Fifty patients undergoing primary total hip arthroplasty (THA) were randomized to receive intravenous TXA 10 mg/kg (max 1 g) after induction (n = 25) or placebo saline (n = 25). The primary outcome was the degree of fibrinolysis by rotational thromboelastometry (ROTEM) maximum lysis (ML) (ML; fibrinolysis defined as ML > 15% within 1 h). Secondary outcomes included estimated blood loss, transfusion, perioperative labs (CBC, PT/INR, aPTT, fibrinogen, D-dimer), and thrombotic events until discharge. Outcomes were assessed at baseline, 45 min after drug, and 60 min post-surgery. Overall, the results showed no patient developed fibrinolysis and ROTEM parameters remained within normal ranges without between-group differences; however, postoperative D-dimer rose markedly in both groups and was higher with placebo than TXA. These findings suggest routine prophylactic TXA may offer limited benefit in uncomplicated primary THA absent demonstrable fibrinolysis and that viscoelastic testing could guide selective TXA use.