Background: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level and its potential to decrease waiting list burden in a low-income setting.Methods: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at Mitchell’s Plain Hospital (MPH), a district hospital and Groote Schuur Hospital (GSH), a tertiary academic hospital in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital stay, surgery related readmissions, reoperations, post-operative complications, and mortality were compared between cohorts.Results: 795 primary arthroplasty surgeries were performed at tertiary hospital (TH) level and 228 at district hospital (DH) level. The average hospital stay was 5.2±2.0 days at DH level and 7.6±7.1 days for TH (p<0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p<0.05). Reoperation rate of 1 in every 100 patients at district and 8.3 in every 100 patients at tertiary level (p<0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p>0.05). Periprosthetic joint infection (PJI) rate was 0,43% at DH and 2,26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level.Conclusions: Hip and knee Arthroplasty at district level is safe and may reduce the burden on tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures.Level of Evidence: Level III Retrospective cohort study