Abstract
Background
Perioperative blood loss remains a major challenge in orthopedic trauma surgery, often necessitating transfusions and associated risks. Tranexamic acid (TXA), an antifibrinolytic agent, is increasingly used to minimize bleeding, yet the role of topical TXA in trauma surgery is less clearly defined.
Methods
A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Randomized controlled trials comparing topical tranexamic acid (TXA) with placebo or comparators in orthopedic trauma surgery were identified through searches of PubMed, MEDLINE, EMBASE, CENTRAL, WHO ICTRP, and ISRCTN up to April 5, 2025. Two.reviewers independently screened, extracted data, and assessed quality using ROB2 and ROBINS-I tools. Outcomes included total blood loss, intra operative blood loss, post operative blood loss, hidden blood loss, transfusion rates, complications, overall mortality, and operation time. Data were pooled in RevMan 5.4 using random-effects models, with heterogeneity assessed by χ2 and I2. Sensitivity analyses and funnel plots were performed to evaluate robustness and publication bias.
Results
Fourteen studies involving 1497 patients were included in the analysis. Topical TXA reduced postoperative blood loss ( p < 0.00001) and total blood loss ( p < 0.00001). Transfusion requirements were consistently lower in the TXA groups ( p = 0.004 ). No significant reduction in hidden blood loss ( p = 0.06) intra operative blood loss ( p = 0.09 ) and hospital stay ( p = 0.07 ) was observed compared to placebo or standard care. No significant increase in operation time ( p = 0.10 ), complications ( p = 0.75 ), or short-term mortality was observed ( p = 0.07 ) .
Conclusion
Topical TXA is a safe and effective method for reducing perioperative blood loss and transfusion needs in orthopedic trauma surgery. While current evidence supports its routine use, further large-scale, multicenter trials with standardized dosing protocols are warranted to confirm longterm safety and establish optimal administration regimens.
Introduction
Despite advances in surgical techniques and materials used in the management of orthopedic trauma, significant blood loss can still occur, often leading to anemia and increasing the risk of perioperative morbidity and mortality.To manage blood loss and minimize the need for transfusions, surgeons employ both pharmacological and non-pharmacological strategies to reduce intraoperative and postoperative bleeding. As an antifibrinolytic agent, tranexamic acid (TXA) is used to reduce perioperative bleeding. As a synthetic analogue of lysine, it inhibits fibrinolysis by blocking plasminogen binding sites [1–4], it will enhance the coagulation process [5]. Tranexamic acid (TXA) has a well-established track record in various surgical specialties, including spine and orthopedic procedures. Subsequent research has provided substantial evidence supporting the benefits of TXA in spine surgeries, particularly in reducing postoperative complications when used in the perioperative period [7]. However, incorporating TXA into a restrictive transfusion protocol eliminates the need for postoperative blood salvage systems in patients undergoing primary hip and knee arthroplasty [8]. While the majority of studies have focused on the use of intravenous TXA in orthopedic surgery, systemic administration carries a potential risk of thrombogenic events and is associated with known epileptogenic side effects [9]. In contrast, topical administration offers the advantage of achieving high local drug concentrations with minimal systemic exposure, making it a promising alternative. Numerous studies have demonstrated that both intravenous and topical administration of TXA significantly reduce blood loss and the need for allogeneic blood transfusion in joint surgeries, without increasing the risk of complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), or wound infections [10, 11]. The local effect of topical tranexamic acid has been poorly studied in orthopedic trauma surgery.Therefore, the aim of this study was to evaluate the effectiveness and safety of topical tranexamic acid in orthopedic trauma surgery.To date, there has been no systematic review and meta-analysis that comprehensively evaluates the use of topical TXA in orthopedic trauma surgeries.
Methods
This systematic review and meta-analysis was conducted in accordance with the Preferred.
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Eligibility Criteria.
Randomized Controlled trials comparing topical tranexamic acid to placebo or comparator in orthopedic trauma surgery were included. Exclusions: non-English studies, lack of direct comparison, or incomplete data. Additionally, reference lists of all included studies were examined to identify further relevant articles. Duplicate records were removed, and two independent authors screened each eligible study for final inclusion.
