BACKGROUND: For elderly patients with rheumatoid arthritis, aggressive immunosuppression can be difficult to tolerate, and surgery remains an important treatment option for joint pain and deformity. We sought to examine the epidemiology of surgical reconstruction for rheumatoid arthritis among older individuals who were newly diagnosed with the disorder. METHODS: We identified a 5% random sample of Medicare beneficiaries (sixty-six years of age and older) newly diagnosed with rheumatoid arthritis from 2000 to 2005, and followed these patients longitudinally for a mean of 4.6 years. We used univariate analysis to compare the time from the diagnosis of rheumatoid arthritis to the first operation among the 360 patients who underwent surgery during the study period. RESULTS: In our study cohort, 589 procedures were performed among 360 patients, and 132 patients (37%) underwent multiple procedures. The rate of upper extremity reconstruction was 0.9%, the rate of lower extremity reconstruction was 1.2%, and knee arthroplasty was the most common procedure performed initially (31%) and overall (29%). Upper extremity procedures were performed sooner than lower extremity procedures (fourteen versus twenty-five months; p = 0.02). In multivariable analysis, surgery rates declined with age for upper and lower extremity procedures (p < 0.001). CONCLUSIONS: Knee replacement remains the most common initial procedure among patients with rheumatoid arthritis. However, upper extremity procedures are performed earlier than lower extremity procedures. Understanding the patient and provider factors that underlie variation in procedure rates can inform future strategies to improve the delivery of care to patients with rheumatoid arthritis.