Efficacy and safety of combined intravenous and topical tranexamic acid in primary total hip arthroplasty: a meta‑analysis and systematic review of randomized controlled trials

Both intravenous (IV) and topical tranexamic acid (TXA) reduce bleeding in total hip arthroplasty (THA), but the added benefit of combining the two routes and the potential modifying effect of topical dose remain unclear. We performed a systematic review and meta‑analysis of RCTs comparing combined IV+topical TXA versus IV TXA alone or topical TXA alone in primary THA. We searched PubMed, Embase, Cochrane Library, Web of Science, and Chinese databases up to December 2025, following PRISMA guidelines. Outcomes assessed included total blood loss, hemoglobin decline, transfusion rate, DVT, and PE. Topical‑dose subgroup analyses (< 2 g vs. ≥2 g) were conducted for the combined‑versus‑topical comparison. Eleven RCTs (1499 patients) were included. Compared with IV alone, combined TXA significantly reduced TBL (MD − 143.04 mL, 95% CI − 218.93 to − 67.15, P = 0.0002, I²=90%), hemoglobin decline (MD − 0.52 g/dL, 95% CI − 0.73 to − 0.30), and transfusion rate (RD − 0.07, 95% CI − 0.10 to − 0.03), with no increase in DVT/PE. Compared with topical alone, combined TXA also reduced TBL (MD − 217.65 mL, 95% CI − 283.41 to − 151.90, P < 0.00001, I²=83%). Subgroup analysis suggested a potential modifying effect of topical dose (P for interaction = 0.04), with numerically larger blood loss reduction when the topical dose was < 2 g(304 mL) versus ≥ 2 g (168 mL); however, this finding is hypothesis‑generating and requires confirmation. Combined IV and topical TXA is effective in primary THA, reducing blood loss and transfusion requirements compared with either route alone. Exploratory subgroup analysis suggests a potential modifying effect of topical dose (< 2 g vs. ≥ 2 g), but this hypothesis-generating observation requires confirmation in future dose-comparison RCTs.No increased thromboembolic signal was detected in the available RCTs.