Surgery on the small joints of the hand and wrist can be helpful in certain limited circumstances in patients with RA, particularly if there are fixed deformities; however, such surgeries do not result in fully functional joints. The most interesting thing to me about small joint surgery in RA is that the need for hand and wrist surgery has plummeted; there has been a substantial decrease in referrals for hand and wrist surgery in recent years. We used to see a significant number of tendon ruptures and fixed deformities that were associated with functional impairments, but the number of such cases has declined. The main reason for this decline is the advent of new therapies (eg, bDMARDs, targeted synthetic DMARDs) that are highly effective and have had a beneficial effect on disease activity and joint abnormalities. For example, the authors of a 2015 study in Ireland reported that the rate of musculoskeletal surgical procedures declined by nearly 50% over the previous 15 years and that the decline was mirrored by the rise of early aggressive treatment with disease-modifying therapies such as methotrexate and bDMARDs. The decrease in deformities that require surgery was also evidenced by a large US patient registry study from 2016 that found that the use of mechanical devices has significantly declined in recent years, and that this decline was associated with an increased use of bDMARDs and a decreased level of disease activity in the biologic era. This suggests that advances in treatment have resulted in less disease-related disability. Among specific subgroups, women are more likely to have surgery of the hands and wrists, which may reflect the greater prevalence of osteoarthritis (OA) among female patients. In addition, older individuals who have longer disease durations are also more likely to require small joint surgery because they likely developed RA prior to the introduction of bDMARDs and thus have not benefited from the joint-sparing properties of these agents. In contrast to small joints, large joints (eg, knee, hip) are weight bearing, so this type of joint damage can be more extensive over time, even if the patient is receiving proper treatment for his or her RA. This damage can lead to the development of chronic OA, and damage in these large joints may be due to the underlying RA, OA, and oftentimes, both. Because of this, the use of bDMARDs is unlikely to produce a decline in the rate of knee and hip arthroplasty to the degree that it has produced a decline in small joint surgery.