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Background and Aims Total hip arthroplasty (THA) is associated with significant postoperative pain, necessitating opioid-based analgesia that may lead to side effects. The CHENG Protocol, an intraoperative auricular acupuncture technique, has shown promise in enhancing multimodal analgesia by potentially reducing pain, stress, and inflammation. At our high-volume orthopedic institution, this protocol is routinely employed by anesthesiologists. This preliminary report reports various care outcomes in a high throughput optimized surgical setting with high use of peripheral nerve blocks (PNB).Methods We conducted an institutional retrospective cohort study using electronic health records from January 2021 to March 2025, including 2,193 inpatient and 1,075 outpatient THAs. Two groups were compared: those with acupuncture and without PNB (Acu+PNB-), and those without acupuncture and with a PNB (Acu-PNB+). The primary outcome was total opioid utilization in milligram morphine equivalents (MME) within 48 hours. Secondary outcomes were length of hospital stay (LOS, from post-anesthesia care unit entry to discharge) and the average maximum reported pain score during the stay on the 0–10 numeric rating scale. Adjusted regression models measured associations between intervention groups and outcomes.Results Among inpatient THAs, 28.3% were Acu+PNB− and 71.7% Acu−PNB+; in outpatient THAs, 42.0% were Acu+PNB− and 58.0% Acu−PNB+. In adjusted analyses of inpatients, the Acu+PNB− group showed lower 48-hour MME use (74.4 vs. 84.3), shorter LOS (50.6 vs. 59.7 hours), and lower maximum pain scores (4.7 vs. 5.1) compared to the Acu−PNB+ group. No consistent differences were found in outpatient cases.Conclusions Intraoperative auricular acupuncture using the CHENG protocol may reduce opioid use, pain, and LOS in inpatient THA patients, offering a promising non-pharmacologic adjunct to standard care. Further prospective research is needed to confirm these findings and assess its role in outpatient settings.