Clopidogrel and Hip Fractures, Is It Safe?

A Systematic Review and Meta-Analysis

Christopher G. K. M. Soo; Paul K. Della Torre; Tristan J. Yolland; Michael A. Shatwell

Disclosures

BMC Musculoskelet Disord. 2016;17(136) 

In This Article

Methods

Search Strategy

A comprehensive search was performed using the following databases: The Cochrane Library (Wiley, to February 2015), MEDLINE (Ovid, 1946 to February 2015) and EMBASE (Ovid, 1974 to February 2015), and Google scholar (to February 2015). The following keywords were used: Anticoagulant", "Plavix", "Clopidogrel", "Thienopyridine", "Antiplatelet therapy", "Hip fractures", "Femoral neck fractures", "Neck of femur fractures", "Orthopaedic surgery", "Surgery", "Bleeding", "Blood loss" (Additional file 1 https://static-content.springer.com/esm/art%3A10.1186%2Fs12891-016-0988-9/MediaObjects/12891_2016_988_MOESM1_ESM.docx). Additionally all references of the retrieved articles were also checked for additional relevant studies. Studies selected were original clinical studies that addressed the use of clopidogrel in patients undergoing surgery for neck of femur fractures. All comparative studies with a treatment group and a control group were considered. Data limits were set from all journals up to February 2015. Exclusion criteria were: (1) studies comparing non-clopidogrel anticoagulant medication, (2) studies without neck of femur patients, and (3) studies other than clinical studies such as reviews, letters, editorials and expert opinions.

Data Extraction

Data were extracted by one of the investigators (first author) and checked by a second investigator (second author). The authors were not blind to authorship, journal of publication, or results of the trials. Extracted data included assessment of study quality, study design, number of patients, patient characteristics (age, gender, fracture), surgical treatment, number of days free of clopidogrel, and perioperative use of other anticoagulants, and follow-up. Outcome measures were divided into primary and secondary. Primary outcome measures included (1) allogeneic and autologous blood transfusion exposures or average number of units transfused per patient and (2) a postoperative haemoglobin concentration or a drop in haemoglobin concentration. Secondary outcome measures were recorded from the included studies if available: average time to surgery, length of stay in hospital and postoperative complications (including haematoma, cardiovascular, cerebrovascular, thromboembolic events, death).

Quality Appraisal

The quality of the studies was appraised based on a select number of well described quality appraisal methods.[42–44] These were: (1) study design- whether the study met the requirements of our research question, for example a comparative study with clopidogrel patient groups and non clopidogrel patient groups; (2) prospective or retrospective study; (3) study population clearly specified and defined; (4) homogeneity concerning patient population- for example patients on clopidogrel only or patients who are also on aspirin; (5) transparency of outcome measures and assessment; (6) transparency of missing data; (7) appropriate data management and statistics in relation to our research question; (8) confounding variables assessed, measured and commented on- for example the concurrent use of aspirin. The same investigators scored the items and assessed bias, and any disagreements were resolved by consensus.

Meta-analysis

This was done using the fixed effects model. Heterogeneity of the intervention effect was assessed with the I 2 statistic. Data analysis was performed using Review Manager 5.1 (The Cochrane Collaboration, 2011).

This systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) standards (Additional file 2 https://static-content.springer.com/esm/art%3A10.1186%2Fs12891-016-0988-9/MediaObjects/12891_2016_988_MOESM2_ESM.docx).

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