What is the recommended orthopedic operative plan for a patient with a proximal humeral fracture taking aspirin and clopidogrel (Plavix)?

Orthopedic Operative Plan for Proximal Humeral Fracture on Aspirin and Clopidogrel

Proceed with surgery without delay while continuing aspirin throughout the perioperative period, but stop clopidogrel 5 days preoperatively only if the patient does not have a coronary stent placed within the past 6-12 months. 1

Immediate Risk Assessment Required

Before making any antiplatelet management decisions, you must determine:

• Coronary stent status: If the patient has a drug-eluting stent placed less than 6-12 months ago or bare-metal stent placed less than 4-6 weeks ago, do not stop clopidogrel under any circumstances 1, 2
• Recent acute coronary syndrome: If the patient had unstable angina or MI within the past year, continue both aspirin and clopidogrel 1
• Indication for dual antiplatelet therapy: Patients with recent stents, prior MI, or high thrombotic risk require continued dual therapy 3, 4

Operative Plan Based on Cardiac Risk

For Patients WITHOUT Recent Coronary Stents (>12 months or no stent):

• Continue aspirin at current dose (up to 300 mg/day) throughout the entire perioperative period 1, 4
• Stop clopidogrel 5 days before surgery to allow platelet function recovery 3
• Resume clopidogrel as soon as possible postoperatively, ideally with a 300 mg loading dose 1
• Proceed with surgery immediately—do not delay for antiplatelet washout, as mortality from delaying fracture surgery exceeds bleeding risk 1

For Patients WITH Recent Coronary Stents (<6-12 months for drug-eluting, <4-6 weeks for bare-metal):

• Continue BOTH aspirin and clopidogrel throughout the perioperative period 2, 1
• Accept increased transfusion risk as the alternative (stent thrombosis) carries 45% mortality 2
• Coordinate with cardiology before surgery to confirm thrombotic risk stratification 1
• Avoid neuraxial anesthesia due to epidural hematoma risk with dual antiplatelet therapy 1

Surgical Technique Considerations

• Use meticulous hemostatic technique with careful attention to bleeding control 1
• Consider tranexamic acid for blood loss reduction, though evidence is limited in this specific population 1
• Have blood products available as transfusion rates increase from 31% to 56% in patients on clopidogrel 5
• Expect mean transfusion of 1.5 units if transfusion becomes necessary 6

Critical Pitfalls to Avoid

Never stop both aspirin and clopidogrel simultaneously in patients with coronary stents—this dramatically increases fatal stent thrombosis risk, which far exceeds any surgical bleeding risk 1, 3, 4. The mortality from stent thrombosis approaches 45%, while bleeding complications are manageable 2.

Do not delay surgery waiting for clopidogrel washout—hip fracture data shows increased mortality and morbidity with surgical delay, and this principle applies to proximal humerus fractures 1, 7. The orthopedic literature demonstrates that surgery can proceed safely within 2-3 days even on clopidogrel 5, 7.

Do not substitute heparin or LMWH for antiplatelet therapy—bridging with anticoagulation does not prevent stent thrombosis and increases bleeding risk 1, 4. This is a common error that provides false reassurance while exposing patients to dual risks.

Do not assume aspirin alone is sufficient in recent stent patients—aspirin monotherapy within 6-12 months of drug-eluting stent placement carries unacceptable thrombotic risk 2, 3.

Anesthesia Considerations

• General anesthesia or interscalene block are both acceptable with aspirin alone 1
• Avoid neuraxial techniques if continuing dual antiplatelet therapy due to epidural hematoma risk 1
• Regional anesthesia is safe with aspirin monotherapy 4

Expected Blood Loss Management

Research in peripheral vascular surgery (higher bleeding risk than orthopedic surgery) shows no significant increase in reoperation for bleeding when continuing dual antiplatelet therapy 6. However, hip fracture data demonstrates:

• Transfusion rate increases from 31% to 56% with clopidogrel 5
• Actual measured blood loss does not significantly differ 7
• No increase in mortality or major bleeding complications 7

This suggests the increased transfusion rate reflects lower hemoglobin thresholds being reached rather than catastrophic bleeding, making surgery feasible even on dual therapy when cardiac risk demands it.