Recent advances in prosthesis design, combined with a better understanding of ligamentous balancing and component alignment have renewed interest in total ankle replacement (TAR) as an alternative to ankle arthrodesis in selected patients. The first generation of total ankle prosthesis failed owing to not congruent and unstable designs. Earlier studies for total ankle replacement found excellent or good results in patients who received a newer generation ankle device compared with patients who underwent TAR with previous implants or ankle fusion. Longer follow-up and randomized controlled studies are necessary, but total ankle arthroplasty has become a viable option for surgical treatment of ankle arthritis.