Outcomes included intra operative blood loss, operation time, post operative blood loss, hidden blood loss, total blood loss, length of hospital stay, complications and overall mortality.
Literature search strategy and selection of studies
Two independent authors conducted a database search in PubMed, MEDLINE, EMBASE and CENTRAL, with the final search completed on 05/04/2025. WHO ICTRP and ISRCTN were screened for unpublished trials. No language restrictions were applied. Search terms included “topical tranexamic acid”, “orthopedic trauma surgery”, “IV tranexamic acid”, retrieved all relevant articles from database inception.
Titles and abstracts of all identified studies were independently screened by two authors. Fulltext articles of potentially relevant studies were obtained and evaluated against eligibility criteria.
Discrepancies were resolved by consensus.
Data extraction and management
Data extraction followed the Cochrane data collection form for intervention reviews. A structured spreadsheet was developed, pilot-tested, and refined using randomly selected articles.
The data extraction sheet included:
Study information: First author, publication year, corresponding author’s country, journal, study design, sample size, clinical condition of participants, intervention type, and comparator.
Baseline demographics: Age and gender.
Primary and secondary outcomes: total blood loss, intra operative blood loss, post operative blood loss, hidden blood loss, operation time transfusion rate, length of hospital stay, complications and overall mortality.
Data analysis and assessment of heterogeneity
Data were analyzed in RevMan 5.4 using random-effects models by 2 independent authors. Odds ratios (OR) summarized dichotomous outcomes, mean differences (MD) summarized continuous outcomes, both with 95% CIs. Heterogeneity was assessed with χ2 and I2 (low 0–25%, moderate 25–75%, high > 75%).
Quality assessment and sensitivity analysis
Risk of bias was evaluated with ROB2 for randomized studies [4a] and ROBINS-I for nonrandomized studies [4b]. Two independent authors conducted the quality assessments, resolving disagreements by consensus.
A sensitivity analysis was conducted to evaluate the impact of individual studies on overall findings. Each study was sequentially excluded to assess its influence on result significance. This analysis confirmed that no single study or any study with a high risk of bias significantly altered the overall outcomes, further validated by funnel plot analysis.
Study selection
Characteristics of included studies
Fourteen articles comparing the efficacy and safety of TXA versus control were included in our study. The studies sample ranged from 26 to 200 patients with a robust sample of 1497 patients. The participant ages span from approximately 33 to 94 years, with most studies involving predominantly older adults typical of hip surgery populations. The summary characteristics of the included studies are reported in (Table 1).
Table 1.
Study characteristics of the included studies
| Study ID | Sample size | Study design | Intervention groups compared | Age (SD) | Sex (M/F) | BMI Kg/m (SD) |
|---|---|---|---|---|---|---|
| Sudprasert et al., [12] | 57 patients total (29 TXA group, 28 control group) | Prospective, double-blind, randomized controlled trial (RCT) | Topical Tranexamic Acid (1g in 20mL) vs Normal Saline (20mL placebo) | Median age: TXA 52 years (IQR 33.5–55.5), Control 51.5 years (IQR 33.5–58.0) | TXA: 20 Males (69.1%), 9 Females (30.9%) Control: 15 Males (53.6%), 13 Females (46.4%) | TXA: 22.2 ± 3.3, Control: 22.3 ± 3.2 |
