fragments are performed. For fractures proximal to the fovea capitis, it is recommended to perform osteosynthesis of both the head and acetabular fragments [74, 78].

GCR BLOE 3Grade of Recommendation B (Level of Evidence – 3)

• In patients over 60 years of age with Pipkin type I fractures, removal of the femoral head fragment is recommended; for Pipkin type II-III fractures, THA*** is recommended in accordance with the Algorithm for Selecting Treatment Tactics for Femoral Head Fractures (see Appendix B2). For Pipkin type IV fractures, it is recommended to perform osteosynthesis of the acetabular fracture and THA*** using cementless or hybrid fixation. The choice of fixation type for the endoprosthesis components is determined by the fracture type, the quality of fixation of bone fragments, and the severity of osteoporosis [74, 78].

GCR BLOE 3Grade of Recommendation B (Level of Evidence – 3)

The algorithm for choosing treatment tactics for patients with femoral head fractures is given in Appendix B2.

Garden I-II, Pauwels I medial fractures

• Garden I-II (Pauwels I) femoral neck fractures include impacted valgus fractures and non-displaced fractures. These types of femoral neck fractures have a favorable prognosis for bone healing due to their stability and minimal disruption of the femoral head blood supply [139]. Nevertheless, due to the high (31%) risk of secondary displacements, the use of active surgical tactics with osteosynthesis of the bone fragments is recommended [65].

GCR BLOE 3Grade of Recommendation B (Level of Evidence – 3)

• For osteosynthesis of Garden I and II femoral neck fractures, it is recommended to use parallel-inserted cannulated cancellous screws (non-absorbable non-sterile orthopedic bone screw***) with washers, a dynamic hip screw system (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***), or three parallel-inserted dynamic bone screws fixed in a plate (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***) [147].

GCR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

Comments: A meta-analysis of the results of 25 randomized controlled trials, including the evaluation of treatment outcomes in 4,925 patients, revealed no advantages of cannulated cancellous screws (non-absorbable non-sterile orthopedic bone screw***) over the dynamic hip screw (dynamic hip screw***) [147]. According to publications [7, 148], three parallel-inserted dynamic bone screws*** fixed in a plate (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***) have an advantage over all other fixators in the osteosynthesis of Garden I-II femoral neck fractures due to the rotational and angular stability of the construct.

The algorithm for choosing treatment tactics for femoral neck fractures is given in Appendix B3.

Garden III-IV (Pauwels II-III) medial fractures

Garden III-IV (Pauwels II-III) medial fractures include femoral neck fractures with incomplete varus displacement and/or complete displacement with separation of fragments. Such fractures have an unfavorable prognosis for union due to impaired blood supply to the femoral head; however, in patients younger than 60 years, emergency osteosynthesis may be performed.

• In patients younger than 60 years, it is recommended to perform osteosynthesis using three cannulated cancellous screws (non-absorbable non-sterile orthopedic bone screw***), a dynamic hip screw system (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***), or three parallel-inserted dynamic bone screws fixed in a plate (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***). Equivalent outcomes have been proven for the use of three cannulated cancellous screws (non-absorbable non-sterile orthopedic bone screw***) and the dynamic hip screw system (dynamic hip screw***) (even without an additional derotation screw) [204]. Three parallel-inserted dynamic bone screws*** fixed in a plate (dynamic hip screw***, non-absorbable sterile bone fixation plate with screws***, non-absorbable non-sterile bone fixation plate with screws***) have an advantage due to the axial and rotational stability of the screws within the plate [7, 147, 148].

GCR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

• Fixation with three parallel dynamic bone screws*** fixed in a plate (dynamic bone screw***, non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***) for Garden III fractures is recommended to be considered as a possible alternative to arthroplasty (orthopedic hip arthroplasty) in patients with a high risk of arthroplasty complications [7, 148].

GCR BLOE 3Grade of Recommendation B (Level of Evidence – 3)

Comments: evaluation of the results of studies on osteosynthesis with three parallel dynamic bone screws*** fixed in a plate (dynamic bone screw***, non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***) for Garden III fractures in patients over 60 years of age demonstrated a complication rate of 13%; moreover, in 60% of patients with femoral neck fracture nonunion, the femoral head retained its viability and, in combination with the hardware, functioned as a "bioprosthesis", which helped eliminate pain and functional impairments, prompting patients to decline revision surgeries [7, 148].

• In patients over 60 years of age with Garden type III and IV femoral neck fractures, arthroplasty (orthopedic hip arthroplasty) is recommended [47, 66, 76, 100, 105, 165, 166].

GCR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

Comments: randomized prospective studies and meta-analyses of RCTs [47, 66, 76, 100, 105, 165, 166] comparing the outcomes of arthroplasty*** (bipolar and/or total) and osteosynthesis (using three parallel cancellous cannulated screws (non-absorbable non-sterile orthopedic bone screw***) or a DHS system (dynamic bone screw***, non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***)) in the treatment of Garden type III and IV fractures in elderly patients showed that the complication rate after femoral neck fracture osteosynthesis ranged from 34.4% to 50%, necessitating reoperations in 30–43% of cases. Better outcomes were observed in patients who underwent arthroplasty (reoperation rate, pain severity, patient subjective satisfaction with post-operative quality of life, functional outcomes, and complication rate).

Arthroplasty (orthopedic hip arthroplasty) as a surgical treatment method may be chosen when the patient is unable to walk with partial weight-bearing in the postoperative period.

The cited studies [47, 66, 76, 100, 105, 165, 166] showed no statistically significant differences in mortality rates within the first 12 months after osteosynthesis or arthroplasty (orthopedic hip arthroplasty); however, despite no differences in mortality between osteosynthesis and arthroplasty (orthopedic hip arthroplasty) (61/226 vs. 63/229, p = 0.91), there is a trend toward increased survival with osteosynthesis in older and less active patients.

Hip Arthroplasty

• Total hip arthroplasty for unstable femoral neck fractures is recommended for patients who can walk independently and have no severe cognitive impairment. In elderly patients with severe cognitive impairment, hip hemiarthroplasty (metallic femoral head prosthesis ***, bipolar femoral head prosthesis component ***, press-fit femoral stem ***, uncoated single-component femoral stem ***, drug-free bone cement ***, drug-containing bone cement ***) is recommended [91, 105, 124, 194].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

• In functionally active patients over 60 years of age with an active lifestyle prior to injury, total hip arthroplasty is recommended as it is associated with better functional outcomes and lower pain intensity compared to monopolar (unipolar) or bipolar arthroplasty [91, 105, 124, 194]. No significant differences were found in parameters such as mortality, length of hospital stay, and the degree of return to pre-injury activity levels [91, 105, 124, 194].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

• A comparative evaluation of total and hemiarthroplasty outcomes in patients over 70 years of age with femoral neck fractures showed that monopolar (unipolar) arthroplasty is recommended for patients with low mobility, cognitive dysfunction, and severe somatic pathology. Compared to total hip arthroplasty, hemiarthroplasty is characterized by a shorter operative time, lower intraoperative blood loss, and a lower risk of prosthesis dislocation [88, 194].

GGR CLoE 1Recommendation Grade C (Level of Evidence – 1)

Comments: thus, when choosing the type of arthroplasty, each patient should be evaluated individually. Total hip arthroplasty should be used for patients with high physical activity. Patients whose low pre-injury mobility does not justify total arthroplasty—which is associated with greater surgical trauma, longer duration, and a higher risk of dislocation—should undergo hemiarthroplasty.

Comparison of Monopolar and Bipolar Hemiarthroplasty

• In cases of hemiarthroplasty, it is recommended to use monopolar (unipolar) (metallic femoral head prosthesis***, press-fit femoral stem***, uncoated single-component femoral stem***, drug-free bone cement***, drug-containing bone cement***) and bipolar prostheses (metallic femoral head prosthesis***, press-fit femoral stem***, uncoated single-component femoral stem***, drug-free bone cement***, drug-containing bone cement***) [49, 50, 62, 66, 90, 99, 160].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: randomized studies have shown no fundamental differences between short-term and long-term outcomes of monopolar (unipolar) and bipolar hemiarthroplasty in patients with unstable (displaced) femoral neck fractures.

Randomized studies comparing the outcomes of monopolar (unipolar) and bipolar hemiarthroplasty in the treatment of displaced femoral neck fractures have shown equivalence in functional and radiological outcomes, revealing no significant advantages of one type of prosthesis over the other. Meta-analyses of mortality at six months and one year postoperatively showed no statistically significant difference between monopolar (unipolar) and bipolar hemiarthroplasty [49, 50, 62, 66, 90, 99, 160].

Total Hip Arthroplasty Using Dual-Mobility Acetabular Components

• The use of dual-mobility prostheses (total hip prosthesis with metal-on-polyethylene bearing surface***) is recommended in the management of patients with a high risk of prosthesis dislocation (e.g., history of stroke, neuromuscular diseases, moderate to severe dementia, epilepsy, and other neurodegenerative diseases) [60, 112].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: in dual-mobility prostheses (total hip prosthesis with metal-on-polyethylene bearing surface***), the prosthetic head articulates within a polyethylene liner (non-restrictive polyethylene hip arthroplasty acetabular component liner***), which in turn articulates within the fixed acetabular component (metallic hip arthroplasty acetabular component***).

Dual-mobility systems are more commonly used in the treatment of femoral neck fractures, tumors, and revision surgeries; several studies [60, 73, 112] have established that the use of dual-mobility components leads to a low dislocation rate (0%-0.88%) after arthroplasty. It would seem that two friction pairs necessitate more frequent revision interventions due to component wear, but according to the Australian Orthopaedic Association National Joint Replacement Registry, the revision rate for dual-mobility components and traditional design endoprostheses is identical [38].

Type of endoprosthesis component fixation

• For adult patients with femoral neck fractures, it is recommended to use cemented and cementless total endoprostheses to ensure early weight-bearing on the operated limb [68, 76, 116, 173, 189, 138].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: randomized clinical trials have not found a significant difference in the outcomes of total arthroplasty with different types of component fixation [68, 76, 116, 173, 189], except for a slight superiority of cemented fixation in functional outcomes one year after surgery and lower pain intensity at 3 months, 1, and 2 years postoperatively [138].

When using cementless endoprosthesis components in patients over 70 years of age, there is a higher risk of periprosthetic fractures during surgery and in the postoperative period, and lower functional scores at 6 weeks [138, 188].

