title: Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis.
abstract: BACKGROUND
  Femoral neck fractures in the elderly make up a large proportion of Orthopaedic surgical admissions each year. Operating on patients with clopidogrel poses a challenge because of the risk of bleeding and the difficulty deciding the optimal timing of surgery. The aim of this systematic review is to examine the published evidence to establish a set of guidelines for approaching neck of femur patients who are on clopidogrel.
  
  
  METHODS
  All comparative studies with an intervention group and a control group were considered. Data on patient blood transfusion exposures, units transfused, haemoglobin concentration and drop in haemoglobin were extracted and pooled using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I (2) statistic.
  
  
  RESULTS
  A total of 4219 studies were identified. After removal of duplicates and after exclusion criteria were applied, there were 14 studies to be included. All 14 were case series with controls. There was no significant heterogeneity amongst the studies. Pooled odds ratio for transfusion exposures was 1.24 (95 % confidence interval 0.91 to 1.71) however this was not statistically significant (p = 0.14). No significant mean differences were found for other primary outcome measures.
  
  
  CONCLUSIONS
  On the available evidence, we recommend that these patients can be managed by normal protocols with early surgery. Operating early on patients on clopidogrel is safe and does not appear to confer any clinically significant bleeding risk. As reported in other studies, we believe clopidogrel, if possible, should not be withheld throughout the perioperative period due to increased risk of cardiovascular events associated with stopping clopidogrel. Care should be taken intraoperatively to minimise blood loss due to the increased potential for bleeding.
  
  
  BACKGROUND
  This systematic review and meta-analysis has been registered on Research Registry on July 16, 2015. The Review Registry Unique Identifying Number is: reviewregistry61 .
authors.affiliation: Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia. gavin.soo@gmail.com.
authors.forename: Christopher G K M
authors.initials: CG
authors.lastname: Soo
authors.affiliation: Orthopaedic surgery department, Concord Repatriation General Hospital, Hospital Rd, Concord, NSW, 2139, Australia.
authors.forename: Paul K
authors.initials: PK
authors.lastname: Della Torre
authors.affiliation: Orthopaedic surgery department, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW, 2305, Australia.
authors.forename: Tristan J
authors.initials: TJ
authors.lastname: Yolland
authors.affiliation: Orthopaedic surgery department, Port Macquarie Base Hospital, Wrights Rd, Port Macquarie, NSW, 2444, Australia.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Shatwell
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control; D016009:Chi-Square Distribution; D000077144:Clopidogrel; D004334:Drug Administration Schedule; D005265:Femoral Neck Fractures / Q000601:surgery*; D005592:Fracture Fixation / Q000009:adverse effects*; D006801:Humans; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D018570:Risk Assessment; D012307:Risk Factors; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine
keywords: Anticoagulant; Clopidogrel; Hip fracture; Orthopaedics; Surgical blood loss