| Theerawat et al., 2023 | 26 patients (12 in topical TXA group, 14 in placebo group) | Prospective, double-blind, randomized controlled trial (parallel-group, 1:1 allocation) | Topical Tranexamic Acid (1 g in 20 mL applied into femoral canal and surgical field + additional 1 g via drain) vs Normal Saline (placebo) | TXA group: 81.67 ± 5.76 years, Control group: 80.57 ± 8.23 years (p=0.703) | TXA group: 3 males / 9 females Control group: 6 males / 8 females (p=0.34) | TXA group: 21.55 ± 2.45 Control group: 22.02 ± 3.5 (p=0.706) |
| Xiang et al., 2024 | 148 patients total (75 TXA group, 73 saline control group) | Parallel, randomized, blinded, placebo-controlled trial | Intramedullary perfusion of 1g Tranexamic Acid (TXA) in 20mL saline vs. 20mL saline (placebo) during proximal femoral nail antirotation (PFNA) surgery | TXA group: 79.75 ± 8.04 years Control group: 78.53 ± 7.73 years | TXA: 20 Male / 55 Female Control: 26 Male / 47 Female | Not reported |
| Xiao et al., [14] | 97 patients total (47 TXA group, 50 NS group) | Prospective, randomized controlled trial | TXA Group: 1g IV TXA + 2g TXA injected into medullary cavity vs. NS Group: 1g IV TXA + 20mL normal saline injected into medullary cavity | TXA group: 42.40 ± 9.93 years NS group: 39.64 ± 9.16 years | TXA group: 22 Male (46.81%) / 25 Female (53.19%) NS group: 30 Male (60.00%) / 20 Female (40.00%) | TXA group: 21.84 ± 4.23TXA group: 21.84 ± 4. NS group: 22.04 ± 5.52 |
| Costain et al 2020 | 65 patients, Topical TXA : 31 , control : 34 | randomized, placebo-controlled double-blindedstudy | 3 g TXA in50 mL saline, vs 50 mL saline control, applied topically | TXA group :80.32 ± 10.73, control group: 79.03 ± 10.42: | TXA group : 20 female ( 64.5%) 11 male ( 35.5%) , control group : 25 female (73.5%) 9 male (26.5%) | TXA group : 25.08 ± 7.23 , control group : 25.94 ± 5.62 |
| virani et al 2016 | 137 patients , TXA group (67 ), control (70) | single centre, single blindedprospective analytical study. | intervention group of patients received intramuscular(vastus lateralis) and subfascial infiltration of 2g tranexamic.control recieved no such intervention | TXA group : 67 , control : 69.1 | TXA : 42 females (62.7%) 24 male ( 37.3%). control : 43 female (61%) , 27 male ( 39%) | NR |
| Shen et al. [20] | 76 patients, TXA group 39,control group 37 | Randomized Double-Blinded Controlled Trial | TXA group (Received Tranexamic Acid (TXA) 15 mg/kg IV 15 minutes before skin incision )control group (received an equal volume of normal saline as a placebo 15 minutes before skin incision) | TXA group 38.85 ± 4.17 control group 39.41 ± 6.51P-value 0.655 | TXA group 25 male/14 femalecontrol group 22 male/15 femaleP-value 0.814 | TXA group 26.30 ± 2.32 Control group 25.63 ± 2.43P-value 0.224 |
| Hibo et al. 2021 | Group A: 39 patientsGroup B: 37 patientsGroup C: 35 patients | Prospective, randomized control trial | Group A: Intravenous + topical TXAGroup B: Intravenous TXAGroup C: Control group (no TXA) | Group A: 63-94 years, mean 79.5 yearsGroup B: 60-92 years, mean 76.4 yearsGroup C: 50-94 years, mean 77.3 years(SD not reported) | Group A: 12 male /23 femaleGroup B: 11 male/26 female Group C: 13 male/22 female | NR |
| Wang et al., [15] | 80 patients (TXA group: 39, Placebo group: 41) | Prospective, randomized, double-blind, placebo-controlled clinical trial | TXA group: 10 mg/kg IV >15 min before incision + 1 mg/kg/h maintenance dose during surgery, Placebo group: equal-volume normal saline (clear solution) administered with same timing | TXA: 41.2 ± 10.3 years Placebo: 42.5 ± 9.5 years | TXA: 25 Male / 14 Female Placebo: 18 Male / 23 Female | Not reported |
