Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis much like its total hip and knee counterparts. Orthopaedic surgeons are well equipped to evaluate and treat patients with end-stage hip or knee arthritis; however, the management of patients with ankle arthritis represents a challenge to both general orthopaedic surgeons and to the foot and ankle surgeons to whom these patients are often referred. Although techniques for both hip and knee arthroplasty have evolved to provide long-term pain relief and functional improvement, neither ankle arthrodesis nor arthroplasty has demonstrated comparably favorable outcomes in long-term follow-up studies. Early ankle arthroplasty designs with highly constrained cemented components were abandoned due to unacceptably high failure rates and complications. While arthrodesis is still considered the "gold standard" for treatment of end-stage ankle arthritis, progression of adjacent joint arthrosis and diminished gait efficiency has led to a resurgence of interest in ankle arthroplasty. Long-term outcome studies for total ankle replacement found excellent or good results in 82% of patients who received a newer generation ankle device compared with 72% if undergoing ankle fusion. Continued long-term follow-up studies are necessary, but total ankle arthroplasty has become a viable option for surgical treatment of ankle arthritis.