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. DESIGN: Retrospective cohort study. SETTING: Multicenter 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 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 nonautologous red blood cell transfusion and 90-day postoperative complications. Minor and major complications analyzed were mortality, DVT, PE, myocardial infarction, 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 7644 patients were included in the study. The mean age was 57.0 ± 23.2 in the TXA group (n = 3,822, 54.1% women) and 57.0 ± 23.2 in the non-TXA group (n = 3,822, 52.3% women). Transfusion rates were lower in the TXA cohort (8.37%) than in 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%) than in the non-TXA cohort (2.15%) [OR 0.60 (0.42-0.86), P = 0.005]. No significant differences were observed in DVT [ P = 0.298], PE [ 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. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.