The Use of Tranexamic Acid in Hip and Pelvic Fracture Surgeries

John D. Adams, Jr, MD, FAAOS; William A. Marshall, MD


J Am Acad Orthop Surg. 2021;29(12):e576-e583. 

In This Article


Based on the current literature, TXA likely decreases blood loss and, more importantly, transfusion requirement in hip fracture patients without posing a notable risk for increased complications. A smaller amount of literature exists on TXA use during acetabular and pelvic ring surgeries. The benefits seen during hip fracture surgery have not been reflected in the limited number of reports available. Patients with acetabular fractures and pelvic ring disruption are often multiply injured and have large variations in fracture severity. Therefore, it is difficult to design a study that accounts for such a wide range of confounding variables. It is possible the efficacy of TXA is merely overwhelmed by the complexity of these patients. Protocols for administration vary, with studies supporting both IV and local TXA use. Neither of these routes have been shown to increase complications. Oral administration is supported by the arthroplasty literature because of its low cost and efficacy, but this route has not been studied in fracture patients.[37] Data exist to suggest that a substantial portion of blood loss for a hip fracture patient occurs at the time of injury, and admission hemoglobin values may in fact be falsely elevated because of dehydration.[36,38] Afterward, potential exists for a "second-hit phenomenon" during the time of surgery with manipulation of the fracture, surgical exposure, and instrumentation.[39] It is presumed that this could be extrapolated to other trauma-related fracture injuries. Given this information, we suggest that future studies should focus on determining a superior regimen for administration of TXA to potentially include an initial dose of TXA on arrival to the ED, followed by an additional dose at surgery. Until this is established, the routine use of TXA in hip fracture patients using any of the described methods in the literature is likely safe and effective for blood conservation. The same recommendation cannot be made for acetabular or pelvic ring injuries because the efficacy of TXA is uncertain in this patient cohort.