Efficacy and safety of tranexamic acid in patients undergoing hip hemiarthroplasty: an updated systematic review and meta-analysis.

Hip hemiarthroplasty for femoral neck fractures is often associated with substantial perioperative blood loss and transfusion requirements. Tranexamic acid (TXA) may reduce bleeding, but concerns remain regarding thromboembolic safety. This systematic review and meta-analysis evaluated the efficacy and safety of TXA in hip hemiarthroplasty. PubMed, Embase, and Cochrane were searched from inception to February 2026. Randomized controlled trials and cohort studies comparing TXA with no TXA or no TXA in patients undergoing hip hemiarthroplasty were included. Random-effects meta-analyses were performed to pool risk ratios (RRs) and mean differences (MDs), with subgroup and sensitivity analyses conducted to assess the robustness of the findings. The primary outcome was total blood loss. Secondary outcomes included postoperative haemoglobin, transfusion requirement, mortality, thromboembolic events, surgical site infection, stroke MI and length of hospital stay. Although total blood loss was the pre-specified primary outcome, transfusion requirement was also evaluated as an important secondary outcome because of its direct clinical relevance. Fourteen studies comprising 7,660 patients (3,271 TXA and 4,389 controls) were included. TXA significantly reduced allogeneic transfusion requirements (RR 0.48, 95% CI 0.38-0.61; P<0.001) and improved postoperative day-1 haemoglobin (MD 0.48 g/dL, 95% CI 0.14-0.83; P=0.011). A reduction in 30-day mortality (RR 0.69, 95% CI 0.49-0.96; P=0.029) and length of hospital stay (MD -1.57 days, 95% CI -3.12 to -0.03; P=0.047) was observed, although both findings were sensitive to individual studies and should be interpreted cautiously. Total blood loss was not significantly different between groups (MD -162.73 mL, 95% CI -346.49 to 21.02; P=0.076) because of extreme heterogeneity. TXA was not associated with an increased risk of DVT, PE, MI, stroke, or surgical site infection. No significant differences were observed between intravenous and intra-articular administration. TXA is an effective and safe adjunct in patients undergoing hip hemiarthroplasty. It significantly reduces transfusion requirements and preserves early postoperative haemoglobin without increasing major postoperative complications. Although reductions in 30-day mortality and length of hospital stay were observed, these findings require cautious interpretation because they were less robust and largely derived from observational evidence. Further high-quality randomized controlled trials are warranted to confirm these potential benefits.