Evaluation of International Normalized Ratio Thresholds for Complications in Hip Fractures Treated With Intramedullary Nailing: Analysis of 15,323 Cases
Bibliographic record
Abstract
INTRODUCTION: In hip fracture patients with elevated international normalized ratios (INRs), the risks of delaying surgery for correction of INR are controversial. We examined the association of (1) preoperative INR values and (2) surgical delay with postoperative complications after intramedullary nailing of hip fractures. METHODS: Using the National Surgical Quality Improvement Program database, we retrospectively identified patients that underwent intramedullary nailing for hip fractures from 2005 to 2016. Patients aged older than 55 years with preoperative INR recorded ≤1 day before surgery were included. Patients were stratified into five cohorts-(1) INR ≤ 1.0, (2) 1 < INR ≤ 1.25 (INR [1 to 1.25]), (3) 1.25 < INR ≤ 1.5 (INR [1.25 to 1.5]), (4) 1.5 < INR ≤ 2.0 (INR [1.5 to 2.0]), and (5) INR > 2.0. The primary outcomes of interest were postoperative bleeding requiring transfusion, surgical site infection, and 30-day mortality. Multivariate regression analysis was done to adjust for potential confounding variables. RESULTS: In total, 15,323 patients were included in this analysis. Adjusting for potential confounders, INR [1 to 1.25], INR [1.25 to 1.5], and INR [1.5 to 2.0] were associated with increased mortality (adjusted odds ratio [aOR]: 1.501, P < 0.001; aOR: 2.226, P < 0.001; aOR: 2.524, P < 0.001, respectively) and surgical delay >48 hours (aOR: 1.655, P < 0.001; aOR: 3.434, P < 0.001; aOR: 2.382, P < 0.001, respectively). The INR > 2.0 cohort was not associated with mortality (P = 0.181) or surgical delay (P = 0.529). Surgical delay was associated with mortality (aOR: 1.531, P = 0.004). The INR > 2.0 cohort was associated with increased rate of transfusions (aOR: 1.388, P = 0.039). CONCLUSION: Elevated preoperative INR value within 1 day of surgery between 1.0 and 2.0 was associated with increased risk of 30-day mortality and surgical delay >48 hour, which may represent attempts at INR correction. An INR greater than 2.0 was not associated with mortality or surgical delay but was associated with increased transfusions. Surgical delay was independently associated with increased risk of 30-day mortality. We therefore recommend that INR reversal be attempted but not delay surgical fixation of geriatric hip fractures over 48 hours and counsel patients and their families regarding the risks of surgery with elevated INR. LEVEL OF EVIDENCE: Prognostic-level III/retrospective cohort study.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".