Abstract
BACKGROUND: Intertrochanteric fractures in older adults are associated with substantial blood loss, but the optimal tranexamic acid (TXA) regimen remains unclear. Most hip fracture studies have evaluated single-route intravenous TXA versus placebo, with limited data on combined regimens, particularly in the very old. METHODS: We conducted a multicentre retrospective cohort study of patients aged ≥65 years with intertrochanteric fractures who underwent closed reduction and intramedullary nailing at four hospitals. Patients were classified into four groups by intraoperative TXA regimen: combined intravenous plus topical, intravenous only, topical only, or no TXA. Inverse probability weighting was used to address confounding and between-group imbalances. The primary outcome was total blood loss; intraoperative and hidden blood loss were also assessed. Secondary outcomes included transfusion status and volume and 90 day complications. Prespecified age strata (65-74, 75-84, and ≥85 years) were analysed for total blood loss and transfusion rate, and treatment-by-age interaction terms tested age-related differences in treatment effects. RESULTS: We included 1,228 patients; weighting achieved good baseline balance between treatment groups. All TXA regimens significantly reduced total blood loss compared with no TXA, with the largest reduction in the intravenous-plus-topical group, which had the lowest transfusion rate and volume. TXA was not associated with higher rates of thrombotic events or other major complications, and postoperative length of stay was shorter in the intravenous-plus-topical and topical-only groups than in controls. Age-stratified analyses showed a significant treatment-by-age interaction for total blood loss; TXA reduced blood loss across all age strata, and its transfusion-sparing effect did not diminish with age. CONCLUSION: In older adults undergoing intramedullary fixation for intertrochanteric fractures, TXA reduces blood loss without increasing complications, with greatest benefit from combined intravenous plus topical use. These findings support TXA as a key component of perioperative blood management in this population.