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OBJECTIVE To determine and compare the clinical efficacy of spinal anesthesia with bupivacaine combined with fentanyl and bupivacaine alone in geriatric patients scheduled for total hip arthroplasty (THA). STUDY DESIGN Experimental study. PLACE AND DURATION OF STUDY Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China, from April 2016 to April 2017. METHODOLOGY Sixty-five geriatric patients were randomised into two groups. Group B was anesthetised with 0.5% bupivacaine 10 mg and Group F with 0.5% bupivacaine 7.5 mg plus fentanyl 20 μg. Hemodynamic stability, effect and satisfaction of anesthesia, time to the first postoperative analgesic requirement, adverse effects, and incidence of postoperative indwelling catheter were compared. RESULTS There was no significant difference in time to reach maximum sensory block level, maximum sensory block level, maximum motor block, duration of motor block, quality of anesthesia, adverse effects or the incidence of postoperative indwelling catheter between the two groups. However, Group F required less dosage of ephedrine for stable hemodynamics and longer time to use the primary postoperative analgesic in comparison to Group B (p<0.05). CONCLUSION Adding 20 μg fentanyl to a lower dose of 7.5 mg bupivacaine can provide safe and effective spinal anesthesia for THA in geriatric patients.