Nine randomized controlled trials including 1,024 elderly patients with hip fractures were included in this systematic review and meta-analysis comparing topical tranexamic acid (TXA) with intravenous TXA or placebo. Pooled outcomes of interest included transfusion rates, transfused blood units, hemoglobin drop, hematocrit loss, total blood loss, drain output, hospital stay, surgery duration, deep vein thrombosis (DVT) rate, and mortality. Compared with placebo, topical TXA significantly reduced hemoglobin loss and transfused blood units but had no effect on transfusion rate, total blood loss, DVT, mortality, hospital stay, or surgical time. No significant differences were found between topical and intravenous TXA for any primary or secondary outcomes. In the arthroplasty subgroup, topical TXA significantly reduced hemoglobin drop and total blood loss versus placebo, while no benefit was seen in osteosynthesis. These findings suggest topical TXA can safely reduce some perioperative blood loss parameters in hip fracture arthroplasty, with efficacy comparable to intravenous TXA.