title: Clopidogrel dilemma for orthopaedic surgeons.
abstract: BACKGROUND
  Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates.
  
  
  METHODS
  This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis.
  
  
  RESULTS
  Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism.
  
  
  CONCLUSIONS
  The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.
authors.affiliation: Wollongong Hospital, 4 Mansion Pt Road, Grays Point, Sydney, NSW 2232, Australia. mitchelljsteele@gmail.com
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Steele
authors.forename: John S
authors.initials: JS
authors.lastname: Fox
authors.forename: John P
authors.initials: JP
authors.lastname: Fletcher
authors.forename: Leeanne E
authors.initials: LE
authors.lastname: Grigg
authors.forename: Gordon
authors.initials: G
authors.lastname: Bell
mesh_terms: D001291:Attitude of Health Personnel; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D000077144:Clopidogrel; D003657:Decision Making; D004305:Dose-Response Relationship, Drug; D054855:Drug-Eluting Stents; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D019637:Orthopedic Procedures; D019990:Perioperative Care / Q000592:standards / Q000639:trends; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000139:chemically induced* / Q000453:epidemiology / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D013927:Thrombosis / Q000139:chemically induced* / Q000453:epidemiology / Q000517:prevention & control; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine