Efficacy of Tranexamic Acid in a Large Population with Proximal Femur Fractures—A Matched Pair Study of 7394 Patients from the Registry for Geriatric Trauma (ATR-DGU)

Background: Perioperative blood loss represents a major challenge in elderly patients undergoing hip fracture surgery. Although tranexamic acid (TXA) has been shown to reduce bleeding complications, evidence from large registry-based cohorts remains limited. This study assessed the efficacy and safety of perioperative TXA administration in geriatric proximal femoral fracture surgery and evaluated in a subgroup analysis whether repeated TXA administration provides additional benefit compared with a single intraoperative dose. Methods: Data were derived from the Registry for Geriatric Trauma of the German Trauma Society (ATR-DGU), a prospective multicenter registry of patients aged ≥70 years undergoing surgery for proximal femoral fractures. From a total cohort of 23,830 patients, 1:1 nearest-neighbor matching based on age, sex, America Society of Anesthesiologists (ASA) classification, fracture type, and pre-fracture mobility yielded 3697 patients receiving intraoperative TXA and 3697 controls without TXA. Outcomes included transfusion requirements, thromboembolic events, mortality, reoperation rate, and length of stay. A subgroup analysis compared single-dose intraoperative TXA with combined pre- and intraoperative administration. Results: Intraoperative TXA significantly reduced packed red blood cell transfusion rates compared with controls (44.6% vs. 52.2%; p < 0.001). No significant differences were observed in thromboembolic events, mortality, overall complication rates, or length of hospital stay. Subgroup analysis showed no additional benefit of repeated pre- and intraoperative TXA administration compared with a single intraoperative dose but was associated with a significantly higher incidence of thromboembolic risks in the multiple-dose cohort (3.56% vs. 1.1%; p = 0.038). Conclusions: Intraoperative TXA administration significantly reduces transfusion requirements in geriatric patients undergoing surgery for proximal femoral fractures without increasing thromboembolic complications or mortality. TXA should therefore be considered a safe and effective adjunct in the perioperative management of geriatric hip fracture patients.