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

Abstract and Introduction


Tranexamic acid (TXA) use has expanded across many surgical specialties. It has been shown to reduce blood loss, decrease transfusion rates, and, in some cases, improve mortality. Within orthopaedic surgery, its popularity has primarily grown within arthroplasty and spinal surgery. It has only recently gained traction within the field of orthopaedic trauma and fracture care. At this time, most literature focuses on hip fracture and pelvic trauma surgery. For hip fractures, the results are encouraging and generally support the claim that TXA may lower overall blood loss and decrease transfusions. Conversely, less support exists for TXA use in fractures of the acetabulum or pelvic ring. Based on the current fracture-related studies, TXA does not seem to carry an increased risk of thromboembolism or other complications. In addition, few studies have been noted discussing the route of administration, timing, or dosage. This article reviews the most current literature regarding TXA use in fracture care and expands on the need for further research to evaluate the role of TXA in orthopaedic trauma populations who carry a high risk for transfusion.


The first clinical trial of tranexamic acid (TXA) was published in 1968 and highlighted the use of TXA in the management of heavy menstrual bleeding.[1] Over the following decades, clinical application expanded to areas such as dental, urologic, cardiac, and transplant surgery.[2–5] It was not until the 21st century that the use of TXA began in orthopaedic surgery, such as arthroplasty and spinal surgery.[6,7]

More pertinent to the patient cohort in orthopaedic trauma, the role of TXA in the management of the polytraumatized patient has been investigated. A large multicenter double-blinded randomized controlled trial known as the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2, referred to as CRASH-2, evaluated more than 20,000 trauma patients in 274 hospitals across 40 countries who were at risk for hemorrhage within eight hours from injury.[8] Each patient was randomized to receive either TXA or placebo within eight hours from injury. The results of this landmark study demonstrated a statistically notable decrease in all-cause mortality risk by 9%. In addition, the Military Application of Tranexamic Acid in Trauma Emergency Resuscitation study was a retrospective observational study that compared TXA versus no TXA in combat injury patients. Nearly 900 patients were examined and revealed a 6.5% absolute reduction in mortality rate. This observation was even more substantial in patients undergoing massive transfusion (>10 units packed red blood cells) with a 13.7% absolute reduction in mortality.[9] These studies provided valuable insight into the use of TXA as an antifibrinolytic agent for trauma patients. As the use of TXA has gained traction within the general management of the trauma patient, research has expanded to include the field of orthopaedic trauma and fracture surgery. Although not comprehensive, this review summarizes the most recent and highest-level data on TXA use during surgical management of hip and acetabular and pelvic ring injuries.