Forty patients with osteogenesis imperfecta (OI) were randomized to receive intraoperative tranexamic acid (intravenous plus topical) (n=20) or no tranexamic acid (n=20). The primary outcome was total blood loss. Secondary outcomes included changes in hemoglobin and hematocrit, transfusion rate, operative time, and short-term TXA-related complications. Outcomes were assessed intraoperatively and through the first 24 hours (suction drain and immediate postoperative labs). Overall, the study showed substantially lower blood loss with TXA, a smaller postoperative drop in hemoglobin and hematocrit, a lower transfusion rate, and shorter operative time, with no TXA-related complications observed. These findings suggest integrating TXA into perioperative protocols for femoral telescoping nailing in osteogenesis imperfecta to mitigate blood loss and related morbidity.