Bearing surfaces of endoprostheses

• In total hip arthroplasty, it is recommended to use the following bearing surfaces: ceramic-on-polyethylene, metal-on-polyethylene, ceramic-on-ceramic [120, 200].

GCR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

• In patients with femoral neck fractures, it is not recommended to use a metal-on-metal bearing surface to prevent early instability of the endoprosthesis components [120, 200].

GCR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

Comments: in patients younger than 45 years, the use of ceramic-containing bearing surfaces is advisable.

According to randomized trials and national registry data analyses, ceramic-bearing surfaces have a slight advantage over metal-on-polyethylene bearings due to reduced osteolysis, aseptic loosening, and a lower revision rate [29, 95, 200].

Surgical approaches

• In orthopedic hip arthroplasty for patients with femoral neck fractures, it is recommended to perform an anterolateral approach [180].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• In orthopedic hip arthroplasty for adult patients with femoral neck fractures, it is recommended to perform an anterior approach [61].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• In orthopedic hip arthroplasty for patients with femoral neck fractures, it is recommended to use transgluteal and dorsal approaches, although the use of the latter leads to a higher rate of postoperative dislocations in this patient group [42].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Postoperative wound drainage

Comments: meta-analyses of studies investigating the comparative outcomes of arthroplasty with and without active postoperative wound drainage showed no differences between the two groups (regarding the incidence of infectious complications and postoperative hematomas) [106, 205]. At the same time, these meta-analyses demonstrated a statistically significant increase in the number of blood transfusions when drains were used. No other differences between the two groups were identified [106, 205].

Stable intertrochanteric fractures

• As a method of choice in the treatment of stable intertrochanteric fractures, it is recommended to perform osteosynthesis using the DHS system (dynamic hip screw***, bone fracture fixation plate with screws, non-absorbable, sterile***, bone fracture fixation plate with screws, non-absorbable, non-sterile***) [31, 192, 195].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: no advantages of the DHS osteosynthesis technique over proximal femoral nails (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) were identified; however, it was established that for the fixation of stable intertrochanteric fractures using DHS, blood loss volume and surgery duration were lower compared to the use of proximal femoral nails [31, 192, 195].

Stable intertrochanteric fractures include AO/OTA type 31A1.2 fractures with the possibility of maintaining medial support (lesser trochanter is intact). The radiological criterion for stability is the disruption of the medial cortical layer at only one level [182].

Bone fragments in stable intertrochanteric fractures can be fixed either with an extramedullary implant (DHS) (dynamic hip screw***, bone fracture fixation plate with screws, non-absorbable, sterile***, bone fracture fixation plate with screws, non-absorbable, non-sterile***) or with a proximal femoral nail, the design of which allows shearing forces at the fracture line to be transformed into interfragmentary compression forces [135].

Moreover, according to a review by the British NICE guideline [139], the implantation of proximal femoral nails (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) was accompanied by a higher incidence of both intraoperative femoral fractures and periprosthetic fractures in the long-term postoperative period [71].

In patients older than 60 years with stable intertrochanteric fractures (AO/OTA 31A1.2) in the presence of stage 3 coxarthrosis, arthroplasty is recommended if a primary endoprosthesis stem can be implanted. If implantation of a primary endoprosthesis stem is not possible, osteosynthesis is recommended.

Unstable intertrochanteric fractures

• In cases of unstable intertrochanteric fractures, it is recommended to use intramedullary locked osteosynthesis with a proximal femoral nail (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) [31, 109, 117, 191, 196].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: unstable intertrochanteric fractures include AO/OTA types 31A1.3 and 31A2 [139]; such fractures are characterized by comminution with damage to the medial support.

When evaluating the outcomes of osteosynthesis using DHS and proximal femoral nails for unstable intertrochanteric fractures with avulsion of the lesser trochanter but without subtrochanteric extension (AO/OTA 31A1.3, 31A2), advantages of proximal femoral nails (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) were revealed [117, 191, 196]. In addition, osteosynthesis with a proximal femoral nail (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) is accompanied by better functional outcomes [191] and a shorter recovery period for function and weight-bearing capacity of the injured limb [117].

For the prevention of periprosthetic fractures, it is advisable to use versions of proximal femoral nails (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) with a length of at least 210 mm, as longer nails tended to carry a lower risk of fracture, although the difference was not statistically significant [141].

In patients older than 60 years, when using proximal femoral nails (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***) with a helical blade neck element, the risk of implant cutout is lower [92, 149, 179, 184].

Implants can be installed in two modes:

1. Dynamic, in which mobility of the neck element relative to the nail is preserved after insertion.

2. Static, in which the neck element is locked after insertion and becomes immobile relative to the intramedullary nail (intramedullary femoral nail, non-sterile***, intramedullary femoral nail, sterile***).

A specific feature of the consolidation of unstable trochanteric fractures is the collapse of the fracture zone and potential shortening of the lower limb; therefore, to maximally preserve topographic and anatomical relations in patients younger than 60 years, it is advisable to perform internal fixation with a proximal femoral nail (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) in a static configuration. Following the insertion of the proximal femoral nail (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) in a static configuration, full weight-bearing should be permitted no earlier than 8-10 weeks postoperatively. For patients older than 60 years, a dynamic type of osteosynthesis is indicated.

The algorithm for selecting treatment tactics in patients with trochanteric fractures is provided in Appendix B4.

Subtrochanteric AO/OTA 32-A/B/C.1, transverse and reverse oblique intertrochanteric fractures (AO/OTA 31-A3)

• For the purpose of bone fragment fixation in subtrochanteric fractures and type 31A.3 fractures, it is recommended to use proximal femoral nails (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) [32, 139, 174, 175, 204].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments: the results of most studies reflect the obvious advantages of fixing unstable intertrochanteric and subtrochanteric fractures with proximal femoral nails (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) [174, 204]. The use of proximal femoral nails (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) is also characterized by a lower rate of complications, better functional outcomes, and a faster recovery period [174, 204]. The insertion of an extramedullary fixation device (dynamic hip screw***, bone fracture fixation plate with screws, non-absorbable, sterile***, bone fracture fixation plate with screws, non-absorbable, non-sterile***) is associated with a high risk of secondary fragment displacement and loss of fixation strength; specifically, when comparing intramedullary and extramedullary types of fixation, the latter were characterized by higher blood loss, longer operative time, and a higher rate of revision interventions [170].

The insertion of a short version of proximal femoral nails (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) for type 31.A.3 and subtrochanteric fractures is accompanied by a high risk of periprosthetic fracture; therefore, the distal end of the fixation device (femoral intramedullary nail, non-sterile***, femoral intramedullary nail, sterile***) must be positioned 0.5–2 cm proximal to the roof of the intercondylar notch (Blumensaat's line) [169].

In patients older than 60 years with transverse and reverse oblique intertrochanteric fractures (AO/OTA 31-A3) in the presence of stage III coxarthrosis osteosynthesis should be performed.

Basic requirements for the implantation of metal constructs and arthroplasty components are provided in Appendix A3.1.

3.7. Treatment of proximal femur fractures in children

The main principles of treatment are: maximum possible mitigation of potential risks of aseptic necrosis, minimizing damage to the growth plate of the proximal femoral epiphysis (where possible), and achieving anatomical reduction of fragments and stable osteosynthesis [217].

• In children with Delbet type II-IV fractures without fragment displacement and AO/OTA type 31-M/3.1 I-III fractures, it is recommended to perform conservative treatment with hip spica casting. It should be taken into consideration that hip spica casting may lead to various complications, and treatment choice may lean toward surgery, which is the method of choice for displaced fractures [218, 219].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: to date, there is no consensus among pediatric traumatologists regarding either the choice of reduction (open or closed) or the optimal timing for its performance to prevent the development of avascular necrosis of the femoral head in children with proximal femoral fractures [202]. However, most authors are convinced that reduction and osteosynthesis of femoral neck fragments within the first 24 hours after injury significantly reduces the risk of avascular necrosis [220-223]. The choice of closed or open reduction depends on the degree of fracture displacement and the surgeon's ability to achieve anatomical reduction by closed means. In addition, hip joint decompression via arthrocentesis or capsulotomy reduces the incidence of avascular necrosis [225, 226, 239].

To date, there is a fairly large arsenal of metal constructs for performing osteosynthesis of femoral neck fragments in pediatric patients (Kirschner wires, threaded-tip wires, pediatric DHS systems, locking plates (orthopedic bone wire***, dynamic bone screw***, bone fracture fixation plate with screws, non-absorbable, sterile***, bone fracture fixation plate with screws, non-absorbable, non-sterile***)). The choice of implant should be determined based on the child's age, body mass index, anatomical and anthropometric data of the proximal femur, fracture type, and the experience of the operating surgeon or orthopedic traumatologist [227, 239].

• In traumatic proximal femoral osteoepiphysiolysis, it is recommended to perform closed or open reduction and osteosynthesis with screws (non-absorbable, non-sterile orthopedic bone screw***) [243].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• In avulsion fractures of the greater and lesser trochanters, it is recommended to primarily use conservative treatment, which includes restriction of motion for 6 weeks. Reduction and internal fixation may be used in the presence of significant fragment displacement [241].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• In children with proximal femoral fractures, it is recommended to perform primary open reduction of femoral neck fragments for Delbet type I and AO/OTA 31-E/2.1, 31-E/8.1-2 fractures, as well as when the time since injury exceeds 24 hours. Open reduction has a number of advantages over closed reduction, such as better visualization of the fracture site, accuracy of reduction, drainage effect, better functional outcomes, and a lower complication rate [229-231].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

3.8. Other treatment

3.8.1. Perioperative antibiotic prophylaxis

• As the primary drugs for perioperative antibiotic prophylaxis of surgical site infections in the surgical treatment of patients with proximal femoral fractures, it is recommended to use cefazolin** [1]; reserve drugs (e.g., in case of a history of anaphylactoid reactions, in hospitals where MRSA frequently causes wound infections) are vancomycin** [1], #clindamycin** (for dosing regimens, see Table 3) [1].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• When prophylaxis is performed using cefazolin**, #clindamycin** (for dosing regimens, see Table 3), it is recommended to administer the drugs 30-40 minutes before the start of the surgical intervention [1].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• When prophylaxis is performed using vancomycin**, administration is carried out as an intravenous infusion over 60 minutes. Administration is started 1.5 hours before the start of the surgical intervention [1].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• For any surgery in proximal femoral fractures, all patients are recommended to undergo surgical site infection prophylaxis [1].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• For any surgery in proximal femoral fractures, all patients are recommended to receive antibiotic prophylaxis for 24 hours [1, 176].

