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Introduction: Preoperative optimization of obese patients is a critical component of risk stratification in primary total hip arthroplasty (THA). Body mass index is ubiquitously utilized as a proxy for obesity due to its ease of attainment and simplistic interpretation. The use of adiposity as a proxy for obesity is an emerging concept. Local adiposity provides insight into the magnitude of peri-incisional tissue and has demonstrated an association with postoperative complications. Our objective was to review the literature to determine if local adiposity is a reliable predictor for complications following primary total hip arthroplasty., Methods: In keeping with the PRISMA guidelines, a database search of PubMed was conducted for articles which reported on the relationship between quantified measures of adiposity at the hip and rates of complication following primary THA. Methodological quality was assessed using GRADE and risk of bias using ROBINS-I., Results: A total of six articles (N = 2931) met the inclusion criteria. Local adiposity at the hip was measured on anteroposterior radiograph in four articles and was measured intraoperatively in two. Across four of the six articles, adiposity was significantly associated with postoperative complications including prosthesis failure and infection., Conclusion: The use of BMI as a predictor for postoperative complication has been fraught with inconsistency. There is momentum for adiposity to be used as a proxy for obesity in preoperative THA risk stratification. The current findings demonstrated that local adiposity may be a reliable predictor for complications following primary THA., Competing Interests: The authors declare no potential conflicts of interests with respect to the research, authorship, and/or publication of this article., (©2023ProfessorPKSurendranMemorialEducationFoundation.PublishedbyElsevierB.V.)