Combined Intravenous and Topical Tranexamic Acid for Blood Loss and Enhanced Recovery After Total Hip Arthroplasty: A Three-Arm Randomized Trial

Abstract Background This study evaluated different topical tranexamic acid (TXA) administration routes combined with intravenous (IV) TXA for perioperative blood loss and enhanced recovery after total hip arthroplasty (THA). Methods In this prospective, patient- and assessor-blinded randomized controlled trial, 96 patients undergoing THA were randomized to three groups (n = 32 each); all received IV TXA 1.0 g 15 minutes before incision. The PAI group received periarticular injection (PAI) (TXA 1.0 g/10 mL) before closure; the combined group received PAI (0.5 g/5 mL) plus intra-articular injection (IAI) (0.5 g/5 mL); the control group received IAI (TXA 1.0 g/10 mL). The primary outcome was total blood loss; secondary outcomes included hidden blood loss, maximum hemoglobin drop, length of hospital stay, time to first ambulation, transfusion rate, Harris Hip Score (HHS), Goodman Satisfaction Score, and inflammatory markers. Results Total blood loss was significantly lower in the PAI group (1,180.44 ± 440.83 mL) and the combined group (1,085.19 ± 353.84 mL) than in the control group (1,549.83 ± 503.66 mL) ( P < 0.01 ), with concordant trends in hidden blood loss and maximum hemoglobin drop. The combined group showed enhanced recovery after surgery (ERAS) benefits, with earlier first ambulation (2.92 vs. 3.28 and 3.18 hours) and shorter hospital stay (4.62 vs. 5.72 and 5.87 days) ( P < 0.05 ). Inflammatory markers, HHS, Goodman Satisfaction Score, transfusion rates, and adverse events did not differ significantly among groups ( P > 0.05 ). Conclusions Combined IV, PAI, and IAI TXA can reduce blood loss, shorten hospital stay, and promote early ambulation without increasing complications. Trial registration Chinese Clinical Trial Registry, ChiCTR2600128882. Registered retrospectively (July 2026).