UC RLE 3Recommendation Strength Level C (Level of Evidence – 3)

• In the presence of risk factors for periprosthetic joint infection, it is recommended to prescribe antibiotic therapy [176].

UC RLE 3Recommendation Strength Level C (Level of Evidence – 3)

Table 3. Dosing regimen of drugs for perioperative prophylaxis in proximal femoral fractures [1].

*Parenteral cefazolin**, vancomycin**, #clindamycin** (for dosing regimens, see Table 3) may be administered as a single dose immediately before surgery.

Comments: the purpose of antibiotic prophylaxis is to establish a concentration of the systemic antibacterial drug in the bloodstream and tissues sufficient to prevent microorganism colonization, taking into account the potential development of microbial resistance. The choice of systemic antibacterial drug should be made in accordance with the recommendations of the clinical pharmacologist of the medical institution.

Prophylactic administration of systemic antibacterial drugs is generally ineffective in situations where there is a high probability of tissue re-contamination in the postoperative period, for example:

➣ in patients with a tracheostomy;

➣ intubated patients;

➣ in patients with an indwelling urinary catheter;

➣ in patients with central venous catheters.

• For patients with Gustilo type II and type III open fractures, systemic antibacterial therapy for 72 hours after trauma is recommended [57].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: in the case of open fractures, prophylactic administration of systemic antibacterial drugs is effective for the prevention of early infection. Antibiotics should be administered as soon as possible after trauma; the systemic antibacterial drug of choice is cefazolin**, however, in patients with Gustilo type II and type III open fractures, it is advisable to broaden the spectrum of systemic antibacterial drugs to cover Gram-negative (G(-)) pathogens. In such cases, adult patients may be considered for the addition of #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** [93, 183]. An alternative to this combination in adult patients may be #ampicillin + sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [186], with the latter being particularly relevant in the case of a risk of clostridial infection. According to the majority of researchers, in Gustilo type II and type III open fractures, the administration of systemic antibacterial drugs should not be continued for more than 72 hours after trauma or more than 24 hours after soft tissue wound closure [130].

Information on the mandatory administration of antibiotic prophylaxis to children with proximal femoral fractures is absent and remains at the discretion of the attending physician.

3.8.2. Thromboprophylaxis

• All patients with proximal femoral fractures are recommended to undergo thromboprophylaxis for venous thromboembolic events (VTE) [15, 39].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

• Thromboprophylaxis is an urgent measure and is recommended to be performed immediately after the patient seeks medical attention, as the risk of venous thrombosis increases sharply from the moment of injury [15, 39].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

Comments: patients with proximal femoral fractures belong to the high-risk group for VTE development due to the nature of the fracture itself, regardless of the treatment method; therefore, along with mechanical VTE thromboprophylaxis, pharmacological prophylaxis is indicated for this category of patients.

Non-pharmacological means of VTE prophylaxis include:

➣ Elastic and/or intermittent sequential pneumatic compression of the lower extremities.

➣ Early mobilization and activation of the patient.

➣ Physiotherapy exercises for bone fractures.

The thromboprophylaxis regimen for patients at high risk of VTE should be used in accordance with the National Standard of the Russian Federation GOST R 56377-2015 "Clinical guidelines (treatment protocols) for the prevention of thromboembolic syndromes" [15].

In pediatric patients with lower limb fractures, the incidence of thromboembolic complications is about 0.058%. Adolescents with a femoral fracture are included in the risk group for this probability of embolism [233].

Comments: in accordance with clauses 4156-4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is carried out for any injuries involving a breach of the skin and mucous membranes. Emergency tetanus prophylaxis is performed up to the 20th calendar day from the moment of injury [26]. The prescription of drugs for emergency tetanus immunoprophylaxis is carried out differentially depending on the availability of documentary confirmation of preventive vaccination or immunological monitoring data on the titer of anti-tetanus immunity, as well as taking into account the nature of the injuries.

Emergency tetanus immunoprophylaxis is carried out in the form of:

- passive immunization or seroprophylaxis with human anti-tetanus immunoglobulin** (TIG), and in its absence - tetanus antitoxin** (TAT);

- active-passive prophylaxis, consisting of the simultaneous administration into different parts of the body of human anti-tetanus immunoglobulin** (and in its absence - TAT) and tetanus toxoid** (TT);

- emergency revaccination with tetanus toxoid** (or diphtheria-tetanus toxoid** with a reduced antigen content - Td-m) to stimulate immunity in previously vaccinated individuals [25, 118].

3.8.3. Postoperative patient management

Patients with proximal femoral fractures may require transfer to an intensive care unit or critical care unit for vital function monitoring. The need to transfer the patient to an intensive care unit or critical care unit is determined by the anesthesiologist-resuscitator administering the anesthesia.

Adequate analgesia and thermal comfort must be ensured in the intensive care unit or critical care unit.

The duration of the patient's stay in the intensive care unit or critical care unit is determined by the anesthesiologist-resuscitator.

Postoperative analgesia in adult patients.

• Medical analgesia is recommended in an amount sufficient to ensure patient mobilization 24 hours after surgery [89, 131, 161].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: for this purpose, paracetamol**, NSAIDs, opioids (tramadol**, morphine** for severe pain not relieved by other drugs) can be used depending on the severity of the pain syndrome according to the Numerical Rating Scale (NRS) and Visual Analog Scale (VAS), similar to the preoperative analgesia regimen (see Section 3.1.4. Analgesia).

In the postoperative period, prolonged epidural analgesia can be used. Epidural analgesia can be used in this group of patients in subanalgesic doses without the development of a motor block in the absence of contraindications for regional techniques. Depending on the hospital protocol, multimodal analgesia and regional blocks can be used.

3.8.4. Principles of postoperative examination and treatment of patients with proximal femur fractures

Table. Assessment of the patient's condition in the postoperative period.

Delirium

Delirium is a common perioperative complication of fragility fractures of the proximal femur (FFPF), leading not only to an increased length of hospital stay and higher in-hospital mortality [126, 198], but also to an increased post-discharge mortality rate [139, 200].

• To prevent the development of perioperative delirium in adult patients, it is recommended to restore mental functions as early as possible. This is facilitated by maintaining a wake-sleep cycle (using earplugs, sleep mask), restoring the patient's ability to communicate fully with loved ones (availability of glasses, hearing aid, dentures, telephone, and allowing relatives to visit), and ensuring the patient is dressed (wearing a hospital gown) [126, 139, 198].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

• In all adult patients with FFPF, it is recommended to ensure early detection of pre-delirium symptoms, which allows for the early initiation of treatment for this complication and prevents its progression into a full-blown phase, which is a life-threatening condition [126, 139, 198].

GGR BLoE 2Recommendation Grade B (Level of Evidence – 2)

Comments: perioperative delirium in patients with FFPF occurs in an average of 17% of cases and can reach up to 51% [98]. It should be noted that prevention and early treatment of delirium help reduce its incidence and the severity of its consequences.

Risk factors for delirium include advanced age, history of cognitive impairment or psychogenic depression, unmanaged pain, use of psycholeptics, dehydration, electrolyte imbalances, protein-energy malnutrition, visual and/or hearing impairments, and urinary catheterization [125].

Risk factors for postoperative delirium:

➣ age > 65 years;

➣ chronic cognitive decline, dementia;

➣ visual or hearing impairment;

➣ severity of the patient's condition;

➣ need for admission to the intensive care unit;

➣ presence of infectious foci.

Main symptoms of perioperative delirium (if symptoms appear – initial examination (consultation) by a psychiatrist):

➣ consciousness disturbance (reduced clarity of consciousness, inability to focus, shift attention, and concentrate);

➣ altered thinking (memory impairment, disorientation, speech disorders);

➣ psychomotor disturbances;

➣ sleep disturbance (circadian rhythm disruption - the patient sleeps during the day and is awake at night).

If a psychiatrist is not on the medical organization's staff or if it is impossible to arrange a consultation with a staff psychiatrist within 2 hours of the onset of delirium signs, a specialized psychiatric emergency team (EMC) must be called.

To call a psychiatrist, the attending physician (from the intensive care unit or traumatology department) must dial the emergency medical service number "103" and request a specialized psychiatric emergency team to the hospital.

The day after the psychiatric team arrives, a consultant psychiatrist of the medical organization must take over the patient's care and continue daily monitoring until the patient recovers from delirium. If there is no psychiatrist on the hospital staff, repeated daily calls to the psychiatric emergency team must be made until the patient recovers from delirium.

List of medications used to treat postoperative delirium in adult patients (availability must be ensured in the multidisciplinary hospital pharmacy):

Haloperidol** solution for intravenous and intramuscular injection; oral drops (start with oral administration) [128].

Droperidol** solution for intravenous and intramuscular injection (more suitable in cases where a faster onset of action and a higher level of sedation are required) [128].

3.8.5. Anemia

Long-standing compensated anemia is extremely common in patients who have sustained FFPF; thus, more than 80% of such patients have a hemoglobin concentration of less than 110 g/L [52].

Comments: the results of recent studies have made it possible to revise the tactics of blood hemoglobin correction. Previously, the target threshold was a concentration of 90–100 g/L; however, currently, in accordance with the latest clinical guidelines of the American Society of Hematology, the Cochrane Database systematic review, and Order of the Russian Ministry of Health No. 183n dated April 2, 2013, the target hemoglobin concentration level for transfusion of red blood cell components is 70–80 g/L [19, 51, 53, 54].

• In adult patients who have undergone surgery for FFPF, it is recommended to prescribe iron supplements in the postoperative period according to indications to increase hemoglobin concentration levels [178].

GCR BLOE 1Grade of Recommendation B (Level of Evidence – 1)

Comments: systematic reviews and meta-analyses demonstrate that perioperative use of intravenous iron preparations, in particular ferric carboxymaltose**, in trauma and orthopedic patients older than 14 years, and/or iron (III) hydroxide polymaltose** in children older than 4 months, especially in the postoperative period, is an effective alternative to blood transfusion, as it reduces the proportion of patients who undergo blood transfusion, reduces the volume of red blood cell mass transfused, and leads to a lower incidence of infectious complications without altering mortality rates. The dosage of medications is calculated individually in accordance with the instructions [102, 178].

