Osteoarthritis can result in pain, stiffness and deformity, most commonly at the distal interphalangeal (DIP) joint, thumb carpometacarpal (1st CMC) joint and proximal interphalangeal (PIP) joint in the hand. Although osteoarthritis is a multifactorial condition, genetic and environmental factors are thought to play an important role. Treatment options include splintage, injection and analgesia. Where conservative measures fail, joint excision, denervation, fusion or arthroplasty may be considered. At the DIP joint, fusion remains the preferred treatment option for relief of the painful joint, whereas for PIP joint and 1st CMC joint osteoarthritis, motion-preserving procedures are generally preferred. The use of small joint arthroplasty in the hand continues to cause controversy with little consensus, despite a growing evidence base. The evolution and current role of small joint arthroplasty in the hand is explored.