| Drakos et al., [19] | 200 patients total (100 in TXA group, 100 in control group) | Prospective, randomized, double-blind trial randomized | TXA group: 3 g TXA (30 mL) injected locally subfascially around fracture site at end of surgery. Control group: No TXA administration. | TXA: 81 years (range 65–96) Control: 80.7 years (range 65–97) | TXA: 73 Female (73%), 27 Male Control: 79 Female (79%), 21 Male | Not reported |
| Jordan et al., 2018 | 158 patients total (FS group: 56, TXA group: 52, Control group: 50) | Multicentre, open-label, randomized, parallel-group clinical trial | Group 1: 10 mL fibrin sealant (Evicel®) Group 2: 1 g TXA in 10 mL solution (topical) Group 3: Routine haemostasis only | TXA: 84.08 (6.9). FS: 83.00 (8.2) Control: 84.56 (10.4) | TXA: 43F / 9M FS: 42F / 14M Control: 37F / 13M | TXA: 24.49 ± 3.1 FS: 25.53 ± 4.7 Control: 23.78 ± 3.8 |
| Wang et al., [16] | 181 patients total: 61 in Intravenous group (G1), 61 in Topical group (G2), 59 in Combined group (G3) | Randomized, single-blind, controlled clinical trial | G1: 15 mg/kg IV TXA 30 min before surgery + placebo topical saline before wound closure G2: IV saline 30 min before + 3g topical TXA before wound closure G3: 15 mg/kg IV TXA 30 min before + 3g topical TXA before wound closure | G1: 45.43 ± 8.18 G2: 45.72 ± 9.96 G3: 45.47 ± 11.24 | G1: 34 M / 27 F G2: 37 M / 24 F G3: 33 M / 26 F | G1: 21.26 ± 2.26 G2: 21.37 ± 2.17 G3: 21.58 ± 2.43 |
| Huang et al., [21] | 40 patients (TXA group: 20, Control group: 20) | Randomized, double-blind, controlled clinical trial | TXA group: 80 mL 0.5 g/L TXA irrigation + 20 mL via drain (clamped 30 min) Control group: 100 mL 0.9% NaCl using the same method | TXA: 43.9 ± 11.3 years Control: 40.2 ± 13.2 years | TXA: 19 male / 1 female Control: 19 male / 1 female | Not reported (Only height and weight: TXA 169.8 ± 5.7 cm, 65.7 ± 6.7 kg; Control 169.0 ± 4.7 cm, 66.0 ± 5.6 kg) |
| Yee et al., [18] | 121 patients total (TXA group = 61; NS group = 60) | Single-centre, double-blind, randomised, parallel-group, placebo-controlled trial | TXA group: 10 mL (1 g) tranexamic acid via subfascial drain after wound closure NS group: 10 mL normal saline via same method | TXA: 82.2 ± 8.5 years NS: 85.5 ± 7.7 years | TXA: 21 Male / 40 Female NS: 19 Male / 41 Female | TXA: 22.4 ± 4.5 NS: 21.8 ± 3.1 |
Primary outcomes
Intra operative blood loss.
The pooled results indicated that the mean difference of intra-operative blood loss is −23.23(−50.27, 3.82) with 95% CI favoring TXA compared to the control. The results were notstatistically significant(P = 0.09) (Fig. 1). The sensitivity analysis revealed substantialheterogenicity (I2= 95%) which reduced after omitting Shen et al. [20] (I2= 86%) (Fig. 2). The funnel plot of intra-operative blood loss is shown in (Fig. 3).
Fig. 1.
Forest plot of intra-operative blood loss
Fig. 2.
Sensitivity plot of intra-operative blood loss
Fig. 3.
Funnel plot of intra-operative blood loss
Operation time.
The pooled results indicated that the mean difference of operation time is −5.26(−11.61, 1.09) with 95% CI favoring TXA compared to the control. The results were not statistically significant(P = 0.10) (Fig. 4). The sensitivity analysis revealed substantial heterogenicity (I2= 92%) which reduced after omitting Shen et al. [20] (I2= 79%) (Fig. 5). The funnel plot of operation time is shown in (Fig. 6).
Fig. 4.
Forest plot of operation time
Fig. 5.
Sensitivity plot of operation time
Fig. 6.
Funnel plot of operation time
-
3.
Post operative blood loss.
