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Objectives and questions: Periprosthetic joint infection (PJI) remains one of the most devastating complications following total hip arthroplasty (THA). Surgical management strategies vary substantially and include head and liner exchange (HL), one-stage (1S), and two-stage (2S) revision. Contemporary real-world data on treatment patterns, temporal trends, and early failure rates are limited. This study aimed to describe surgical treatment strategies for THA PJI in Ontario, Canada, and to identify patient- and system-level factors associated with revision and early re-revision.

Material and methods: We performed a population-based retrospective cohort study using linked administrative health databases and the Canadian Joint Replacement Registry. All adult patients undergoing primary THA for osteoarthritis between 2012 and 2020 were included. Patients revised for PJI within five years were identified and categorized by initial surgical strategy (HL, 1S, 2S). Multivariable logistic regression was used to identify factors associated with undergoing revision for PJI and repeat revision within two years.

Results: Among 67,267 primary THAs, 312 (0.5%) underwent revision for PJI within five years. Initial revision strategies included HL (n=126, 40.4%), 1S (n=70, 22.4%), and 2S (n=116, 37.2%). From 2012–2014 to 2018–2020, the proportion of 2S revisions decreased from 40.7% to 20.8%, while 1S revisions increased from 22.0% to 35.4% and HL increased from 37.4% to 43.8%. Independent risk factors for revision for PJI included Charlson Comorbidity Index (CCI) ≥2 (OR 1.75, 95% CI 1.12–2.72), higher material deprivation (OR 1.57, 95% CI 1.05–2.37), and longer wait time for primary THA (OR 1.01 per month, 95% CI 1.00–1.02). Within two years after the first PJI revision, 61/312 patients (19.6%) required a second revision: 16.7% after HL, 20.0% after 1S, and 22.4% after 2S. Recurrent infection was the most common indication for repeat revision (HL 76.2%, 1S 57.1%, 2S 84.6%). There were no statistically significant differences in repeat revision risk between strategies. Patients aged ≥80 years had lower odds of repeat revision compared to age 18–59 (OR 0.28, 95% CI 0.08–0.88), while living closer to hospital (0–14 km) was protective (OR 0.40, 95% CI 0.22–0.75).

Discussion and conclusions: In Ontario, surgical management of THA PJI has shifted substantially over time, with declining use of 2S and increasing adoption of 1S and HL exchange. Despite evolving practice patterns, approximately one in five patients required repeat revision within two years, most commonly due to recurrent infection. Comorbidity burden, socioeconomic deprivation, and access to timely primary THA were significant predictors of PJI revision.