Association of tranexamic acid use and autologous predonation with blood loss and transfusion outcomes after periacetabular osteotomy: An arm‐based multilevel meta analysis

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Purpose: To evaluate the association between tranexamic acid (TXA) use, autologous predonation and perioperative blood management outcomes after periacetabular osteotomy (PAO) using an arm-based multilevel meta-analytic framework. Methods: A systematic search of PubMed, Embase, Epistemonikos and the Cochrane Central Register of Controlled Trials (CENTRAL) was performed up to 30 March 2026. Prospective and retrospective primary clinical studies reporting perioperative blood management outcomes after PAO were included. Comparisons between TXA and non-TXA arms, as well as predonation and no-predonation arms, were performed using arm-based multilevel random-effects meta-analysis. Results: Forty-three studies comprising 4315 patients and 4674 hips were included. TXA use was associated with lower estimated blood loss (mean difference [MD] -185.6 mL, 95% confidence interval [CI]: -341.1 to -30.1), lower intraoperative blood loss (MD: -299.4 mL, 95% CI: -392.2 to -206.6), fewer transfused units (MD: -0.67, 95% CI: -0.89 to -0.45) and a lower transfusion rate (OR: 0.14, 95% CI: 0.056-0.338). No significant differences were observed for haemoglobin-related outcomes, complications, reoperations or conversion to total hip arthroplasty. Autologous predonation was not associated with reductions in blood loss or transfusion-related outcomes and was associated with lower postoperative haemoglobin levels (MD: -5.5 g/L, 95% CI: -9.0 to -1.9). The certainty of evidence ranged from low to very low, and substantial heterogeneity was observed across most analyses. Conclusion: TXA use was associated with reduced blood loss and transfusion requirements after PAO, whereas autologous predonation was not associated with measurable clinical benefit. Given the substantial heterogeneity and low certainty of evidence, these findings should be interpreted cautiously. Level of Evidence: Level III, systematic review and meta-analysis of predominantly retrospective cohort studies.