Displaced Femoral Neck Fracture in a Patient on Apixaban
A 78-year-old woman (62 kg, eGFR 48 mL/min/1.73 m²) is brought to the emergency department after a mechanical fall at home. She takes apixaban 5 mg twice daily for atrial fibrillation, bisoprolol and atorvastatin. Her last apixaban dose was 18 hours ago. She is alert, orientated and independently mobile with a stick outdoors. Radiographs show a displaced intracapsular femoral neck fracture. Haemoglobin is 10.8 g/dL, platelets 180 × 10⁹/L, INR 1.1, and she is haemodynamically stable. The on-call anaesthetist is reluctant to proceed tonight because of the anticoagulant, and the ward team plans surgery in 5 days when the drug has washed out. The patient has no other injuries; pressure areas are intact and she has been catheterised. Hospital policy permits neuraxial anaesthesia only after guideline-directed apixaban interruption.
1. Critique the plan to delay surgery for 5 days and outline how you would time and prepare her operation, including any reversal strategy.
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The plan to wait 5 days is not justified. Hip fracture surgery within 48 hours of admission reduces mortality, delirium, pressure injury and pneumonia; delay should be a documented exception. Apixaban has a half-life of about 12 hours and its effect 18 hours after the last dose is still substantial, but that is not a reason to wait a week.
Options:
- Operating at 48-72 hours under general anaesthesia without reversal, with meticulous haemostasis. This aligns with ASRA guidance (neuraxial anaesthesia requires 72 hours off apixaban) if a spinal is planned, and avoids reversal-related thrombosis.
- If earlier surgery is essential or a neuraxial block is needed, measure anti-Xa activity and consider andexanet alfa (where available) or 4-factor PCC 50 U/kg. Vitamin K and fresh frozen plasma do not reverse factor Xa inhibitors.
Given that she is stable and alert, I would plan surgery at about 72 hours from the last dose under general anaesthesia, or sooner with PCC if the delay risks deterioration. Give tranexamic acid cautiously, correct anaemia, keep her warm, and document the shared decision with anaesthesia and the family.
2. Discuss the choice between hemiarthroplasty and total hip arthroplasty, and the method of fixation, for this patient.
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Total hip arthroplasty is preferred for patients who were independently mobile outdoors, cognitively intact, medically fit (ASA I-II) and expected to survive more than 4-5 years, because it gives better function and lower reoperation for acetabular erosion. Hemiarthroplasty is preferred for lower-demand, frail patients with cognitive impairment or limited life expectancy.
This patient is 78, walks with a stick but is independent, alert, and ASA III because of atrial fibrillation and CKD stage 3b. Given the comorbidity and the small but real risk of dislocation and revision with total hip arthroplasty, a cemented hemiarthroplasty is the safer default. A total hip arthroplasty with a dual-mobility or large femoral head could be justified only if a geriatric assessment judged her physiologically robust.
Fixation: use a cemented stem with modern cementing technique (lavage, drying, cement restrictor, vacuum mixing), because cemented implants give less thigh pain and better early mobility than uncemented implants. The trade-off is bone cement implantation syndrome, so hydrate, monitor closely, and warn anaesthesia. A bipolar head reduces acetabular wear in longer survivors.
3. Outline the VTE prophylaxis and analgesic plan, considering her renal function, anticoagulation and the need for physiotherapy.
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VTE prophylaxis: start intermittent pneumatic compression on admission and continue until mobilisation. Pharmacological prophylaxis with enoxaparin 40 mg subcutaneously daily is appropriate at eGFR 48, started 12-24 hours after surgery once haemostasis is secure, and continued for 28-35 days after hip fracture surgery. Fondaparinux should be avoided if eGFR falls below 30.
Anticoagulation for atrial fibrillation is a separate indication. Restart apixaban once surgical haemostasis is secure, usually 24-72 hours post-operatively, after discussion with cardiology; until then prophylactic LMWH provides cover. Bridging with LMWH is not needed for a DOAC.
Analgesia: regular paracetamol; oxycodone sparingly because of delirium risk; avoid NSAIDs with CKD. A fascia iliaca compartment block is useful, can be performed while on apixaban (peripheral blocks are safer than neuraxial), reduces opioid requirements and allows earlier physiotherapy. A spinal would require 72 hours off apixaban under hospital policy, which is one reason to favour general anaesthesia plus a peripheral block.