3.8.6. Osteoporosis

Low-energy FFPF are markers of systemic osteoporosis, the treatment of which should be initiated (or continued) within the first 24 hours after surgery [27].

Diagnosis and pharmacotherapy of systemic osteoporosis should be carried out in accordance with the clinical guidelines: "Osteoporosis" [26].

The discharge summary should recommend that the patient consult an osteoporosis specialist.

3.8.7. Blood-sparing technologies

Comments. Tranexamic acid** effectively reduces blood loss and leads to a lesser decrease in postoperative hemoglobin levels in adult patients undergoing surgery for FFPF. Clinical studies demonstrate the efficacy of intravenous administration of #tranexamic acid** in adults at a single dose of 1.0 g in 100 ml of sodium chloride** infusion solution during osteosynthesis. Dosing regimen for hemiarthroplasty and total arthroplasty: first administration of #tranexamic acid** at a dose of 15 mg/kg body weight in 100 ml of sodium chloride** infusion solution 10 minutes before surgery, second administration of #tranexamic acid** at a dose of 15 mg/kg body weight in 100 ml of sodium chloride** infusion solution before closing the surgical wound [251, 252].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Patient mobilization is recommended to begin within 24 hours after surgery [139, 152].

GCR BLOE 3Grade of Recommendation B (Level of Evidence – 3)

Comments: early patient mobilization helps prevent postoperative complications such as pressure ulcers, deep vein thrombosis of the lower extremities, and pneumonia [139, 152].

The tasks of the preoperative period include: training the patient in proper deep thoracic and diaphragmatic breathing, and coughing to prevent the risk of cardiovascular and respiratory complications, as well as exercises for uninjured limbs.

There are no contraindications to rehabilitation and mobilization of patients with FFPF. Rehabilitation measures should be carried out for all patients without exception in the postoperative treatment period of FFPF.

Equipment and supplies:

When conducting rehabilitation measures in patients after surgery for FFPF, the following are used:

- bedside Balkan frames (trapeze bars for pulling up) equipped with standard mechanotherapy blocks and cuffs,

- continuous passive motion (CPM) device for knee and hip joints,

- group and individual therapeutic gymnastics hall, set of exercise therapy equipment, exercise bikes (rehabilitation bicycle with accessories), mechanotherapy equipment, parallel bars for gait training,

- dynamic step-bar trainer (step-bars with electronic step height adjustment),

- medical massage couch, kinesitherapy table.

The goal of rehabilitation for patients who have undergone surgery for proximal femoral fractures, according to the International Classification of Functioning, Disability and Health (ICF), is the restoration of:

- functions of the operated limb (at the body structure/function level, per ICF),

- mobility and self-care abilities (at the activity level, per ICF),

- social and professional activity, and improvement in quality of life (at the participation level, per ICF).

Rehabilitation measures for patients are carried out in accordance with the following principles: early start (12–48 hours), comprehensiveness, evidence-based rationale, individualized approach, phased delivery, continuity, multidisciplinary approach, and duration until positive dynamics are sustained.

Postoperative rehabilitation measures are initiated within the first 24 hours in the intensive care unit or trauma ward (stage I of rehabilitation) and are continued after discharge from the trauma ward in the rehabilitation department of multidisciplinary hospitals or in rehabilitation centers (departments) specializing in "pathology of the musculoskeletal system and peripheral nervous system" (stage II of rehabilitation).

The entire course of inpatient rehabilitation is divided into two stages (early and late postoperative periods).

The early postoperative period lasts for the first one to two weeks. Its objectives include the prevention of postoperative complications from the cardiovascular system, respiratory system, and gastrointestinal tract, the prevention of trophic disorders (primarily pressure ulcers), the reduction of soft tissue edema, and the creation of optimal anatomical and physiological conditions for the healing of tissues traumatized during surgery.

The late postoperative period begins on days 7–15 after surgery and lasts for four to eight weeks (up to 10–12 weeks from the time of surgery). The late postoperative period is conventionally divided into the early convalescent phase, which lasts from the second-third to the fifth-sixth weeks from surgery (carried out, as a rule, in an inpatient rehabilitation setting), and the late convalescent phase, which lasts from the sixth to the tenth (twelfth) weeks from surgery (depending on indications, it may be longer and include multiple courses). The main objectives of the late postoperative period are the restoration of support and locomotor functions, self-care skills, and professional and social activity. In the presence of postoperative complications, comorbid somatic diseases, or significant limitations in mobility, activity, or participation, the duration of the late rehabilitation period may be extended.

Upon completion of the inpatient (second) stage of rehabilitation, patients are referred for outpatient treatment at outpatient clinics or sanatorium-resort institutions (third stage of rehabilitation).

It is very important that all instructions given to the patient regarding post-operative behavior are clear, specific, consistent with the recommendations of other specialists, and reinforced through numerous repetitions and instructional reminder materials (examples of such patient instructions, including simple typical sets of therapeutic exercises in bed with and without assistive devices, are presented in Appendix A3.2). These sets must be clearly written and illustrated with pictures, and should not contain specific medical terms. The exercises described in these handouts should be performed several times a day, starting from the first hours and days after surgery. Depending on the patient's condition after surgery, the physical and rehabilitation medicine physician and exercise therapy instructor add or exclude certain exercises. In addition to the simplest and most basic exercises, increasingly complex and active exercises are prescribed dynamically.

When conducting therapeutic exercise sessions, physical and rehabilitation medicine physicians and exercise therapy instructors must also follow certain rules:

1. The patient should be thoroughly instructed on how to perform a given gymnastic exercise. The patient must understand their responsibility for independently performing the entire set of therapeutic exercises in accordance with the recommendations.

2. Therapeutic exercise sessions with patients after proximal femoral fracture surgery should be conducted several times a day, for a minimum of 5–10 minutes, followed by a half-hour rest. The patient should not be overloaded with prolonged single exercise therapy sessions.

3. Therapeutic exercise sessions must be painless. At the same time, a mild sense of "discomfort" that occurs when muscles are stretched as they begin to operate in a new range of motion should be distinguished from postoperative pain that requires analgesics. It is generally accepted that pain after completing the exercise therapy set should not persist for longer than 1–2 minutes.

It is a mistake to administer analgesics before starting a therapeutic exercise session.

4.1. Postoperative weight-bearing regimens

Intertrochanteric, peritrochanteric, and subtrochanteric fractures:

• In patients younger than 60 years, it is recommended to apply static fixation and immediate postoperative body weight bearing at 15%. Full body weight bearing is recommended to be permitted based on radiological data regarding fracture consolidation, on average 12 weeks after surgery [169].

GRC CLEL 5Grade of Recommendation C (Level of Evidence – 5)

• In patients older than 60 years, it is recommended to apply dynamic fixation and full body weight bearing immediately after surgery [111].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Femoral neck fractures:

• Following osteosynthesis of femoral neck fractures with cannulated screws or a dynamic hip screw in patients younger than 60 years, body weight bearing is avoided for 12 weeks; after 12 weeks, it is recommended to introduce graduated body weight bearing based on the dynamics of fracture consolidation according to radiography or computed tomography data [189].

GRC CLEL 5Grade of Recommendation C (Level of Evidence – 5)

• Following osteosynthesis with three parallel dynamic bone screws fixed in a plate (dynamic bone screw***, non-absorbable sterile bone fracture fixation plate with screws***, non-absorbable non-sterile bone fracture fixation plate with screws***) in adult patients younger than 60 years, it is recommended to use graduated, gradually increasing weight bearing. Full weight bearing is permitted 6 weeks after surgery [148].

GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4)

• During osteosynthesis in patients older than 60 years, it is recommended to allow full body weight bearing immediately after surgery [103, 154].

GCR BLOE 3Grade of Recommendation B (Level of Evidence – 3)

Comments: patients older than 60 years cannot titrate weight bearing. They require stable internal fixation that allows immediate full body weight bearing [103, 154].

• Following arthroplasty for femoral neck fractures, adult patients are recommended to bear full body weight immediately after surgery [191].

GRC BLEL 3Grade of Recommendation B (Level of Evidence – 3)

Femoral head fractures:

• Following the removal of femoral head fragments in Pipkin I fractures, graduated body weight bearing is recommended immediately after surgery; the level of loading depends on the patient's pain syndrome and is selected individually [74, 78].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• Following osteosynthesis for Pipkin I, II, and IV fractures, body weight bearing is avoided for a period of 12 weeks. After 12 weeks, it is recommended to introduce graduated body weight bearing based on the dynamics of fracture consolidation according to radiography or computed tomography data [74, 78].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

• Following arthroplasty for Pipkin II–III fractures, adult patients are recommended to bear full body weight immediately after surgery [191].

GRC BLEL 3Grade of Recommendation B (Level of Evidence – 3)

• Following arthroplasty combined with acetabular fracture osteosynthesis, body weight bearing is recommended to be avoided for 12 weeks. After 12 weeks, it is recommended to permit graduated body weight bearing based on the dynamics of acetabular fracture consolidation according to computed tomography data [74, 78].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

4.2. Early postoperative rehabilitation

From the first day after surgery, the patient is prescribed breathing exercises, active exercises for the joints of the healthy leg (hip, knee, ankle), and isometric exercises for the muscles (gluteal, quadriceps, hamstrings, calf muscles) of the operated limb. Robotic mechanotherapy of the upper and lower extremities can be used (Robotic mechanotherapy for bone fractures, Robotic mechanotherapy for joint diseases and injuries) with a gradual increase in the flexion angle for the operated leg as prescribed by the physical and rehabilitation medicine physician. Exercises on the continuous passive motion (CPM) machine are carried out for 15-30 minutes 3-5 times a day. In addition, the patient is taught to lift the pelvis while supporting themselves on their elbows and the foot of the operated leg.

On days 1-2 after surgery, the patient is recommended to bend the healthy leg at the hip and knee joints, pulling the knee to the chest with their hands. The heel of the operated leg must press against the bed while performing this exercise (strengthening the hip extensors). Three to ten exercises are performed, with 3-10 repetitions per day.

During the same period, the operated patient is allowed to sit up in bed. From the "semi-sitting with legs dangling" position, the patient performs leg extensions at the knee joints, holding the position for 3-5 seconds (the foot is in dorsiflexion during the exercise). Eight to twenty exercises are performed with 3-10 repetitions per day.

