Hemophilia increases risk of bleeding and thromboembolism after total shoulder arthroplasty

Background: Hemophilia, including hemophilia A, hemophilia B, and related coagulation disorders, poses unique perioperative challenges in total shoulder arthroplasty (TSA). Factor replacement and postoperative immobilization may paradoxically increase thromboembolic risk, yet the literature defining venous thromboembolism (VTE) and other complications in this population is limited. We aimed to charac-terize 90-day postoperative outcomes among patients with hemophilia undergoing TSA. Methods: A multicenter electronic health record database (TriNetX Global) was retrospectively analyzed to identify patients undergoing TSA between December 2005 and December 2025. Patients with hemophilia were compared to propensity-matched controls based on rele-vant comorbidities. Primary outcomes included 90-day rates of readmission, periprosthetic joint infection (PJI), revision surgery, and bleeding complications. Secondary outcomes included deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, pneumonia, acute kidney injury (AKI), and urinary tract infection (UTI). Odds ratios with 95% CIs were calculated. P-value <0.05 was considered statistically significant. Results: Compared with matched controls, patients with hemophilia had significantly higher rates of readmission and revision surgery. They also demonstrated increased risk of bleeding complications and thromboembolic events, including DVT, PE, VTE, and stroke. Higher rates of postoperative medical complications, including pneumonia, AKI, and UTI, as well as greater postoperative opioid prescription utilization were observed. Rates of PJI did not differ between groups. Conclusions: Patients with hemophilia are at significantly increased risk of thromboembolic complications and revision surgery following TSA. Prospective studies evaluating preoperative optimization and management of modifiable VTE risk factors are warranted. Level of evidence: III.