Introduction: Drain use in total knee arthroplasty (TKA) remains controversial. Use has been associated with increased complications, particularly post-operative transfusion, infection, increased cost, and longer hospital stays. However, studies examining drain use were performed before widespread adoption of tranexamic acid (TXA) which markedly reduces transfusion without increasing VTE events. We aim to investigate incidence of post-operative transfusion and 90-day return to the operating room (ROR) for hemarthrosis in TKA with use of drains and concomitant intravenous TXA. Methods: Primary TKAs from a single institution were identified from August 2012-December 2018. Inclusion criteria were primary TKA, age 18 years and over where use of TXA, drains, anticoagulant, and pre-and post-surgical Hb were documented during the patient’s admission. Primary outcomes were 90-day ROR specifically for hemarthrosis and rate of post-operative transfusion. Results: A total of 2008 patients were included. Sixteen patients required ROR, three of which were due to hemarthrosis. Drain output was statistically higher in the ROR group (269.3mL vs. 152.4mL (p = 0.05)). Five patients required transfusion within 14 days (0.25%). Patients requiring transfusion had significantly lower presurgical Hb (10.2g/dL, p=0.01) and 24-hr postoperative Hb (7.7g/dL, p< 0.001). Drain output between the transfusion and no transfusion groups varied significantly (p=0.03), with transfusion patients having higher POD 1 drain output of 362.6mL and total drain output of 376.6mL. Conclusion: In this series, post-operative drain use with concomitant weight-based IV TXA is shown to be safe and efficacious. We observed exceedingly low risk of post-operative transfusion compared to prior reports of drain use alone, as well as preserved low rate of hemarthrosis that has previously been positively linked to drain use.