On days 1-3, the patient is "verticalized" with unilateral support (walker or axillary crutches) under the supervision of a physical therapy instructor. For elderly individuals, transferring the patient to a vertical position is carried out cautiously, taking into account the risk of dizziness:

• initially, the patient is accustomed to sitting on the edge of the bed,

• subsequently, to standing by the bed,

• and only after that, to walking with the help of a walker or crutches (with medical staff providing insurance/support).

The most convenient way to do this is as follows. From a sitting position on the edge of the bed, leaning on the backs of two chairs placed on the sides, the patient rises by pushing up on the healthy leg (with the support of the physical therapy instructor). Initially, the patient must acquire the ability to stand steadily on the healthy leg, holding onto the back of the bed with their hands, leaning on the back of a chair, and then on crutches. A similar technique can be used if a walker is available. After this, training in walking with axillary crutches or a walker begins, monitoring their correct placement and supporting the patient to prevent falls.

It should be borne in mind that with unskilled use of crutches, when the body weight falls not on the hands but on the armpits, patients with severe somatic diseases and elderly individuals with femoral neck fractures may suddenly develop symptoms of so-called "crutch palsy".

Gait training after surgery begins in the early and continues in the late postoperative period. It is carried out individually depending on the patient's age, physical status, and specifics of the surgery. Most patients are first taught to walk using a walker, and then, taking into account the patient's condition, using two crutches. Walking training with additional support devices is carried out in front of a large full-length mirror.

Typical potential errors when developing a correct gait stereotype:

The first and most frequent error consists of stride asymmetry: the patient takes a longer step with the operated leg and a shorter step with the "healthy" leg. This is due to the patient's desire to avoid extension in the operated joint, which causes a feeling of "discomfort" in the groin area. To correct this error, the patient should be taught to take a shorter step with the operated leg and a longer step with the "healthy" leg in order to ultimately achieve stride symmetry.

The second most frequent error is that the patient bends the operated leg at the knee joint at the end of the stance phase. Bending the leg at the knee joint is accompanied by an earlier and faster heel rise in the final stage of the stance phase. This error is also caused by the patient's desire to avoid extension in the operated hip joint. To correct this error, the patient should be taught not to lift the heel and to keep it as close to the ground surface as possible in the final stage of the stance phase (until the entire leg is lifted into the swing phase). Throughout the entire stance phase, the patient must not bend the leg at the knee joint (the knee should be, as it were, "locked"). Normally, when supporting on the heel at the beginning of the step phase, the leg is extended at the knee joint, flexion in the joint occurs in the middle of the phase, then extension again, and finally, upon completion of the phase and toe-off, the leg is flexed again at the knee joint. After arthroplastic hip surgeries, the patient must keep the leg extended at the knee joint throughout the entire stance phase (from heel strike to toe-off). As the patient begins to walk more confidently and quickly, slight knee flexion is permitted.

The third error in gait training appears in the middle and late stages of the stance phase, during which the patient leans the torso forward. This error is most frequently observed in patients using forearm crutches. It is also associated with the patient's endeavor to avoid extension in the operated hip joint. When such an error appears, the patient should be taught to maintain the "pelvis forward – shoulders back" position during the middle and late stages of the stance phase, while not forgetting about the "blocked" knee joints.

The fourth error is a modification of the first and consists in the fact that the patient's torso ends up ahead of the crutches during the step (the crutches remain somewhat behind and the axial load on them is redistributed incorrectly).

After surgery, the patient is taught stair climbing: when going up the steps, the unoperated leg steps first, and then the operated leg joins along with the crutches. When going down the stairs, the crutches go down first, then the operated leg takes the first step, and finally the healthy leg joins.

It is recommended to increase walking time gradually: from 5-10 to 30 minutes one to three times a day.

To strengthen the abductor, extensor, and external rotator muscles of the operated hip, isometric tension exercises are performed. They are performed in a supine position with legs straight, feet in dorsiflexion, simultaneously pulling one leg downwards (lengthening) and the other leg upwards (shortening). Four to ten exercises are performed, with 5-10 repetitions per day.

A week later (rarely sooner), the patient is allowed to turn onto their stomach and back onto their back, which can be done via the healthy side. When turning, a pillow must be placed between the patient's legs. During the turn, the operated leg can be supported by the physical therapy instructor. Turns onto the stomach and back are performed 3-10 times a day.

From the "prone" position, the patient performs five to fifteen active knee flexions-extensions 5-10 times a day, as well as three to ten active extensions of the operated leg at the hip joint with 3-5 repetitions per day.

The set of physical exercises is supplemented with movements in the knee joint with the lower leg dangling over the edge of the bed. These exercises are performed with the support and assistance of the physical therapy instructor. In addition, the patient is instructed to bend the lower limb at the knee joint, sliding it along the bed surface, attempt to lift the leg, abduct it to the side, and adduct it. This group of exercises is used for more intensive contraction of certain muscle groups by the patient, which is necessary for their strengthening.

To reduce secondary changes in the capsular-ligamentous apparatus of the knee joint and decrease pain during movements in it, massage of the knee joint area (lateral surfaces, around the patella) is performed.

After surgery, usually in 2 weeks, therapeutic gymnastics in the physical therapy gymnasium is added in the conditions of the rehabilitation department. According to indications, block mechanotherapy for the ankle and knee joints is prescribed.

Before transfer to stage 2, an assessment using the Lequesne index is carried out. The patient must acquire basic crutch-walking skills at stage 1.

For the prevention of pneumonia and pulmonary congestion, chest massage or vibratory massage is prescribed. Starting from the 3rd-5th day after surgery, massage of the contralateral limb is prescribed.

In the event of a complicated postoperative course (pronounced edema, tissue infiltration, presence of neurological and vascular disorders), various methods of physical therapy, physiotherapy, and reflexology (according to indications) are additionally included in the rehabilitation program; physiotherapy procedures may be carried out 2 times a day.

4.3. Late postoperative rehabilitation

In a rehabilitation inpatient facility, medical massage of the operated limb (#10–15) is prescribed following a follow-up X-ray and sonographic examination (ultrasound) of the lower extremity veins (duplex scanning of the lower extremity veins).

If pain occurs during the mobilization of movements in the hip joint, low-frequency electrotherapy is prescribed: application of sinusoidal modulated currents (SMC therapy) for bone pathology, as well as low-frequency magnetotherapy. If there are contraindications to physiotherapy, auricular reflexotherapy techniques can be used, particularly in frail, elderly patients with comorbid cardiovascular diseases. 3–4 months after surgery, therapeutic medicinal baths, air-bubble (pearl) baths, gas baths (oxygen, carbon dioxide, nitrogen, etc.), and underwater shower-massage may be prescribed.

In the late postoperative period, functional multichannel muscle stimulation (multifunctional electrical stimulation) during walking (FMSW) can be used. Various hardware-software systems can be used for this purpose. During FMSW, the gluteus maximus and medius muscles on both sides, as well as the quadriceps and biceps femoris on the operated side, are stimulated. The FMSW procedure is performed on a treadmill at a set speed of 0.8–1.2 km/h for 20 minutes during the first three to four sessions. Subsequently, the speed and walking time are gradually increased (by the 10th procedure, up to 2.5–3.0 km/h for 35–40 minutes).

Orthotic management in the postoperative period is not required for patients with proximal femoral fractures.

4.4. Evaluation of rehabilitation efficacy

To evaluate the effectiveness of patient rehabilitation, clinical and instrumental research methods are used, as well as scales and questionnaires measuring the degree of limitation in daily activities and changes in quality of life. Among clinical methods, the most informative are the analysis of pain dynamics using the NRS (Numeric Rating Scale) or VRS (Verbal Rating Scale), lower limb muscle strength (on a 6-point scale), goniometric measurements, severity of limp, degree of muscle hypotrophy, and magnitude of limb shortening. For an in-depth analysis of changes at the body structures and functions level (according to the ICF), clinical tests are used (the 6-minute walk test, 10-meter walk test, total time of the «Timed Up and Go» test Appendix G6) [157], along with biomechanical research methods: podometry, stabilometry, and computer optical topography of the spine.

To assess the dynamics of activity in daily life (activity level according to the ICF), Lequesne's functional index is the most widely used in clinical practice Appendix G1 [116].

The index consists of three subscales (pain or discomfort — Table 1, maximum walking distance — Table 2, activities of daily living — Table 3) (Appendix G1).

Based on the sum of points on the Lequesne index, the degree of disability is assessed (Appendix G1, Table 4).

5. Prevention and Dispensary Observation

Comments: after discharge from the hospital, the patient should be referred to a trauma center, outpatient traumatology department, district surgeon, or surgeon providing outpatient follow-up for patients at their place of residence, accompanied by a description of the treatment provided and detailed recommendations for continuing treatment and rehabilitation. This ensures continuity between the inpatient and outpatient stages of treatment.

Follow-up examinations with X-rays or multislice computed tomography (MSCT), including metal artifact reduction (MAR) mode, and evaluation of functional recovery dynamics are performed at 6–8 weeks postoperatively (assessment of fracture consolidation and feasibility of full weight-bearing on the limb in extra-articular fractures), 12 weeks postoperatively (assessment of fracture consolidation and feasibility of weight-bearing on the limb in intra-articular fractures), 24 weeks postoperatively (assessment of functional recovery dynamics), and 1 year postoperatively (assessment of the functional outcome of treatment and decision-making regarding the necessity and timing of implant removal).

Prevention of femoral fractures consists in citizens observing social safety rules when performing household chores, being in traffic areas, walking on poor-quality surfaces, and during icy conditions.

A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

To prevent low-energy proximal femoral fractures, all citizens over 60 years of age are indicated for health screening (dispensarization) to determine both the risk of falls and/or fractures and the need for diagnosis and treatment.

Indications for prevention: all citizens over 60 years of age.

Contraindications for prevention: none.

Diagnosis and medical treatment of systemic osteoporosis should be carried out in accordance with the Federal Clinical Guidelines: "Pathological Fractures Complicating Osteoporosis" [22].

6. Organization of Medical Care

Clinical application of the guidelines: traumatology and orthopedics, anesthesiology and intensive care, internal medicine, geriatrics, medical rehabilitation, public health and healthcare organization.

