The decision to use regional or general anesthesia for patients undergoing total joint arthroplasty continues to be controversial. Recent reviews of the literature support the growing trend for the use of regional anesthesia with a multifaceted approach, spanning nuances in block placement as well as pharmacologic agents and delivery systems. Innovative developments offer appealing options and encouraging results for the management of pain after major orthopaedic procedures. The ultimate decision, although varied, requires careful preoperative planning and protocols to ensure adequate pain control and patient satisfaction.