Reinfection and complication rates in two-stage revision for chronic hip periprosthetic joint infections using the direct anterior approach

Introduction: The direct anterior approach (DAA) used in primary total hip arthroplasty (THA) is gaining popularity and has infection rates comparable to other surgical approaches. While two-stage revision remains the gold standard for chronic periprosthetic joint infection (PJI), little data exist on the DAA. This study evaluated reinfection, and complication rates of two-stage septic revisions performed using the DAA. Methods: This retrospective single-center study included data from 8476 patients who underwent primary THA using the DAA between 2013 and 2024. All patients who underwent a two-stage procedure for chronic PJI were included. Clinical outcomes, complication rates, and microbiological spectrum were assessed. All patients received an antibiotic-loaded cement spacer at first stage, followed by antimicrobial therapy. Results: We identified 36 / 8476 (0.4 %) patients (female: 41.7 %, male: 58.3 %) who underwent septic two-stage revision after primary DAA THA. Infection-free survival was 83.4 % at a median 6.2-year follow-up. Successful second-stage reimplantation occurred in 28 / 36 patients (77.8 %), while 2 / 36 (5.6 %) remained infection free after a 1.5-stage procedure due to being clinically unfit for reimplantation. Four patients (11.1 %) underwent a second stage but developed reinfection, requiring septic revision. Two patients (5.6 %) had failed first stage and underwent a Girdlestone procedure. The reinfection rate was 11.1 %, all culture positive at the second stage. Spacer-related complications occurred in 2 / 36 (5.6 %), including one dislocation (2.8 %) and one spacer fracture (2.8 %). Revision for dislocation after the second stage was required in 3 / 36 (8.3 %). Patients with successful reimplantation were younger (P<0.001). Most common microorganisms were Cutibacterium spp. (28.8 %) and coagulase-negative Staphylococci (26.9 %). Conclusions: Two-stage septic revision using the DAA shows reinfection rates comparable to other approaches, with low rates of spacer dislocation and postoperative dislocation after reimplantation.