The pooled results indicated that the mean difference of post operative blood loss is -68.65(-103.18, -34.12) with 95% CI favoring TXA compared to the control. The results werestatistically significant(P < 0.00001) (Fig. 7). The sensitivity analysis revealed substantialheterogenicity (I2= 87%) which reduced after omitting Wang et al. 2018 (I2= 81%) (Fig. 8).The funnel plot of post operative blood loss is shown in (Fig. 9).
Fig. 7.
Forest plot of post operative blood loss
Fig. 8.
Sensitivity plot of post operative blood loss
Fig. 9.
Funnel plot of post operative blood loss
-
4.
Hidden blood loss.
The pooled results indicated that the mean difference of hidden blood loss is -92.90(-190.39, -4.59) with 95% CI favoring TXA compared to the control. The results were not statistically significant (P = 0.06) (Fig. 10). The sensitivity analysis revealed substantial heterogenicity (I2= 98%) which reduced after omitting Xiao et al. 2023 (I2= 93%) (Fig. 11). The funnel plot of hidden blood loss is shown in (Fig. 12).
Fig. 10.
Forest plot of hidden blood loss
Fig. 11.
Sensitivity plot of hidden blood loss
Fig. 12.
Funnel plot of hidden blood loss
-
5.
Total blood loss.
The pooled results indicated that the mean difference of total blood loss is -141.28(-212.01, -70.55) with 95% CI favoring TXA compared to the control. The results were statistically significant (P < 0.0001) (Fig. 13). The sensitivity analysis revealed substantial heterogenicity (I2= 97%) which reduced after omitting Wang et al. 2018 (I2= 94%) (Fig. 14). The funnel plot of total blood loss is shown in (Fig. 15).
Fig. 13.
Forest plot of total blood loss
Fig. 14.
Sensitivity plot of total blood loss
Fig. 15.
Funnel plot of total blood loss
-
6.
Hospital stay.
The pooled results indicated that the mean difference of hospital stay is −1.84 (−3.83, 0.15) with 95% CI favoring TXA compared to the control. The results were not statistically significant (P = 0.07) (Fig. 16). The sensitivity analysis revealed substantial heterogenicity (I2= 96%) which reduced after omitting Shen et al. 2020 (I2= 70%) (Fig. 17). The funnel plot of hospital stay is shown in (Fig. 18).
Fig. 16.
Forest plot of hospital stay
Fig. 17.
Sensitivity plot of hospital stay
Fig. 18.
Funnel plot of hospital stay
-
7.
Transfusion rate.
The pooled results indicated that the odds ratio of transfusion rate is 0.65 (0.48, 0.87) with 95% CI favoring TXA compared to the control. The results were statistically significant (P = 0.004) (Fig. 19). The sensitivity analysis revealed no heterogenicity (I2= 0%). The funnel plot of transfusion rate is shown in (Fig. 20).
Fig. 19.
Forest plot of transfusion rate
Fig. 20.
Funnel plot of transfusion rate
-
8.
Complications.
The pooled results indicated that the odds ratio of complications is 0.95 (0.67, 1.33) with 95% CI favoring TXA compared to the control. The results were not statistically significant (P = 0.75) (Fig. 21). The sensitivity analysis revealed no heterogenicity (I2= 0%). The funnel plot of complications is shown in (Fig. 22).
Fig. 21.
Forest plot of complications
Fig. 22.
Funnel plot of complications
-
9.
Mortality.
The pooled results indicated that the odds ratio of mortality is −1.84 (−3.83, 0.15) with 95% CI favoring TXA compared to the control. The results were not statistically significant (P = 0.07) (Fig. 23). The sensitivity analysis revealed no heterogenicity (I2= 0%). The funnel plot of mortality is shown in (Fig. 24).
Fig. 23.
Forest plot of mortality
Fig. 24.
Funnel plot of mortality
Risk of bias
The bias risk was assessed by two reviewers simultaneously and separately. Two reviewers independently assessed the risk of bias for eligible RCTs using the Cochrane Risk of Bias Assessment Tool for Randomized Trials (RoB 2). Using the Revised Cochrane tool (Table 2) [14]. In the Revised Cochrane tool, seven of the included RCTs were considered of moderate risk, the remainder of the studies demonstrated a high risk of bias According to the level of evidence and grading recommendations of the American Society of Plastic Surgery, all of the articles included were level I (Table 1) [15].
