Background: Blood loss is one of the major perioperative problems in elderly patients undergoing hemiarthroplasty. Such patients, if they require blood transfusion, may be exposed to the complications associated with the same. Intravenous tranexamic acid (TXA) has been used with success in preventing blood loss in total knee arthroplasty and total hip arthroplasty. Concern about thromboembolic complications has led to the topical use of TXA in both TKA and THA. We prospectively evaluated the efficacy of topical TXA for reduction of blood loss in patients undergoing hemiarthroplasty and the related need for blood transfusion. Materials and methods: Fifty-nine patients aged more than 60 years who presented with a fresh femoral neck fracture and were planned for hemiarthroplasty were randomly divided into two groups. Twenty-nine patients (study group) had local use of TXA during surgery, and 30 patients (control) had only placebo. Postoperative blood loss estimation was compared, which was estimated by hemoglobin (Hb) balance formula based on the postoperative fall of hemoglobin and hematocrit when compared to preoperative values. Complications such as postoperative bleeding, rehabilitation delays, and infection rates were documented. Results: The Hb decline on the fifth postoperative day in the study group was 1.15 ± 0.40 g/dL in contrast to 1.97 ± 0.60 g/dL in the control group (p value 0.001). The blood loss in the study group was 694.14 mL when compared to 1000.2 mL in the control group patients (p value 0.001). Conclusion: Despite inherent limitations, the study demonstrated effectiveness of topical use of TXA for decreasing blood loss and reducing need of blood transfusion in hemiarthroplasty patients.