Patients with rheumatoid arthritis suffer from systemic manifestations of their disease and their antirheumatic chemotherapies and are often elderly with multiple medical comorbidities. Polyarticular involvement of both the upper and lower extremities and the spine requires special perioperative considerations. In short, the patient profile of patients with rheumatoid arthritis presenting for reconstructive foot and ankle surgery is an elderly, fragile patient with coexisting medical problems. Patients with rheumatoid arthritis often present for surgical management of foot and ankle deformities. All too often, the focus is on their extremity deformities alone. To maximize outcomes, the surgeon must complete a thorough preoperative assessment of numerous factors that may influence the patient with rheumatoid arthritis’ ability to heal and recuperate after surgery. We offer some insight into our perioperative assessment and management strategies for patients with rheumatoid arthritis.