Perioperative Management of Aspirin and Clopidogrel for Calcaneal Fracture Surgery
For a patient with an undisplaced calcaneal fracture requiring surgery: discontinue clopidogrel 5 days before surgery, continue aspirin throughout the perioperative period unless the patient has a recent coronary stent (placed within 6-12 months for drug-eluting or 4-6 weeks for bare-metal), in which case both agents must be continued despite bleeding risk. 1, 2, 3
Risk Stratification: Coronary Stent Status is Critical
The single most important factor determining antiplatelet management is whether the patient has a coronary stent and its timing:
Patients WITH Recent Coronary Stents
- Continue both aspirin AND clopidogrel throughout the perioperative period regardless of bleeding risk 2, 4, 5
- Drug-eluting stents require dual antiplatelet therapy for 12 months; bare-metal stents for 4-6 weeks 2, 6
- Premature discontinuation increases stent thrombosis risk, which carries 10% risk of major vascular events including death—far exceeding surgical bleeding risk 6, 7
- Never substitute with heparin bridging—anticoagulants do not prevent stent thrombosis and actually increase bleeding without providing adequate platelet inhibition 5
Patients WITHOUT Recent Coronary Stents
- Stop clopidogrel 5 days before surgery (last dose on day -5) 1, 4, 3
- Continue aspirin throughout the perioperative period 1, 2
- This applies to patients on antiplatelet therapy for secondary cardiovascular prevention, prior stroke, or peripheral arterial disease 1, 2
Pharmacologic Rationale
Clopidogrel requires 5-day discontinuation because it irreversibly inhibits platelet aggregation for the platelet's 7-10 day lifespan 3. The 5-day window allows sufficient platelet turnover to restore hemostasis 1. Shorter discontinuation periods significantly increase major bleeding and surgical re-exploration rates 1.
Aspirin continuation is recommended because the thrombotic risk of discontinuation (approximately 2% absolute increase in cardiovascular events within 30 days) typically outweighs the modest increase in surgical bleeding 2, 6. Aspirin should be stopped only for closed-space surgeries (intracranial, posterior eye chamber) where even minor bleeding causes catastrophic complications 2, 6.
Bleeding Risk Classification for Calcaneal Surgery
Foot and ankle surgery, including calcaneal fracture repair, is classified as intermediate bleeding risk 2. This classification supports:
- Safe continuation of aspirin monotherapy 2
- Discontinuation of clopidogrel in patients without recent stents 1, 2
- Continuation of dual antiplatelet therapy only when stent thrombosis risk is extreme 2, 5
Postoperative Resumption Protocol
Resume clopidogrel within 24 hours after surgery once adequate hemostasis is achieved 2, 3. The FDA label explicitly states: "Resume clopidogrel as soon as hemostasis is achieved" 3.
For patients with drug-eluting stents who had clopidogrel held, some experts recommend a 300 mg loading dose when resuming therapy, though this is not universally agreed upon 2, 4.
Continue aspirin without interruption postoperatively 1, 2.
Critical Caveats and Common Pitfalls
Pitfall #1: Stopping Both Agents Simultaneously
Never discontinue both aspirin and clopidogrel in patients with recent stents—this dramatically increases stent thrombosis mortality beyond surgical bleeding risk 5, 6.
Pitfall #2: Excessive Preoperative Delay
Many clinicians unnecessarily stop clopidogrel for 7-10 days when 5 days is sufficient and evidence-based 1, 2, 4. Longer delays increase thrombotic risk without additional hemostatic benefit.
Pitfall #3: Attempting Heparin Bridging
Low molecular weight heparin bridging for antiplatelet therapy is contraindicated—it increases bleeding, is difficult to reverse, and provides no protection against arterial thrombosis 1, 5.
Pitfall #4: Inadequate Medication Reconciliation
Patients may not report over-the-counter NSAIDs with antiplatelet effects 2. Explicitly ask about all antiplatelet and anticoagulant medications.
Special Consideration: Osteoporosis Context
The possible osteoporosis mentioned in this case does not alter antiplatelet management but may influence:
- Surgical approach selection (operative vs. conservative management)
- Fixation technique choices
- Postoperative weight-bearing protocols
However, antiplatelet management follows the same algorithm regardless of bone quality 1, 2.
Transfusion Risk Data
Patients taking clopidogrel at admission for orthopedic surgery who undergo operation within 48 hours have a 56% transfusion rate versus 31% in patients not on the drug 8. This increased transfusion risk must be balanced against the 10% risk of major vascular events from premature antiplatelet discontinuation in high-risk patients 6, 7.