Background: Operating theatre efficiency and utilization patterns in secondary healthcare centers across sub-Saharan Africa remain poorly documented despite their critical role in surgical care delivery. Understanding these patterns is essential for optimizing resource allocation and improving surgical outcomes in resource-limited settings. Objective: To analyze operating theatre utilization patterns, case complexity, resource optimization strategies, and perioperative outcomes in orthopedic surgery at a Nigerian secondary healthcare center, comparing findings with international benchmarks. Methods: A retrospective audit of 62 consecutive orthopedic surgical cases at Adeoyo State Hospital was performed conducted over 36 months from June 2022 to June 2025. Data analyzed included surgical procedures, case complexity, duration, blood loss, transfusion requirements, and perioperative outcomes. Theatre efficiency metrics were calculated, and statistical analysis using SPSS version 21. Results: ORIF procedures dominated (29.0%), followed by hemiarthroplasty (22.6%) and amputations (12.9%). Mean case duration was 3.2±1.4 hours with 51.6% classified as moderate complexity. Blood transfusion was required in 41.9% of cases (mean 1.2±0.4 units). Theatre utilization averaged 65.4% with 70% emergency procedures. Overall complication rate was 6.5% with no perioperative mortality. Mean length of stay was 12.8±6.7 days. Conclusion: Secondary care orthopedic theatres demonstrate efficient utilization despite resource constraints, successfully handling complex cases with acceptable outcomes. However, high transfusion rates and extended hospital stays suggest opportunities for optimization through enhanced perioperative protocols and improved resource planning.