To evaluate the efficacy and safety of tranexamic acid (TXA) in reducing perioperative blood loss in patients with intertrochanteric fractures (ITF) undergoing proximal femoral nail antirotation (PFNA) treatment.

Randomized controlled trials (RCTs) evaluating the effect of TXA on perioperative blood loss in ITF patients treated with PFNA were searched in medical electronic databases, including China National Knowledge Infrastructure, China Biology Medicine Database, VIP Journal Integration Platform, Wanfang Data Knowledge Service Platform, Web of Science, PubMed, Excerpta Medica Database (Embase), and Cochrane Library, from the establishment of each database up to October 31, 2024. The quality and risk of bias of the included studies were assessed using the modified Jadad scale and the Cochrane Risk of Bias Tool 2.0 for randomized controlled trials. Meta-analysis, heterogeneity analysis, sensitivity analysis, subgroup analysis, publication bias analysis, trim-and-fill analysis, and trial sequential analysis were performed using StataSE 15, with trial sequential analysis conducted using TSA 0.9.5.

This study included 21 RCTs with a total of 1 938 patients. Meta-analysis indicated that compared to equivalent normal saline or placebo controls, TXA significantly reduced total blood loss [mean difference (MD)=-225.42, 95% confidence interval (CI) (-281.49, -169.36), P<0.001], hidden blood loss [MD=-215.43, 95% CI (-267.48, -163.38), P<0.001], and transfusion rate [relative risk (RR)= 0.54, 95% CI (0.48, 0.62), P<0.001]. It also reduced visible blood loss, intraoperative bleeding, postoperative 24h drainage volume, transfusion volume, and maintained hemoglobin concentration on the third postoperative day without significantly increasing the incidence of serious adverse events. Subgroup analysis demonstrated that the reduction in perioperative blood loss for patients with ITF treated with PFNA using TXA was not influenced by the type of intervention, average patient age, average body mass index (BMI), preoperative hemoglobin concentration, or total TXA dosage, all showing significant superiority over the control group. The publication bias analysis did not reveal significant publication bias for primary outcomes such as total blood loss, hidden blood loss, and transfusion rate. Trial sequential analysis further confirmed the robustness of the conclusions regarding the primary outcome measures.

TXA is effective and safe in reducing perioperative blood loss in ITF patients undergoing PFNA. However, due to methodological and design limitations in existing studies, these conclusions should be interpreted with caution. More rigorously designed and high-quality RCTs are needed in the future to further validate these findings.