Perioperative Use of Tranexamic Acid is Associated with Reduced Transfusion Rates in Femoral Shaft Fractures: A Propensity-Matched Cohort Study

OBJECTIVES: To evaluate the association between perioperative tranexamic acid (TXA) use and transfusion rates, perioperative blood loss, and 90-day postoperative complications in patients undergoing intramedullary nailing of femoral shaft fractures. METHODS: Design : Retrospective cohort study. Setting: Multi-center academic and community hospitals participating in the TriNetX research network. Patient Selection Criteria: Adult patients (≥18 years) who underwent open intramedullary nailing of OTA/AO 32 (femoral diaphyseal) fractures between 2010 and 2025 were included. Patients with a prior history of malignant neoplasm, deep vein thrombosis (DVT), and pulmonary embolism (PE) were excluded. Patients were required to have ≥90 days of postoperative follow-up. The TXA group included patients who received perioperative TXA, while the comparison group did not. Outcome Measures and Comparisons: Primary outcomes included the incidence of non-autologous red blood cell transfusion and 90-day postoperative complications. Minor and major complications analyzed were mortality, DVT, PE, myocardial infarction (MI), stroke, and renal failure. Propensity-score matching was performed to balance demographics and comorbidities. Chi-squared tests were used to compare outcomes. RESULTS: A total of 7,644 patients were included in the study. The mean age was 57.0 ± 23.2 in the TXA group (n=3,822, 54.1% female) and 57.0 ± 23.2 in the non-TXA group (n=3,822, 52.3% female). Transfusion rates were lower in the TXA cohort (8.37%) compared to the non-TXA cohort (10.47%) [OR 0.78 (0.67, 0.91); p =0.002]. Mortality was also lower in the TXA group (1.31%) compared to the non-TXA cohort (2.15%) [OR 0.60 (0.42, 0.86), p=0.005]. No significant differences were observed in deep vein thrombosis [p=0.298], pulmonary embolism [p=0.611], myocardial infarction [p=1.00], stroke [p=0.482], renal failure [p=0.479], readmissions [p=0.772], and reoperations [p=0.110]. CONCLUSIONS: Perioperative TXA use during intramedullary nailing for femoral shaft fractures was associated with a reduction in transfusion rates without an increase in short-term complications.