The 78-Year-Old with a Displaced Femoral Neck Fracture and a New Anticoagulant
A 78-year-old woman is brought to the emergency department after a mechanical fall at home. She has a displaced femoral neck fracture (Garden III). Her medical history includes atrial fibrillation on apixaban, hypertension, and stage 3b chronic kidney disease (eGFR 38 mL/min/1.73 m²). She took her last dose of apixaban 18 hours ago. Her hemoglobin is 9.8 g/dL, platelets 140,000, and INR 1.1. She is alert but frail, lives alone, and was independently ambulatory with a cane before the fall. The anesthesia team is concerned about neuraxial anesthesia given the anticoagulant, and the internist asks whether surgery should be delayed until anticoagulation reverses. The family asks why she cannot simply be treated in traction and mobilized later.
1. How would you weigh timing of surgery against bleeding risk in this patient, and what is your operative plan?
Read the worked answer
The dominant risk here is not the apixaban - it is delay. Displaced femoral neck fractures in frail elderly patients carry substantial mortality that rises with each day of delay, and early surgery (within 24–48 h when medically optimized) improves outcomes. Apixaban at 18 h with normal renal function would normally permit neuraxial anesthesia after ~48–72 h, but the eGFR of 38 prolongs elimination. The practical path is to proceed with general anesthesia rather than wait for neuraxial eligibility, since general anesthesia removes the neuraxial hematoma concern entirely. For the fracture itself, a displaced Garden III femoral neck fracture in a 78-year-old with low demand but independent pre-injury ambulation is best treated with arthroplasty, not internal fixation - fixation has a high reoperation and nonunion/avascular necrosis rate in this age group. Given her age and activity level, a hemiarthroplasty (or total hip arthroplasty if she were higher demand and cognitively intact) is appropriate. I would not delay for reversal; there is no effective rapid reversal agent for apixaban, and the bleeding risk of arthroplasty in a therapeutically anticoagulated patient is manageable with careful hemostasis, tranexamic acid (renal dosing considered), and blood product availability. Traction and delayed mobilization is not a treatment - it converts an operative problem into a pressure-ulcer, pneumonia, and thromboembolism problem.
2. The family asks about reversing the apixaban with andexanet alfa before surgery. How do you counsel them, and what does the evidence and resource context suggest?
Read the worked answer
Andexanet alfa is a recombinant factor Xa decoy indicated for reversal of apixaban/rivaroxaban in life-threatening bleeding, not routinely for elective or semi-urgent surgery. Its use here would be off-label, expensive, and carries thrombotic risk - particularly problematic in a patient with atrial fibrillation who needs ongoing anticoagulation. For a semi-urgent hip fracture, the better strategy is timing and anesthetic choice: proceed under general anesthesia with attention to hemostasis, and accept a modestly increased transfusion risk rather than expose her to a prothrombotic reversal agent. If bleeding proves problematic intraoperatively, prothrombin complex concentrate (4-factor PCC) is a more available and cheaper off-label option than andexanet, though evidence for efficacy against direct factor Xa inhibitors is limited. I would counsel the family that the risk of waiting (mortality, complications of immobility) exceeds the risk of operating on residual anticoagulation, and that reversal agents are reserved for catastrophic bleeding. This is a judgement call the oral examiners probe: the correct answer is not 'reverse and wait,' it is 'recognize that delay is the greater harm and choose an anesthetic that sidesteps the neuraxial issue.'