Total hip replacement is widely regarded as “the operation of the century”[1] due to its excellent long-term outcomes [2]. Its success in restoring mobility and relieving pain has been well established across multiple populations. Despite these advances, access to THR remains uneven, particularly in low-resource and rural settings [5,6]. In countries like India, barriers such as poor healthcare infrastructure, limited surgeon availability, and financial constraints significantly affect outcomes [4,19].

Socioeconomic disparities have been shown to influence both access to surgery and postoperative outcomes [3,21]. Additionally, the burden of untreated musculoskeletal disease remains high in developing regions.

MATERIALS AND METHODS

Study Design

This systematic review followed PRISMA guidelines.[fig 1]

Search Strategy

A structured search of PubMed, Scopus, and Google Scholar was conducted using keywords related to THR and rural healthcare.

Search terms included combinations of:

• “Total hip replacement”
• “Rural healthcare”
• “Low-resource settings”
• “Arthroplasty outcomes”
• “Developing countries orthopaedics”

Eligibility Criteria

Inclusion Criteria:

• Studies published between 2000–2025
• Articles focusing on THR in rural or low-resource settings
• Observational studies, clinical trials, and reviews
• English language publications

Exclusion Criteria:

• Case reports with <5 patients
• Studies from high-resource urban-only settings
• Non-English articles
• Data Extraction

Data extracted included:

• Study design
• Population characteristics
• Identified challenges
• Surgical outcomes
• Complication rates

RESULTS

Study Selection

A total of 42 studies were included after screening and eligibility assessment.[table 2]

Key Challenges [table 1] [fig 2 & 4]

• Delayed Presentation

Late presentation is common due to poor awareness and lack of access to healthcare facilities [11,26]. Patients often present with advanced deformities requiring complex surgical management.

• Financial Constraints

The cost of THR remains a major barrier, particularly in low-income populations [6,25,27]. Out-of-pocket expenditure limits accessibility despite government schemes.

• Infrastructure Limitations

Many rural centers lack essential surgical infrastructure, including modular operating rooms, Laminar airflow systems and infection control systems [4,13,14,15].

• Shortage of Skilled Personnel

There is a global deficit of trained arthroplasty surgeons, inadequate anesthesia support and staff in rural areas [5,12,13].

• Perioperative Risks

Patients often present with comorbidities such as anemia and malnutrition, increasing surgical risk [10,17,23].

• Rehabilitation Barriers

Limited physiotherapy services, Long travel distances and poor follow-up contribute to inferior functional outcomes [18,19].

• Higher Complication Rates

Increased rates of infection, dislocation, and implant failure have been reported in low-resource settings [8,9,22,24]. Primarily due to inadequate follow-up and infrastructure.

• Sociocultural Barriers

Cultural beliefs, gender bias, and reliance on traditional healers delay treatment [11,27,29].

Table 1. Key challenges of THR in rural and resource limited settings.

Table 2. Different studies data extracted for evaluation.

Fig 1. Prisma flow diagram for study design

Fig 2. Challenges for THR observed in rural settings.

Fig 3. Pyramid showing strategies for Improvement

Fig 4. Flowchart showing stages of challenges

DISCUSSION

This review demonstrates that challenges in rural THR are multifactorial, involving patient-related, surgical, and systemic issues. Studies have shown that socioeconomic status significantly influences surgical outcomes and satisfaction [3,21]. Additionally, infection remains a major concern due to inadequate sterilization and infrastructure [9,24].

Strategies for Improvement [fig 3]

• Expansion of insurance coverage
• Training of rural surgeons
• Use of cost-effective implants
• Telemedicine-based follow-up
• Mobile surgical camps and outreach programs

Global health initiatives emphasize strengthening surgical systems to improve access and outcomes [5,20,30].

Innovations such as cemented prostheses and standardized surgical protocols have shown promise in reducing costs and complications.

Clinical Implications

• Orthopaedic surgeons working in rural settings must:
• Adapt surgical techniques to available resources
• Focus on infection prevention
• Ensure patient education and follow-up

CONCLUSION

THR in rural and resource-limited settings presents significant challenges that impact both access and outcomes. Addressing these requires coordinated efforts in healthcare policy, infrastructure development, and clinical training.

Limitations

• Heterogeneity among included studies
• Lack of randomized controlled trials
• Publication bias

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