Objective To compare the advantages and disadvantages of iliac fascia block (blocking femoral nerve, lateral femoral cutaneous nerve and obturator nerve simultaneously) composite laryngeal mask anesthesia with spinal anesthesia in elderly patients (≥80 years old) undergoing artificial femoral head replacement (not bone cement type), so as to explore the individualized anesthesia scheme for orthopedic elderly patients. Methods We retrospectively analyzed the anesthesia-related data of 98 elderly patients (≥80 years old) undergoing artificial femoral head replacement, including 44 cases with iliac fascia block composite laryngeal mask anesthesia in group G and 54 cases with spinal anesthesia in group S, with the American Association of Anesthesiologists (ASA) grade being Ⅱ-Ⅳ. Mean arterial pressure (MAP) and heart rate (HR) of patients were recorded before anesthesia induction, and after anesthesia induction for 5, 10, 15, 20, and 30 min. Visual Analogue Scale (VAS) score was recorded before surgery, immediately after surgery, and at 6 h, 24 h after surgery. The number of methamphetamine used, complications, incidence of side effects, length of hospital stay, and sleep quality before and 1 day after operation were recorded, and surgeon's satisfaction with the anesthesia scheme was investigated. Results There were no significant differences in age, gender or body mass index of patients between the two groups. The number of ASA Ⅳ patients in the group G was significantly larger than that in the group S (P<0.05). VAS score in the group G was significantly lower than that in the group S (P<0.01) at 6 h and 24 h after surgery, and the analgesic effect was satisfactory. There was no significant difference in hemodynamics between the two groups before and after anesthesia induction. The number of methamphetamine used in the group G was significantly higher than that in the group S (P<0.01). Incidence of postoperative urinary retention in the group S was significantly higher than that in the group G (P<0.05). There was no significant difference in length of hospital stay after surgery between the two groups (P>0.05). Conclusion Individualized anesthesia scheme for elderly patients undergoing hip arthroplasty should be considered. In selected patients, iliac fascia blockade composite laryngeal mask anesthesia has longer time of postoperative analgesia, and is safer and more feasible compared with spinal anesthesia.