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Background Virtual reality (VR) has shown promise as a nonpharmacological alternative to pharmaceutical pain relievers and anxiety medications in clinical trials by decreasing pain and anxiety in orthopedic surgeries. The aim of the study was to evaluate the impact of VR on these outcomes in individuals undergoing total hip arthroplasty (THA). Methods This randomized, controlled, open-label research included 50 participants planned for THA with spinal anesthesia (SA). Patients were allocated equally to group VR: patients were immersed in a peaceful natural environment with soft music preoperatively and intraoperatively, and group C did not receive VR. Results The STAI-S for anxiety and PSS-10 scores for stress were significantly lower in group VR before SA and immediately postoperatively ( P  < 0.05). Hemodynamics at 5 min, 30 min, and 60 min, pain scores at 4 h and 6 h, 24 h pethidine consumption, haloperidol dose, and cortisol level at 6 h postoperative were decrease in group VR in comparision to group C ( P  < 0.05). Time to first analgesia request and satisfaction level were higher in group VR in comparision to group C ( P  < 0.05). Conclusions VR can reduce perioperative anxiety, stress, pain, and opioid requirements, and improve satisfaction in THA patients. Trial registration The trial was registered https://clinicaltrials.gov/study/NCT06088069?id=NCT06088069&rank=1((ID:NCT06088069 , Principal investigator: (SAAD AHMED MOHARAM, Date of registration: 18-10-2023).