One hundred thirty-three patients undergoing elective total hip arthroplasty were randomized to receive either esketamine-based PCIA (n=44), sufentanil-based PCIA (n=45), or continuous fascia iliaca compartment block (FICB, n=44). The primary outcome was postoperative pain assessed via visual analogue scale (VAS) at rest and during movement. Secondary outcomes included pre- and postoperative anxiety and depression scores (SAS/SDS), patient and surgeon satisfaction, Harris hip function scores at 1 and 3 months, and the incidence of adverse reactions. Outcomes were assessed up to 3 months postoperatively. Overall, the results revealed that esketamine and FICB both provided superior pain control at 48 hours compared to sufentanil, with esketamine also showing better patient satisfaction and mood improvement. These findings suggest that esketamine PCIA is an effective and safer alternative for postoperative analgesia following hip arthroplasty.