The Influence of Multiple Doses of Intravenous Tranexamic Acid on Transfusions and Complications in the Treatment of Fragility Hip Fractures

OBJECTIVE: To determine the association between multiple intravenous tranexamic acid (TXA) doses and blood transfusions and complication rates in patient treated for fragility hip fractures. DESIGN: Retrospective cohort study. SETTING: Single Level I trauma center. PATIENTS/PARTICIPANTS: Patients that were at least 50 years old and treated for a fragility fracture of the femoral neck (OTA31B), intertrochanteric (OTA31A1/A2), or subtrochanteric (OTA31A3) aspect of the femur between January 2018 and January 2024 were included . INTERVENTION: TXA dosing (i.e. none, single dose, multiple doses) based on institutional protocols. TXA dosing was not based on intra-operative blood loss. MAIN OUTCOMES: The primary outcomes were post-operative blood transfusions, venous thromboembolism (VTE), surgical site infections (SSI), and death within one year of surgery compared among the study groups (patients that received no TXA, a single dose, or multiple doses). RESULTS: A total of 1,691 patients (632 patients [average age 81.4 (53 to 104), 71.8% female] did not receive TXA, 551 [average age 79.9 (51 to 102), 72.4% female] received a single TXA dose, 508 [average age 79.2 (51 to 100), 70.3% female] received multiple TXA doses). Surgical time did not differ between groups (no TXA: 72.6 ± 30.9 minutes, single dose: 74.9 ±32.9 minutes, and multiple doses: 70.6 ± 32.3 minutes, p=0.073). TXA use significantly reduced the risk of blood transfusion compared to the no TXA group (no TXA: 31.8%, single dose: 15.9%, multidose 14.2%, p<0.001). There were no significant differences in transfusion rates with two, three and four doses of TXA compared to the single dose group (single dose: 15.9%, two doses: 15.3% three doses 13.6% and four doses 13.1%, p=0.791). The frequency of VTE was the lowest in the single dose group compared to the other study groups (no TXA: 2.7%, single dose: 0.9%, multiple dose 2.7%, p=0.040). There was no difference in death rates among study groups (no TXA: 9.3%, single dose: 7.3%, multiple dose 8.5%, p=0.433). CONCLUSION: Intravenous tranexamic acid (TXA) reduced transfusion needs without an increased complication rate in comparison to not using TXA. Regression analysis demonstrated that three and four doses of TXA did significantly reduce the transfusion rate beyond a single dose of TXA, but did not provide significant reduction beyond two-doses. LEVEL OF EVIDENCE: Level 3.