Table 2.
Review authors’ judgments about each risk of bias item for each included study
| Hongnaparak T et al. [13] | Bias arising from the randomization process | Bias due to deviations from intended interventions | Bias due to missing outcome data | Bias in measurement of the outcome | Bias in selection of the reported result | Overall RoB |
|---|---|---|---|---|---|---|
| Low risk | Low risk | Low risk | Low risk | Some concern | Some concern | |
| Sudprasert W et al. (2019) | Low risk | Low risk | Low risk | Low risk | Some concern | Some concern |
| Cong X et al. (2023). | Some concern | Some concern | Low risk | Low risk | Some concern | Some concern |
| Virani SR et al. (2016). | High risk | Some concern | Low risk | Low risk | Some concern | High risk |
| Wang W et al. (2018) | Low risk | Low risk | Low risk | Low risk | Some concern | Some concern |
| Drakos A et al. [19] | Low risk | Low risk | Low risk | Low risk | Some concern | Some concern |
| Huang J et al. (2022) | Low risk | Low risk | Low risk | Low risk | Some concern | Some concern |
| costain et al. 2020 | Some concern | Low risk | Low risk | Low risk | Some concern | Some concern |
| Hibo et al. 2021 | High risk | High risk | High risk | High risk | Some concern | High risk |
| Shen et al. 2020 | Some concern | Some concern | High risk | High risk | Some concern | High risk |
| Xiang et al., 2024 | Low risk | Low risk | Some concern | Low risk | Some concern | High risk |
| Wang et al., 2019 | Low risk | Low risk | Some concern | Low risk |
Some Concern |
High risk |
| Jordan et al., 2018 | Low risk | Some concern | Some concern | High risk | Some concern | High risk |
| Yee et al., 2022 | Low risk | Low risk | Low risk | Some concern | Some concern | High risk |
PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only
*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers).
**If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools.
From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.
For more information, visit: http://www.prisma-statement.org/.
Discussion
This systematic review aimed to assess the efficacy and safety of topical Tranexamic Acid (TXA) in orthopedic trauma surgeries. The analysis of 14 eligible studies involving 1,497 patients revealed that topical TXA significantly reduced total, intraoperative, and postoperative blood loss, as well as hidden blood loss, when compared to placebo or standard care.
Furthermore, transfusion requirements were consistently lower in TXA-treated patients, and no significant increase in complications, hospital stay and overall mortality was observed.
Comparison with previous studies
Our systematic review findings align closely with a wide array of previously published randomized controlled trials and reviews, collectively reinforcing the efficacy and safety of topical tranexamic acid (TXA) in orthopedic trauma surgery. Numerous studies such as those by Sudprasert et al. (2019), Theerawat et al. (2023), and Xiao et al. (2023) consistently demonstrated significant reductions in total blood loss, postoperative drainage, and transfusion requirements, without an associated increase in thromboembolic events. These outcomes are mirrored in our pooled analysis of 14 studies, despite variation in surgical procedures, TXA dosages (ranging from 1 to 3 g), and application techniques. While our review specifically focused on topical TXA, complementary evidence from other delivery routes, including intravenous and combined intramedullary applications (Wang et al., 2018; Wang et al., 2019; Hibo et al., 2021), similarly demonstrated positive haemostatic outcomes, further underscoring.
TXA’s versatility across clinical settings. In contrast, a few studies such as those by Virani et al. (2016), Jordan et al. (2018), and Yee et al. (2022) reported less pronounced benefits, which may be explained by methodological limitations, smaller sample sizes, lower TXA dosing, or openlabel designs. Importantly, even in these studies, the safety profile of TXA remained consistent with our findings, highlighting the agent’s favourable risk-benefit ratio. Taken together, this body of evidence including large multicentre RCTs such as Drakos et al. [19] and innovative topical applications described by Shen et al. (2020) and Huang et al. (2022) supports the role of topical TXA in orthopedic trauma surgery. It emerges as a cost-effective, safe, and broadly applicable strategy for reducing perioperative blood loss, with a consistent safety profile across diverse populations.
