Tranexamic Acid in Femoral and Tibial Fracture Surgery A Narrative Review of Administration Routes and Effects on Blood Loss Safety and Fracture Healing

Tranexamic acid (TXA) is used to reduce perioperative bleeding in fracture surgery, but the preferred administration route and its effects on fracture healing remain uncertain. This narrative review examines intravenous, topical, and combined TXA in adult femoral and tibial fracture surgery, emphasizing direct route comparisons and the distinction between blood conservation and patient-centered outcomes. Publications identified in an initial Elicit-assisted evidence report were selectively checked against primary sources, supplemented by targeted source searches. No meta-analysis or formal risk-of-bias assessment was performed. Randomized trials generally support reductions in calculated blood loss with intravenous TXA, although transfusion benefits are not uniform. Topical TXA improves selected blood-conservation outcomes, while direct comparisons with intravenous administration yield procedure-dependent results. Adding local TXA to intravenous treatment reduced calculated blood loss in a tibial nailing trial, but observational hip-fracture studies do not establish a consistent advantage for combined administration. Studies generally did not detect increased thromboembolic events; limited sample sizes and selected populations preclude firm conclusions about uncommon harms or comparative safety. Fracture-union evidence is sparse and does not establish that TXA accelerates healing or that one route is preferable for this purpose. TXA is a useful blood-conservation adjunct in selected femoral and tibial fracture procedures, but current evidence does not support a universal ranking of administration routes. Procedure-specific randomized comparisons with standardized transfusion criteria and longer-term union and functional outcomes are needed.