Objective To investigate the comprehensive efficacy and cost-effectiveness of early nutritional intervention combined with acupoint electrical stimulation under the enhanced recovery after surgery (ERAS) concept in elderly patients undergoing total hip arthroplasty (THA), and to verify the robustness of the results through Monte Carlo validation. Methods Elderly patients who underwent THA in the Ziyang Central Hospital between January 2022 and December 2024 were retrospectively selected. Patients who did not implement the ERAS protocol between January and December 2022 were included in the control group, while patients who implemented the ERAS protocol between January 2023 and December 2024 were included in the intervention group. Total hospitalization costs, postoperative complication rates, patient satisfaction, and clinical indicators were collected to construct a comprehensive efficacy score. Monte Carlo validation was used to analyze the incremental cost-effectiveness ratio and parameter uncertainty. Results A total of 140 patients were enrolled, with 70 in each group. There were no statistically significant differences in gender, age, and preoperative indicators between the two groups (P>0.05). The Richmond Agitation-Sedation Scale scores [(?0.03±0.87) vs. (0.53±0.85) points; P<0.05] and the incidence of agitation [5.7% (4/70) vs. 34.3% (24/70); P<0.05] were lower in the intervention group compared to the control group. The total incidence of adverse reactions in the postoperative intervention group [5.7% (4/70) vs. 18.6% (13/70); P<0.05] was lower than that in the control group. The comprehensive efficacy score, hospitalization costs, and cost-effectiveness ratio were all superior in the intervention group compared to the control group (P<0.05). Monte Carlo validation results further confirmed the advantages of early nutrition combined with acupoint electrical stimulation in improving cost-effectiveness. Conclusions ERAS-based early nutritional intervention combined with acupoint electrical stimulation can significantly enhance the comprehensive efficacy and reduce medical costs in elderly THA patients. Monte Carlo validation verifies the robustness of its cost-effectiveness, providing health economic evidence for clinical decision-making.