One hundred sixty-five elderly patients with intertrochanteric fractures were randomized to receive intramedullary TXA perfusion (n=83) or intramedullary saline alone (n=82 randomized) during proximal femoral nail antirotation (PFNA) surgery. The primary outcomes were total peri-operative blood loss and post-operative concentrated red blood cell (CRBC) transfusion rate. Secondary outcomes included hidden blood loss, peri-operative haemoglobin trends, transfusion volume and cost, thrombotic events (including lower-limb DVT, myocardial infarction, stroke, pulmonary embolism), re-operation, wound infection, and 3-month mortality. Outcomes were assessed from admission through the peri-operative period to 3 months after surgery. Overall, the results of the study revealed that intramedullary TXA significantly reduced total peri-operative and hidden blood loss, lowered transfusion rates and blood-related costs, without increasing DVT or short-term mortality compared with saline. These findings suggest that intramedullary TXA is an effective and apparently safe adjunct for blood management in elderly patients undergoing PFNA fixation for intertrochanteric fractures.