Purpose of the clinical guidelines: the clinical guidelines have been developed to improve the quality of medical care and to standardize diagnostic and treatment algorithms for patients with proximal femoral fractures.

Proximal femoral fractures (PFF) are one of the most common reasons for admission to orthopedic and trauma inpatient units, frequently occurring not only in elderly patients with osteoporosis and osteopenia [139]. For the absolute majority of patients with PFF, such an injury means the loss of their previous level of mobility, and for less active patients, a permanent loss of the ability to care for themselves even within their own home. The forced period of immobilization prior to surgical treatment, in the presence of pre-existing comorbidities, leads to an aggravation of existing somatic problems; thus, within the first three months after a femoral neck fracture, mortality reaches 5.75% in women and 7.95% in men [85].

In Saint Petersburg in 1996, mortality among patients with PFF who received conservative treatment alone was 42% [3], and in 2011, according to the Vreden National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, it reached 61%. In Yaroslavl, between 1997 and 2004, the average mortality rate in the group of patients with PFF older than 60 years within the first twelve months after injury was 71.8% [5]. According to foreign authors, in 2007, mortality within 120 days after injury with conservative treatment reached 62% [59].

It should be noted that even after surgical treatment, the number of complications and unsatisfactory functional outcomes remains very high, reaching 30% [28, 45, 101]. Re-operations following osteosynthesis for PFF are largely associated both with errors in the choice of treatment method, violations of the methodology of metal implant fixation and surgical technique, and with incorrect postoperative patient management. Therefore, when choosing a surgical strategy, it appears very important to be guided not only by the nature of the fracture itself and the availability of sufficient material and technical support of the medical organization to comply with the implantation technique of a particular metal structure, but also by the level of professional skill of the operating surgeon.

In Russia, the system of care for patients with PFF differs significantly from those in European countries and the USA [4] due to the lack of a unified treatment protocol for this group of patients. In the treatment of patients with PFF in the Russian Federation, a number of unresolved problems persist: an unreasonably long pre- and/or postoperative inpatient period, a lack of sufficient rehabilitation support and nursing patronage after discharge from the hospital, and most importantly, the unjustified formation of the concept of conservative treatment in patients who would undergo surgical treatment in European countries and the USA.

According to data from the Vreden RNIITO for 2014, the average length of hospital stay for a patient with a proximal femur fracture in St. Petersburg hospitals was 7 bed-days (ranging from 2 to 12); this indicates that some patients did not receive the required surgical treatment. In 2011, the proportion of patients who did not receive surgical care in the city's hospitals approached half of all patients with proximal femur fractures (46% were treated conservatively, and 7% of patients with proximal femur fractures were sent home from the emergency department) [4]. According to the 2016 annual report of the Research Institute for Healthcare Organization and Medical Management of the Moscow Healthcare Department, the proportion of operated patients with proximal femur fractures in Moscow clinics was 63.6%, and in 2018 it reached 87.9%; at the same time, surgical activity for this group of patients approaches 98% in European countries [59]. In addition, the overwhelming majority of patients in the Russian Federation do not receive a full course of rehabilitation and restorative treatment after discharge from the hospital.

All of the above necessitates the creation of domestic clinical guidelines covering the entire spectrum of specialized medical care issues for these patients.

Since there is no sufficient domestic evidence base dedicated to the treatment of proximal femur fractures, the evidence base of these guidelines was built on materials from national clinical guidelines of European countries and the USA [29, 32, 137, 138, 139, 175], data from RCTs and meta-analyses, with subsequent adaptation to the conditions and specifics of the healthcare system in the Russian Federation.

Indications for planned hospitalization:

1) the presence of patient complaints characteristic of a proximal femur fracture;

2) the absence of weight-bearing capacity in the lower limb;

3) the presence of radiological signs of a femoral neck fracture, intertrochanteric fracture, or subtrochanteric fracture in the patient.

Indications for emergency hospitalization:

1) the presence of patient complaints characteristic of a proximal femur fracture;

2) the absence of weight-bearing capacity in the lower limb;

3) the presence of radiological signs of a femoral neck fracture, intertrochanteric fracture, or subtrochanteric fracture in the patient.

Indications for patient discharge from the hospital:

1) fracture stabilization with hardware or hip arthroplasty has been performed;

2) the first stage of rehabilitation has been carried out;

3) there is no acute infectious process;

4) refusal of the patient or their legal guardians (in case of legally established incapacity of the patient) to continue inpatient treatment (the reason for refusal must be recorded in the medical chart with the personal signature of the patient or their guardians).

Pre-hospital stage

Upon confirming the presence of symptoms suggesting a proximal femur fracture (the patient, lying on their back, is unable to lift the straightened lower limb — a positive "stuck heel" sign, limb shortening, adduction and/or external rotation), every patient (regardless of the severity of comorbidities) must be evacuated to a medical organization.

The paramedic or emergency physician must inform the patient about the risks of complications associated with conservative treatment of proximal femur fractures, including pneumonia, lower extremity vein thrombosis, pulmonary embolism, pressure ulcers, and the high mortality rate associated with conservative treatment of proximal femur fractures (over 70% in the first 12 months after injury) [5].

Transfer of patients to higher-level medical organizations

To transfer a patient to a higher-level medical organization from feldsher-obstetric stations, an electrocardiogram must be recorded.

If it is impossible to provide specialized medical care to a patient admitted to a medical organization with a proximal femur fracture in accordance with these clinical guidelines, the victim must be evacuated to a higher-level medical organization within no more than 24 hours from the moment of admission.

To transfer a patient to a higher-level medical organization from hospitals, the minimum scope of examination must be performed:

- complete blood count,

- blood glucose level test,

- electrocardiogram recording,

- plain radiography of the pelvis and chest organs.

7. Additional Information

The outcome of the disease is influenced by the timing of surgical treatment, the correct choice of implant type and fixation method, and the postoperative limb loading regimen appropriate to the age, physical condition, and activity of each individual patient.

The following factors influencing the disease outcome should be distinguished:

1. Surgical treatment within the first 48 hours significantly reduces mortality during the first twelve months after injury.

2. In a group of functionally active patients over 60 years of age with an active lifestyle prior to injury, total hip arthroplasty is accompanied by better functional results and lower pain intensity.

3. In patients over 70 years of age with femoral neck fractures who have a low level of motor activity, cognitive dysfunction, and severe somatic pathology, hemiarthroplasty is characterized by a shorter operation duration, lower intraoperative blood loss, and a lower risk of endoprosthesis dislocation.

4. Osteosynthesis of extracapsular proximal femur fractures using proximal femoral nails with dynamic fixation in patients over 60 years of age is accompanied by better functional results, a shorter period of functional recovery, and weight-bearing capacity of the injured limb.

5. Osteosynthesis of unstable intertrochanteric fractures using proximal femoral nails with static fixation in patients under 60 years of age is accompanied by a reduction in femoral neck length loss and, consequently, a better functional result.

6. Osteosynthesis of subtrochanteric and intertrochanteric fractures using proximal femoral nails with dynamic distal locking is accompanied by a low risk of nonunions and nail breakage at the level of the distal locking hole.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

Head:

Dubrov V.E., MD, Professor. Faculty of Fundamental Medicine, Lomonosov Moscow State University, Moscow, member of ATOR

Executive Editor:

Shelupaev A.A. Research Institute for Healthcare Organization and Medical Management of the Moscow City Health Department, Moscow, member of ATOR

Expert Developers:

Arutyunov G.P., MD, Professor, Corresponding Member of the RAS. Pirogov Russian National Research Medical University, Department of Propaedeutics of Internal Diseases and Radiology, Moscow, member of RMNOT

Belov M.V., PhD, Yaroslavl Clinical Hospital of Emergency Medical Care named after N.V. Solovyov, member of ATOR

Bogopolskaya A.S., Vreden National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Saint Petersburg, member of ATOR

Bozhkova S.A., MD, Vreden National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Saint Petersburg, member of ATOR

Boyarkov A.V., Pirogov Russian National Research Medical University, Faculty of Continuing Medical Education, Department of Anesthesiology and Intensive Care, Moscow, member of FAR

Vorontsova T.N., MD, Vreden National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Saint Petersburg, member of ATOR

Gilfanov S.I., MD, Professor. Central State Medical Academy of the Presidential Administration of the Russian Federation, Moscow, member of ATOR

Gubin A.V., MD, Professor. Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow, member of ATOR

Zagorodny N.V., MD, Professor, Corresponding Member of the RAS. Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow, member of ATOR

Zlobina Yu.S., PhD, Research Institute for Healthcare Organization and Medical Management of the Moscow City Health Department, Moscow, member of ATOR

Kokorev A.I., PhD, Priorov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow, member of ATOR

Koryachkin V.A., MD, Professor. Vreden National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Saint Petersburg, member of ATOR

Kostyuk G.P., MD, Professor. Faculty of Continuing Medical Education, Pirogov Russian National Research Medical University, Department of Psychiatry, Moscow, member of RPS

Lazarev A.F., MD, Priorov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow, member of ATOR

Litvina E.A., MD, Professor, Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Moscow, member of ATOR

Nazarenko A.G., MD, Director of the Priorov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow, member of ATOR, Corresponding Member of the RAS

Ochurenko A.A., MD, Professor, Priorov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow, member of ATOR

Protsenko D.N., PhD, Pirogov Russian National Research Medical University, Faculty of Continuing Medical Education, Department of Anesthesiology and Intensive Care, Moscow, member of FAR

Runikhina N.K., MD, Professor. Pirogov Russian National Research Medical University, Russian Gerontological Research and Clinical Center, Moscow, member of RAGS

Stafeev D.V., Cand. of Sci. (Med.), Vreden National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, St. Petersburg, member of ATOR

Tikhilov R.M., Dr. of Sci. (Med.), Professor. Vreden National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, St. Petersburg, member of ATOR

Tkacheva O.N., Dr. of Sci. (Med.), Professor. Pirogov Russian National Research Medical University, Russian Gerontological Clinical and Research Center, Moscow, member of RAGG

Tsykunov M.B., Dr. of Sci. (Med.), Professor. Pirogov Russian National Research Medical University, Faculty of Additional Professional Education, Department of Medical Rehabilitation, Moscow, member of SRR

Shubnyakov I.I., Cand. of Sci. (Med.), Vreden National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, St. Petersburg, member of ATOR

Kenis Vladimir Markovich, Dr. of Sci. (Med.), Professor, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg

Bortulev Pavel Igorevich, Cand. of Sci. (Med.), Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg

Volkova Olga Anatolyevna, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg

Reviewers:

Prokhorenko V.M., Dr. of Sci. (Med.), Professor. Tsivyan Novosibirsk Research Institute of Traumatology and Orthopedics of the Russian Ministry of Health, Novosibirsk State Medical University, Department of Traumatology, Orthopedics and Military Field Surgery, Novosibirsk, member of ATOR

Davydov S.O., Dr. of Sci. (Med.), Professor. Chita State Medical Academy, Department of Traumatology and Orthopedics, Chita, member of ATOR

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

1. Trauma and orthopedic surgeons;

2. Anesthesiologists-intensivists;

3. General practitioners;

4. Geriatricians;

5. Physical and rehabilitation medicine physicians;

6. Healthcare organization and public health specialists.

Systematic literature search and selection of clinical studies:

The evidence base for the guidelines consists of publications included in the MEDLINE, PUBMED, and COCHRANE databases.

