Displaced Femoral Neck Fracture in an Elderly Patient on Apixaban
An 84-year-old woman is admitted at 22:00 after a mechanical fall at home. She has a displaced femoral neck fracture (Garden III) and is otherwise hemodynamically stable. Her history includes atrial fibrillation, hypertension, and mild cognitive impairment. She takes apixaban 5 mg twice daily; the last dose was at 08:00, 14 hours ago. Creatinine clearance is 41 mL/min, hemoglobin 10.4 g/dL, platelets 190 × 10⁹/L, and INR 1.1. The on-call anesthesiologist is reluctant to proceed because of the anticoagulant, and the ward has no anti-Xa assay available overnight. The theater list is full tomorrow with two emergency laparotomies, but a slot could be created at 08:00. The patient is in traction with good analgesia and has no other injuries. The family asks why surgery cannot happen tonight.
1. How should the timing of surgery be decided, and what does the evidence say about waiting for the anticoagulant to clear?
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Frame the problem as competing risks. Hip fracture surgery delayed beyond 24–48 hours is associated with higher 30-day mortality, more pressure injuries, delirium, and pneumonia; the mortality signal is strongest in fitter patients. Apixaban is not an absolute contraindication to surgery. The key question is not whether the INR is normal - it will be - but what residual anticoagulant effect remains.
With apixaban 5 mg twice daily and a creatinine clearance of 41 mL/min, the last dose was 14 hours ago. Elimination half-life is roughly 12 hours with normal renal function and longer with renal impairment, so at 14 hours there is meaningful residual drug. Neuraxial anesthesia guidelines suggest waiting 48 hours after the last dose with normal renal function and longer, often 72 hours, with significant renal impairment; a spinal at 08:00, 24 hours after the last dose, would still be outside those windows.
The practical answer is therefore: do not delay for reversal, but do not use a neuraxial technique. Book the 08:00 slot with general anesthesia, accept the small bleeding risk, and use tranexamic acid and meticulous hemostasis. Andexanet alfa is not routinely indicated for a stable patient with a survivable fracture and is often unavailable. An anti-Xa level, if it were available, would refine but not determine the decision.
2. Which operation would you offer, and why?
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For an 84-year-old with mild cognitive impairment and a Garden III femoral neck fracture, cemented hemiarthroplasty is the default. Total hip arthroplasty gives better function in independent, cognitively intact patients with a longer life expectancy, but it carries a higher dislocation rate, and cognitive impairment is a recognized risk factor for dislocation and for further falls. The fracture is displaced and the patient is elderly, so internal fixation has an unacceptably high reoperation rate.
Use a cemented stem. Cemented fixation reduces the risk of periprosthetic fracture and gives better early pain relief than an uncemented stem in this age group, at the cost of a small risk of bone cement implantation syndrome; anesthesia should be warned. A lateral or posterior approach is acceptable; if posterior, repair the capsule and short external rotators. Give perioperative antibiotics and tranexamic acid, and mobilize with physical therapy on day 1.
Restart apixaban 24–48 hours postoperatively once hemostasis is secure, in consultation with the medical team, balancing stroke risk against surgical bleeding. Do not withhold thromboprophylaxis altogether simply because she is on a direct oral anticoagulant.
3. The family asks why she cannot simply be kept in traction and treated without surgery. How do you counsel them?
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Nonoperative treatment of a displaced femoral neck fracture in an 84-year-old means prolonged immobilization, and the associated risks are substantial: 1-year mortality may approach 30–40%, with high rates of pneumonia, pressure injury, venous thromboembolism, delirium, and loss of independence. Traction does not reliably control pain in a displaced intracapsular fracture and does not reduce the fracture. The window for a good outcome is short.
However, the question is legitimate - surgery is not risk-free. Frame the decision as a comparison. Operative treatment carries anesthetic and surgical risk, roughly a 5–8% major complication rate in this group, but offers the chance of standing and walking within 24–48 hours. Nonoperative treatment carries a near-certainty of complications from immobility. Discuss goals of care, frailty, and the patient's previously expressed wishes. If she had been bed-bound before the injury with severe dementia, a palliative approach would be reasonable; with mild cognitive impairment and a recent ability to walk, surgery is appropriate.
Document the discussion, including who was present and what was decided, and involve the family in the rehabilitation plan.