Efficacy of Intraosseous Tranexamic Acid in Primary Total Hip Arthroplasty: A Prospective Randomized Controlled Trial

Tranexamic acid (TXA) reduces blood loss and transfusion requirements in patients who underwent primary total hip arthroplasty. However, the optimal route of TXA administration remains unclear. This randomized controlled trial evaluated whether intraosseous (IO) TXA administration was noninferior to intravenous (IV) or topical administration.

In this equal-proportion, noninferior randomized controlled trial, 126 patients undergoing primary total hip arthroplasty from October 2024 to April 2025 were randomized to IO (20 mg/kg TXA applied in the cancellous bone of the femur and ilium), IV (20 mg/kg TXA applied five minutes before incision), or topical (20 mg/kg TXA applied before suture) group. The primary outcome was hemoglobin reduction on the day of surgery (DOS) and postoperative days one to three (POD one to three). The secondary outcomes included blood loss, transfusion rate, and adverse events. Demographics were similar among the groups.

The mean hemoglobin reduction was comparable on the DOS, POD one, POD two, and POD three (P = 0.431, 0.532, 0.479, and 0.443, respectively). Exploratory analyses showed lower mean calculated total blood loss in the IO group on the DOS and POD one than in the other groups (DOS and POD one: P = 0.005 and 0.016, respectively), although the clinical relevance of this finding remains uncertain. Transfusion rates were 2.3, 7.1, and 2.3% in the IO, IV, and topical groups, respectively (P = 0.434). There was one patient in the topical group who developed deep vein thrombosis; no pulmonary embolism or infections were reported.

The blood-sparing efficacy of IO TXA administration is noninferior to that of IV and topical administration, with potential benefit in early postoperative blood loss control. Further high-quality studies are needed to confirm its superiority and establish its clinical value.