Stages of assessing the levels of evidence and grades of recommendation

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

The following sources were used in developing the clinical guidelines:

1. Clinical studies included in the MEDLINE, PUBMED, and COCHRANE databases.

2. Materials from national guidelines, European and global clinical guidelines for the management of proximal femur fractures: American Academy of Orthopaedic Surgeons (AAOS) [32], National Institute of Health and Care Excellence (NICE) [139], Scottish Intercollegiate Guidelines Network (SIGN) [175], National Clinical Guideline Centre (NCGC) [137, 138], Agency for Healthcare Research and Quality (AHRQ) [29], Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group [36].

3. Results of studies by leading global organizations: Anaesthesia Trauma and Critical Care; American Society of Anesthesiologists; American Society of Regional Anesthesia; International Association for Trauma Surgery and Intensive Care Association of Anaesthetists of Great Britain and Ireland; Australian Society of Anaesthetists; European Society of Anaesthesiology, American College of Surgeons Committee on Trauma.

4. Russian national clinical guidelines and standards for the prevention of venous thromboembolic events: "Clinical Guidelines (Treatment Protocols) for the Prevention of Thromboembolic Syndromes". Healthcare Standardization Problems (2015); Russian clinical guidelines "Prevention of Venous Thromboembolic Events in Traumatology and Orthopedics" (2012), Clinical guidelines "Perioperative Management of Patients Receiving Long-Term Antithrombotic Therapy. Regional Anesthesia and Acute Pain Management" (2014).

Determination of LE (Levels of Evidence) and GR (Grades of Recommendation) based on the results of systematic search and selection of publications on CS (clinical studies).

Table E1. Scale for assessing the level of evidence (LE) for diagnostic interventions

Table E2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table E3. Scale for assessing the grades of recommendation (GR) for prevention, diagnosis, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Cost-utility analysis was not performed. Pharmacoeconomic publications were not analyzed.

Method of recommendation validation:

• External peer review;

• Internal expert review.

Description of the recommendation validation method

These guidelines were developed in accordance with the National Standard of the Russian Federation GOST R 56034-2014, Methodological Guidelines for the Development and Updating of Clinical Guidelines of the Center for Healthcare Quality Assessment and Control of the Russian Ministry of Health. In their preliminary version, the guidelines were reviewed by independent experts who evaluated how accessible the interpretation of the presented evidence underlying the recommendations is for understanding. Comments were received from practicing trauma and orthopedic surgeons, anesthesiologists-resuscitators, and clinical pharmacologists regarding the clarity of the presentation of the guidelines and their importance.

Comments received from experts were systematized and discussed by the working group members. Each recommendation item was discussed with subsequent appropriate revisions.

Consultation and peer review

The preliminary version will be posted for broad discussion on the websites of the Association of Trauma and Orthopedic Surgeons of Russia (ATOR) (www.ator-rf.ru), the Federation of Anesthesiologists and Resuscitators of Russia (www.far.org.ru), the Russian Scientific Medical Society of Internal Medicine (www.rnmot.ru), and the Russian Association of Gerontologists and Geriatricians (www.rosagg.ru) so that individuals who did not participate in the discussion have the opportunity to express their opinions.

Appendix A3. Reference Materials

Appendix A3.1. Basic requirements for the implantation of metal constructs and arthroplasty components

A3.1.1 Cannulated screws

A3.1.2 Dynamic hip screw

Correct reduction on the orthopedic table:

➣ Closed reduction

➣ Restoration of segment length

➣ Restoration of the neck-shaft angle (NSA)

➣ Restoration of neck anteversion (10–15°)

• Control of reduction and position of the dynamic screw in two projections under fluoroscopic guidance (C-arm)

• Tip-Apex Distance (TAD)

The TAD value should be less than 25 mm (an increase in this coefficient significantly increases the rate of implant cut-out) [40]

Fig. 8 Method for calculating TAD (Tip-Apex Distance).

A3.1.3 Three parallel dynamic bone screws fixed in a plate.

Fig. Three parallel dynamic bone screws fixed in a plate.

• Control of reduction and screw position using a C-arm in two projections.

• The screws must pass within the femoral neck and parallel to its longitudinal axis.

• The threaded part of the screws must be located past the fracture line.

A3.1.4 Proximal femoral nail

The goals of the surgery are:

• Restoration of segment length.

• Restoration of the neck-shaft angle (NSA).

• Restoration of neck anteversion (10–15°).

Basic requirements for proximal femoral nail insertion:

• Point of nail insertion in the region of the greater trochanter tip.

• Control of screw position in the femoral neck and head using a C-arm in two projections.

• Tip-Apex Distance (TAD) less than 25 mm.

A3.1.5 Arthroplasty

The goals of acetabular component implantation in total hip arthroplasty are:

• preservation of the center of rotation;

• ensuring an inclination angle of the acetabular component within 25–45°;

• acetabular anteversion angle of 15±10°;

• bone coverage of at least 70% of the component surface area.

Femoral component of the endoprosthesis:

• limb length restoration;

• restoration of offset;

• neutral position in the diaphysis;

• ensuring a bone cement mantle thickness (for cemented fixation) of approximately 2 mm.

Appendix A3.2. Main therapeutic exercise routines during the early postoperative rehabilitation phase

Exercise 1. Starting position (hereinafter — S. P.): lying on the back, arms in front of the chest. Moving arms apart — inhalation, bringing them together — exhalation (3–4 times).

Exercise 2. S. P. — lying on the back, arms along the body. Alternate knee flexion with feet resting on the bed surface (4–6 times).

Exercise 3. S. P. — lying on the back, arms along the body. Resting on the semi-flexed healthy leg and partially, for stability, on the affected leg, lift the pelvis and return to S. P. (2–3 times).

Exercise 4. S. P. — lying on the back, hands on hips. Alternate raising of straight legs (raising the injured lower limb is performed with support from the exercise therapist) (2–3 times).

Exercise 5. S. P. — sitting, hands on shoulders forward. Spreading shoulders (bringing shoulder blades together) — inhalation, returning to S. P. — exhalation (3–4 times).

Exercise 6. S. P. — sitting, legs dangling over the edge of the bed. Flexion and extension of the affected leg at the knee joint with the support and assistance of the healthy leg (4–5 times).

Exercise 7. S. P. — sitting, hands on hips. Alternate turns of the torso to the left and right with arms spread to the sides (3 times in each direction).

Exercise 8. S. P. — lying on the side, the affected leg resting on the healthy one. Flexion of the affected leg at the knee joint using the healthy one (4–5 times). Subsequently, a similar exercise can be performed in the S. P. lying on the abdomen.

Exercise 9. S. P. — lying on the side, the healthy leg semi-flexed. Attempt to lift the affected leg (2–3 times).

Exercise 10. S. P. — lying on the abdomen, resting on elbows on the couch. Alternate raising of straight legs with the assistance of a physical therapy instructor (3 times for each leg).

Exercise 11. S. P. — sitting, hands clasped behind the head. Stretching arms upward — inhalation, returning to S. P. — exhalation (3–4 times).

Appendix A3.3. ESA recommendations on time intervals between the administration of antithrombotic agents and neuraxial blockade or catheter removal in adult patients [81]

Appendix B. Physician Action Algorithms

Appendix B1. Algorithm for managing a patient with a proximal femur fracture

Appendix B2. Algorithm for selecting treatment tactics for patients with femoral head fractures

Appendix B3. Algorithm for selecting treatment tactics for femoral neck fractures

Appendix B4. Algorithm for selecting treatment tactics for patients with trochanteric fractures

Appendix C. Patient Information

Proximal femur fractures (PFF) are in most cases associated with osteoporosis and occur as a result of so-called 'low-energy trauma', e.g., a fall from standing height.

In conservative treatment of patients over 60 years old who have sustained a PFF, mortality is extremely high, exceeding 70% in the first year after injury, while mortality within the first six months after injury reaches 62%.

Surgical treatment can reduce the mortality of patients with femoral neck and trochanteric fractures severalfold; therefore, all patients with proximal femur fractures must be hospitalized. Osteosynthesis or arthroplasty surgery (the indications for which are determined by an orthopedic traumatologist) should be performed within the first 48 hours after injury.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Lequesne's functional index for assessing activity dynamics in daily living

Russian name: Lequesne's functional index for assessing activity dynamics in daily living.

Original name: (Lequesne's functional index).

Source: Lequesne M. Indices of severity and disease activity for osteoarthritis. Semin Arthritis Rheum. 1991 Jun;20 (6 Suppl 2):48-54.

Type: scale.

Purpose: assessment of patients' activity dynamics in daily living.

Content (template):

Table 1. PAIN OR DISCOMFORT

Table 2. MAXIMUM WALKING DISTANCE

Table 3. DAILY ACTIVITIES

Scoring (interpretation): the severity index of the condition is determined by the sum of points across all features.

• minimum score for each subscale is 0

• maximum score for each subscale is 0

• minimum total index is 0 points

• maximum total index is 24 points

Table 4. Degree of functional limitation

Appendix G2. American Society of Anesthesiologists physical status classification system

ASA (American Society of Anaesthesiologists)

Russian name: American Society of Anesthesiologists Physical Status Classification System.

Original name: ASA Physical Status Classification System.

Source: Doyle DJ, Garmon EH. American Society of Anesthesiologists Classification (ASA Class) StatPearls Publishing; May 13, 2019.