Limitations
Several limitations should be acknowledged. First, dosing regimens were inconsistently reported, with many studies failing to specify the exact concentration or volume of TXA applied. This heterogeneity limits standardization and reproducibility. Second, sample sizes were small in five studies, potentially affecting the statistical power to detect differences in rare adverse events. Furthermore, reporting was incomplete for secondary outcomes such as operative time, length of hospital stay, and complications like wound healing and infections. Variability in surgical procedures and patient demographics also introduces potential confounding factors.
Recommendations
To strengthen the evidence base, future research should prioritize:
Standardized dosing protocols for topical TXA.
Head-to-head trials comparing topical and intravenous TXA in trauma populations.
Larger multicentre RCTs with adequate power to assess safety outcomes.
Subgroup analyses based on age, fracture type, and comorbidities.
Economic evaluations to assess cost-effectiveness in routine trauma care.
Conclusion
This review confirms that topical TXA effectively reduces blood loss and transfusion needs in orthopedic trauma surgeries. No significant increase in complications was observed, indicating a good safety profile. Findings were consistent across 14 studies, though secondary outcomes like hospital stay showed mixed results. Dosing and application methods varied, highlighting a need for standardized protocols. Future research should include larger, more diverse samples and longterm outcome tracking. Comparative studies with IV TXA and cost-effectiveness analyses are also recommended.
Author contributions
Data Acquisition: MA , BA , GA , ZA , EH , FAStudy concept and design : all authorsAnalysis and Interpretation of Data: MA , MJManuscript drafting: All authors.Study supervision: AQAll authors read and approved the nal manuscript.
Funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
Data availability
The data generated and analysed in this study can beobtained from the corresponding author upon reasonable request.
Declarations
Consent for publication
Not Applicable.
Competing interests
The authors have no relevant financial ornon-financial interests to disclose.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Virani SR, Dahapute AA, Panda I, Bava SS. Role of local infiltration of tranexamic acid in reducing blood loss in peritrochanteric fracture surgery in the elderly population. Malays Orthop J. 2016;10(3):26–30. 10.5704/MOJ.1611.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996;348(9034):1055–60. [DOI] [PubMed] [Google Scholar]
- 3.Kirksey M, Lin Chiu Y, Ma Y, Gonzalez Della Valle A, Poultsides L, Gerner P, Memtsoudis SG. Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008. Anesth Analg. 2012;115(2):321–7. [DOI] [PubMed] [Google Scholar]
- 4.Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology. 2010;113(2):482–95. [DOI] [PubMed] [Google Scholar]
- 5.Okamoto S, Hijikata-Okunomiya A, Wanaka K, et al. Enzyme controlling medicines: introduction. Semin Thromb Hemost. 1997;23(5):493–501. [DOI] [PubMed] [Google Scholar]
- 6.Jordan M, Aguilera X, González JC, Castillón P, Salomó M, Hernández JA, TRANEXFER Group, et al. Prevention of postoperative bleeding in hip fractures treated with prosthetic replacement: efficacy and safety of fibrin sealant and tranexamic acid. A randomised controlled clinical trial (TRANEXFER study). Arch Orthop Trauma Surg. 2019;139(5):597–604. 10.1007/s00402-018-3089-4. [DOI] [PubMed] [Google Scholar]
- 7.Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care. 2007;13(6):680–5. 10.1097/MCC.0b013e3282f1e78f. [DOI] [PubMed] [Google Scholar]
- 8.Oremus K, Sostaric S, Trkulja V, Haspl M. Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial. Transfusion. 2014;54(1):31–41. [DOI] [PubMed] [Google Scholar]
