We evaluated the incidence and risk factors for postoperative ileus (POI) after total joint arthroplasty in a consecutive group of patients between January 2004 and December 2005 using regional anesthesia and multimodal pain management protocols. Postoperative ileus developed in 31 (0.7%) of 4567 patients. Of these patients, 21 (67.7%) were men, and 10 (32.3%) were women, with a mean age of 68 years (range, 52-91 years). The ileus was treated successfully in 29 patients during the hospitalization. One patient died from this complication, and another one required sigmoid colon resection due to perforation. The risk factors for developing POI after joint arthroplasty were older age, male sex, hip arthroplasty, and prior history of abdominal surgery. The type and dose of narcotic medications, as administered using our current protocol, did not appear to influence the development of POI.