Total knee arthroplasty (TKA) is associated with an increased need for blood transfusions and thus an increase in risks associated with blood transfusion such as transfusion reactions, infections, fluid overload, and altered mental status. Tranexamic acid (TXA) is an antifibrinolytic medication that can reduce perioperative blood loss in TKA. However, the best method of delivery has not been defined although topical intra-articular TXA (IA-TXA) may have a theoretical advantage as it is applied directly when and where it is needed to control bleeding. Blinded and nonblinded randomized controlled trials and case-controlled trials published since 2010 were found using database searches. Data were extracted and analyzed with the goal of discovering through meta-analysis if IA-TXA reduces blood loss, blood transfusions, and without increasing adverse events, especially thromboembolic events, compared with placebo. Blood loss from suction drains and calculated total blood loss were significantly lower in the IA-TXA group. The frequency of blood transfusion and the number of units of blood transfused were significantly lower in the IA-TXA group. The risk of adverse events was not increased for IA-TXA versus placebo. Topical IA-TXA in primary, unilateral TKA successfully reduces blood loss and the frequency of blood transfusions. In addition, it does not appear to increase the risk of thromboembolic adverse events. There is need for further research to determine the optimal dosage and the preferred delivery system of IA-TXA in TKA.