What is the role of Tranexamic Acid (TXA) in managing blood loss for a femur fracture?

Tranexamic Acid for Femur Fracture

Tranexamic acid should be administered to all patients undergoing surgery for femur fractures to reduce blood loss and transfusion requirements. 1

Strength of Recommendation

The American Academy of Orthopaedic Surgeons (AAOS) provides a strong recommendation with strong level of evidence that tranexamic acid should be given to reduce blood loss and need for transfusion in hip fracture patients. 1 This is the highest grade recommendation in their 2022 clinical practice guidelines, placing TXA administration on par with other critical interventions like interdisciplinary care and cemented femoral stems.

Standard Dosing Protocol

Administer 1 gram of TXA intravenously at the start of the surgical case (prior to incision). 1 This single-dose regimen has been validated specifically for hip and femur fracture surgery and differs from the trauma protocol. 2, 3, 4

Alternative Dosing Considerations

• For procedures expected to exceed 2-3 hours, consider a maintenance infusion of 1g over 8 hours following the initial bolus. 5
• Topical application (1g applied directly to the surgical site) may be even more effective than IV administration for femoral neck fractures treated with arthroplasty, reducing blood loss by an average of 759 ml compared to no TXA. 6
• Combined IV and topical administration (1g IV + 1g topical) shows intermediate benefit but does not exceed topical alone for arthroplasty cases. 6, 7

Clinical Efficacy

Blood Loss Reduction

• TXA reduces calculated blood loss by approximately 222-305 ml on average. 2, 3
• Hemoglobin drop is reduced by approximately 4.3% compared to no TXA. 3
• Topical application alone achieves the greatest blood loss reduction (759 ml) for femoral neck fractures treated with arthroplasty. 6

Transfusion Requirements

• Absolute risk reduction of transfusion: 7.7% 4
• Relative risk reduction of transfusion: 29% 4
• Transfusion rates decrease from 26-32% without TXA to 8-17% with TXA. 2, 3, 4
• The number needed to treat to prevent one transfusion is approximately 13 patients. 4

Safety Profile

No increased risk of thromboembolic events has been demonstrated in hip fracture patients receiving TXA. 2, 3, 7, 4 Specifically:

• Venous thromboembolism rates are equivalent between TXA and control groups. 3, 4
• No increase in arterial thrombotic events (MI, stroke) has been observed. 5
• Complication rates, reoperation rates, and 30-day and 90-day mortality do not differ with TXA use. 2, 7

Important Caveat from Trauma Literature

While the Association of Anaesthetists notes that "there is no good evidence that tranexamic acid improves hip fracture patient outcomes" in terms of mortality or functional recovery, they acknowledge it reduces transfusion requirements without strong evidence of increased thrombosis risk. 1 This reflects the distinction between reducing blood loss (well-established) versus improving ultimate patient outcomes like mortality or mobility (not yet proven). However, the AAOS guidelines prioritize the strong evidence for reducing transfusion-related morbidity. 1

Clinical Implementation Algorithm

1. Identify all patients undergoing surgical fixation or arthroplasty for femur fractures (femoral neck, intertrochanteric, subtrochanteric). 1

2. Screen for absolute contraindications:

   • Active intravascular clotting or disseminated intravascular coagulation 5
   • Severe hypersensitivity to TXA 5
   • Recent thrombotic event (use extreme caution) 5

3. Adjust dose for renal impairment as TXA is renally excreted and accumulates in renal failure. 1, 5

4. Choose administration route:

   • For arthroplasty (femoral neck fractures): Consider topical application of 1g TXA directly to the surgical site for maximum blood loss reduction. 6
   • For internal fixation (intertrochanteric/subtrochanteric): Administer 1g IV prior to incision. 7, 4
   • For prolonged procedures: Add maintenance infusion of 1g over 8 hours. 5

5. Administer at the start of the case (prior to incision) to maximize efficacy. 1, 4

Common Pitfalls to Avoid

• Do not confuse hip fracture dosing with trauma dosing. The trauma protocol (1g loading dose + 1g over 8 hours, administered within 3 hours of injury) is designed for acute hemorrhagic shock. 8 Hip fracture surgery uses a simpler single-dose regimen. 1

• Do not delay surgery to administer TXA. TXA is given at the start of the surgical case, not pre-operatively in the emergency department. 1

• Do not draw up TXA until after spinal anesthesia is completed to avoid catastrophic intrathecal administration, which is neurotoxic. 1

• Do not withhold TXA based on anticoagulation use alone. The decision requires balancing bleeding risk against thrombotic risk, but TXA has been safely used in patients on antiplatelet and anticoagulant medications. 1

• Do not use TXA as a substitute for proper surgical hemostasis. TXA is an adjunct to meticulous surgical technique, not a replacement. 5

Nuances in the Evidence

The AAOS guidelines provide the strongest and most recent recommendation specifically for hip fractures, making this the primary evidence to guide practice. 1 The Association of Anaesthetists guideline from 2021 is more cautious, noting that while TXA reduces transfusions, it hasn't been proven to improve patient-centered outcomes like mortality or functional recovery. 1 This divergence reflects different philosophical approaches: the AAOS prioritizes reducing transfusion-related morbidity (a measurable intermediate outcome), while the UK guideline emphasizes ultimate patient outcomes.

Recent research from 2023-2025 suggests that topical application may be superior to IV administration for arthroplasty cases, which represents an evolution beyond the AAOS guideline recommendations. 6 This is an area where practice may be ahead of formal guideline updates, and surgeons should consider topical application for femoral neck fractures treated with arthroplasty based on this emerging evidence.