Effectiveness of preoperative intravenous tranexamic acid on reduction of perioperative blood loss in open intramedullary nail fixation of femoral shaft fractures in a tertiary hospital, Uganda: a prospective cohort study

Open intramedullary nailing of femoral shaft fractures (OIN) is frequently performed in low-resource settings where limited access to fluoroscopy necessitates open reduction techniques associated with substantial perioperative blood loss. In environments where blood supply is constrained and transfusion carries additional risks, strategies to minimize bleeding are critical. Tranexamic acid reduces perioperative bleeding in multiple orthopaedic procedures; however, evidence supporting its use during OIN in low- and middle-income countries remains limited. We conducted an open-label, single-arm prospective cohort study at a tertiary hospital in Uganda between December 2018 and March 2019. Adult patients undergoing OIN received a single preoperative intravenous dose of tranexamic acid (15 mg/kg). Perioperative blood loss was assessed using change in haemoglobin concentration measured preoperatively and at 72 h postoperatively, and compared with a historical institutional mean from patients managed without tranexamic acid. Secondary outcomes included blood transfusion requirements and adverse events. Forty-three patients were included. The mean perioperative haemoglobin decline was 1.7 g/dL. This observed decline was lower than the historical mean of 3.31 g/dL reported in cohorts managed without tranexamic acid, corresponding to a mean difference of 1.6 g/dL (p < 0.001). Two patients (4.7%) required intraoperative blood transfusion, each receiving one unit of whole blood. No postoperative transfusions were administered. Minor adverse events were infrequent, and no clinically apparent thromboembolic events were identified during the follow-up period. Preoperative intravenous tranexamic acid was associated with reduced perioperative blood loss and low transfusion requirements during OIN in this resource-limited setting. Controlled studies are needed to confirm these findings. ClinicalTrials.gov NCT07261930. Retrospectively registered on 21 July 2025.