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 2-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 8,476 patients who underwent primary THA using the DAA between 2013-2024. All patients who underwent a 2-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 1^st-stage, followed by antimicrobial therapy.

Results: We identified 36/8,476 (0.4%) patients (Female:41.7%, Male:58.3%) who underwent septic 2-stage revision after primary DAA-THA. Infection-free survival was 83.4% at a median 6.2-year follow-up. Successful 2^nd-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 2^nd-stage but developed reinfection requiring septic revision. Two patients (5.6%) had failed 1^st-stage and underwent Girdlestone procedure. Reinfection rate was 11.1%, all culture-positive at the 2^nd-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 2^nd-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.