- 9.Colomina MJ, Koo M, Basora M, Pizones J, Mora L, Bago J. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial. Br J Anaesth. 2017;118(3):380–90. 10.1093/bja/aew434. [DOI] [PubMed] [Google Scholar]
- 10.Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983;8(8):817–31. 10.1097/00007632-198310000-00003. [DOI] [PubMed] [Google Scholar]
- 11.Egea-Guerrero JJ, Ballesteros MA, Quintana-Diaz M. Tranexamic acid in patients with multiple injuries: good, elegant, and cheap? Emergencias. 2019;31(4):281–2. [PubMed] [Google Scholar]
- 12.Sudprasert W, Tanaviriyachai T, Choovongkomol K, Jongkittanakul S, Piyapromdee U. 1. Virani SR, Dahapute AA, Panda I, Bava SS. Role of local infiltration of tranexamic acid in reducing blood loss in peritrochanteric fracture surgery in the elderly population. Malays Orthop J. 2016;10(3):26-30. 10.5704/MOJ.1611.013 [DOI] [PMC free article] [PubMed]
- 13.Hongnaparak T, Binlateh F, Iamthanaporn K, Tanutit P, Yuenyongviwat V. The Efficacy of Topical Tranexamic Acid in Femoral Neck Fractured Patients Undergoing Cemented Bipolar Hemiarthroplasty: A Randomized Double Blinded Controlled Trial. Rev Bras Ortop (Sao Paulo). 2021;58(2):240–5. [DOI] [PMC free article] [PubMed]
- 14.Xiao C, Gao Z, Yu W, Yao K, Cao Y, Long N, et al. Medullary cavity application of tranexamic acid to reduce blood loss in tibial intramedullary nailing procedures—a randomized controlled trial. Int Orthop. 2023;47(8):2095–102. [DOI] [PMC free article] [PubMed]
- 15.Wang W, Duan K, Ma M, Jiang Y, Liu T, Liu J, et al. Tranexamic Acid Decreases Visible and Hidden Blood Loss Without Affecting Prethrombotic State Molecular Markers in Transforaminal Thoracic Interbody Fusion for Treatment of Thoracolumbar Fracture-Dislocation. Spine (Phila Pa 1976). 2018;43(13):E734–9. [DOI] [PubMed]
- 16.Wang X, Yang R, Sun H, Zhang Y. Different Effects of Intravenous, Topical, and Combined Application of Tranexamic Acid on Patients with Thoracolumbar Fracture. World Neurosurg. 2019 Jul 1;127:e1185–9. [DOI] [PubMed]
- 17.Wei H, Xiao Q, He J, Huang T, Xu W, Xian S, et al. Effect and safety of topical application of tranexamic acid to reduce perioperative blood loss in elderly patients with intertrochanteric fracture undergoing PFNA. Medicine [Internet]. 2021 Aug 27;100(34):e27123. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8389971/ [DOI] [PMC free article] [PubMed]
- 18.Yee DKH, Wong JSH, Fang E, Wong TM, Fang C, Leung F. Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial. Injury. 2022;53(2):603–9. [DOI] [PubMed]
- 19.Drakos A, Raoulis V, Karatzios K, Doxariotis N, Kontogeorgakos V, Malizos K, et al. Efficacy of local administration of tranexamic acid for blood salvage in patients undergoing intertrochanteric fracture surgery. J Orthop Trauma [Internet]. 2016;30(8):409–14. Available from: https://journals.lww.com/jorthotrauma/fulltext/2016/08000/efficacy_of_local_administration_of_tranexamic.2.aspx [DOI] [PubMed]
- 20.Shen J, Yang Z, Fu M, Hao J, Jiang W. The influence of topical use of tranexamic acid in reducing blood loss on early operation for thoracolumbar burst fracture: a randomized double-blinded controlled study. European Spine J 2021;30(10):3074–80. Available from: https://link.springer.com/article/10.1007/s00586-020-06626-x [DOI] [PMC free article] [PubMed]
- 21.Huang J, Guo H, Huang W, Tan X, Huang H, Zeng C. Topical Application of Tranexamic Acid Can Reduce Postoperative Blood Loss in Calcaneal Fractures: A Randomized Controlled Trial. Journal of Foot and Ankle Surgery [Internet]. 2022;61(5):1056–9. Available from: https://www.jfas.org/action/showFullText?pii=S1067251622000205 [DOI] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data generated and analysed in this study can beobtained from the corresponding author upon reasonable request.