Recent investigations support the belief that ankle replacement represents an attractive surgical alternative to arthrodesis for patients with advanced ankle arthritis. Although longer follow-up is necessary for total ankle arthroplasty (TAA) to displace arthrodesis as the surgical "gold standard," intermediate-term results are encouraging. Indications for TAA include primarily posttraumatic and inflammatory arthritis. Contraindications to TAA include unresectable osteonecrotic bone, peripheral vascular disease, neuropathy, active and/or recent ankle infection, nonreconstructible ankle ligaments, loss of lower leg muscular control, and severe osteopenia or osteoporosis. Young, active, high-demand patients with ankle arthritis may be better candidates for arthrodesis than for TAA. Rigorous patient selection is essential in the success of TAA, more than in other joint arthroplasty procedures. Total ankle prosthetic designs (Agility, Scandinavian Total Ankle Replacement, Hintegra, Salto, and Buechel-Pappas) with a minimum of published intermediate follow-up results, and several other innovative and biomechanically supported designs (the Mobility Total Ankle System, BOX, INBONE, and Salto-Talaris) are reviewed to demonstrate the recent evolution of TAA. Some TAA designs feature a nonconstrained polyethylene meniscus (mobile bearing) that articulates between the porous-coated tibial and talar components. The concern for edge loading (when the polyethylene component comes in contact with a metal edge) has been addressed in more recent designs by reducing the superior polyethylene surface area, expanding the tibial component surface, and even offering a convex tibial component. More practical, effective, and safer instrumentation for implantation has also been developed and has been essential to the success of TAA. However, complications with TAA (such as inadequate wound healing and malleolar fractures) are more frequent when compared with total hip and knee arthroplasty, irrespective of the surgeon's training method. As an individual surgeon gains more experience, the chances of a favorable outcome are increased.