Type: scale.

Purpose: assessment of the patient's physical status prior to surgery.

Content (template): to determine the patient's status, the anesthesiologist-resuscitologist uses the following patient data: complaints, medical history, physical examination data, laboratory and diagnostic test results, instrumental examination results.

Scoring (interpretation): depending on the data obtained from the medical history and patient examination, the patient is assigned to one of the following groups:

I – a normal healthy patient (nonsmoker, no regular alcohol use).

II – a patient with mild to moderate systemic disease (smoker, alcoholic, pregnant, obesity with a body mass index of 30 to 40, arterial hypertension, compensated diabetes mellitus, mild pulmonary disease).

III – a patient with severe systemic disease that limits activity. One or more moderate-to-severe conditions (decompensated or uncontrolled diabetes mellitus, end-stage chronic kidney disease with regular hemodialysis, implanted pacemaker***, myocardial infarction > 3 months ago, chronic obstructive pulmonary disease, uncompensated arterial hypertension, obesity with body mass index >40).

IV – a patient with severe disease that is a constant threat to life (stroke and myocardial infarction < 3 months ago, severe valvular heart disease, sepsis, disseminated intravascular coagulation syndrome, severe left ventricular ejection fraction reduction, end-stage chronic kidney disease with irregular hemodialysis).

V – a moribund patient who is not expected to survive without surgery (ruptured aortic aneurysm, intracranial hemorrhage with mass effect, massive trauma, multiorgan failure, bowel ischemia combined with severe cardiac pathology).

VI – a declared brain-dead patient whose organs are being removed for donor transplantation.

E – Emergency intervention.

Appendix G3. Caprini Risk Assessment Scale for Venous Thromboembolism (Caprini J.)

Russian name: Caprini risk assessment scale for venous thromboembolism .

Original name: Caprini Score for Venous Thromboembolism.

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini scale as a tool for individual stratification of the risk of postoperative venous thromboembolism in a high-risk group. Khirurgiya. Zhurnal im. N.I. Pirogova. 2014; (12):16-23.

Type: scale.

Purpose: assessment of the risk of venous thromboembolism.

Content (template):

1 point

Age 41–60 years

Lower extremity edema

Varicose veins

Body mass index > 25 kg/m²

Minor surgery

Sepsis (< 1 month)

Severe pulmonary disease (including pneumonia < 1 month)

Use of systemic hormonal contraceptives, hormone replacement therapy

Pregnancy and postpartum period (< 1 month)

History of: unexplained stillbirths, spontaneous abortions (≥3), premature delivery with gestosis, or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (< 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

History of major surgery (< 1 month)

Chronic obstructive pulmonary disease

2 points

Age 61–74 years

Arthroscopic surgery

Malignant neoplasm

Laparoscopic procedure (duration >45 min.)

Bed rest > 72 h

Limb immobilization (< 1 month)

Central venous catheterization

Major surgery (duration >45 min.)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (within 1 month).

Scoring (Interpretation): Based on the total score obtained from the medical history and patient examination, the patient is assigned to a risk category: low risk: 0–1 point; moderate risk: 2 points; high risk: 3–4 points; very high risk: 5 points or more.

Appendix G4. Numerical rating scale

Russian name: Numerical Rating Scale (NRS).

Original name: Numerical Rating Scale (NRS).

Source: Karcioglu O, Topacoglu H, Dikme O, A systematic review of the pain scales in adults: Which to use? American Journal of Emergency Medicine 36(4) January 2018.

Type: scale.

Purpose: assessment of pain intensity experienced by the patient.

Content (template):

The NRS is a continuous scale presented as a horizontal or vertical line 10 cm (100 mm) in length with two end points: "no pain" and "worst pain imaginable." The patient is asked to make a mark on this line corresponding to the intensity of pain they are currently experiencing.

Numeric Rating Scale (NRS) type:        

The distance from the start of the line ("no pain") to the patient's mark is measured in centimeters and rounded to the nearest whole number. Each centimeter (10 mm) on the scale corresponds to 1 point.

Scoring (Interpretation): no pain – 0 points (0–4 mm), mild pain – 1–4 points (5–44 mm), moderate pain – 5–7 points (45–74 mm), severe pain – more than 7 points (75–100 mm).

Appendix G5. Verbal rating scale

Russian name: Verbal Rating Scale (VRS).

Original name: Verbal Rating Scale (VRS).

Source: Atisook R, Euasobhon P, Saengsanon A, Jensen MP, Validity and Utility of Four Pain Intensity Measures for Use in International Research. J Pain Res. 2021; 14: 1129–1139.

Type: scale.

Purpose: assessment of pain intensity experienced by the patient.

Content (Template): when assessing pain using the VRS, the patient is presented with pain descriptors reflecting increasing severity. The following set of descriptors is used: no pain, mild pain, moderate pain, severe pain, very severe pain, excruciating (unbearable) pain. The patient chooses the word that most accurately matches their sensations.

Scoring (Interpretation): no pain (0), mild pain (1), moderate pain (2), severe pain (3), very severe pain (4), and excruciating (unbearable) pain (5).

Appendix G6. Timed Up and Go test

Russian name: «Timed Up and Go» test.

Original name: Timed Up and Go Test.

Source: Podsiadlo, D; Richardson, S (1991). "The timed 'Up & Go': A test of basic functional mobility for frail elderly persons". Journal of the American Geriatrics Society. 39 (2): 142–8.

Type: scale.

Purpose: measurement of functional mobility limitations in daily life among adult patients

Content (Template): required equipment for the test: arm chair, tape measure, colored tape or marker, stopwatch. The patient should be instructed before performing the timed test. They may perform a first practice trial without timing.

- The patient should sit in the chair with their back resting against the backrest and thighs fully supported by the seat. The chair should be stable. The patient is allowed to use the armrests while sitting and standing up.

- Measure a distance of 3 meters from the chair and mark it with a marker or colored tape so that the mark is visible to the patient.

- Patient instructions: When I say "Go", you must stand up, walk the marked distance, turn around, walk back to the chair, and sit down. Walk at your normal comfortable pace.

- Start timing after saying the word "Go" and stop timing when the patient sits back down correctly in the chair with their back resting against the backrest.

- During the test, the patient should wear their usual footwear and may use assistive devices they normally rely on (e.g., cane or walker). If necessary, the patient may stop to rest during the test.

Key (interpretation):

Appendix G7. Neonatal Infant Pain Scale (NIPS)

Russian name: NEONATAL INFANT PAIN SCALE (NIPS).

Original name: Neonatal Infant Pain Scale (NIPS).

Source: Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993 Sep;12(6):59-66. PMID: 8413140.

Type: scale.

Purpose: assessment of pain intensity experienced by the patient.

Content (template):

Scores across 6 indicators are summed up.

Scoring (Interpretation): no pain – 0 points, moderate pain – 3–5 points, severe pain – more than 5 points.

Low scores may be observed in critically ill children receiving pharmacological sedation.

Appendix G8. FLACC Behavioral Scale (Face, Legs, Activity, Cry, Consolability)

Russian name: FLACC behavioral scale.

Original name: Clinical validation of FLACC (face, legs, activity, cry, consolability).

Source: Manworren R.C.B., Hynan L.S. Clinical validation of FLACC: preverbal patient pain scale//Pediatric nursing. - 2003. - Vol. 29. - N. 2. - P. 140-146.

Type: scale.

Indication: used in children aged 2 months to 3 years and in patients unable to report pain.

Content (template): the scale takes into account facial expression, leg movements, type of cry, how easily the child is consoled, and behavioral characteristics. The total FLACC score is the sum of points across all description items.

Key (interpretation): minimum score is 0, maximum is 10 points.

Total score across five categories: 0 points — calm, 1–3 — mild discomfort, 4–6 — mild pain, 7–10 — severe pain.

Notes: the higher the score, the more severe the pain and the worse the child feels.

Appendix G9. Wong-Baker FACES Pain Rating Scale

Russian name: Wong-Baker FACES Pain Rating Scale.

Original name: Wong–Baker Faces Pain Rating Scale.

Source: https://wongbakerfaces.org/ , Garra G. et al. The Wong-Baker pain FACES scale measures pain, not fear // Pediatric emergency care. – 2013. – Vol. 29. – No. 1. – P. 17-20.

Type: scale.

Indication: used in children over 3 years of age to assess the intensity of experienced pain.

Content (template): the grimace scale consists of 6 faces, ranging from smiling (no pain) to crying (excruciating pain). The child is asked: "show how much it hurts right now."

Key (interpretation): no pain — 0, little pain — 2, mild pain — 4, tolerable pain — 6, severe pain — 8, excruciating pain — 10.

Notes: sometimes, when using this scale, the child may express their emotions rather than pain.

Appendix G10. Hand scale

Russian name: Hand scale.

Original name: Hand scale.

Source: Algorithms for Pain Assessment and Management in Children. — M.: Prospect Publishing House, 2020. — 64 p., Pain Relief in Adults and Children During Medical Care // Abuzarova G.R., Nevzorova D.V., Kumirova E.V. et al. // FGBOU VO Pirogov Russian National Research Medical University of the Russian Ministry of Health, Moscow, 2016, 94 p.

Type: scale.

Indication: Used in children over 3 years of age to assess the intensity of experienced pain.

Content (template): Shows pain fluctuations from none (clenched fist) to very severe pain (fully opened hand).

Key (interpretation): no pain — 0, little pain — 1, mild pain — 2, tolerable pain — 3, severe pain — 4, excruciating pain — 5.

Appendix. Visual Analog Scale (VAS) for pain in children over 7 years of age

Russian name: Visual Analogue Scale (VAS) of pain.

Original name: Visual analogue scale.

Source: Algorithms for Pain Assessment and Management in Children. — M.: Prospect Publishing House, 2020. — 64 p.

Pain Relief in Adults and Children During Medical Care // Abuzarova G.R., Nevzorova D.V., Kumirova E.V. et al. // Pirogov Russian National Research Medical University of the Russian Ministry of Health, Moscow, 2016, 94 p.

Type: scale.

Indication: Used in children over 7 years of age to assess the intensity of experienced pain.

Content (template): VERTICALLY positioned quantitative pain rating scale. Ask the child to place their fingers at the height on the scale that they associate with their pain sensations.

Key (interpretation): The top of the scale means "very, very severe pain", the base means "no pain at all".