Although ankle arthrodesis has been considered the gold standard for treatment of symptomatic end stage arthritis, recent improvements in arthroplasty designs and instrumentation have led to a resurgence in interest in ankle arthroplasty. While first generation arthroplasty systems had high failure rates due to cemented techniques or highly constrained designs, newer generations of ankle replacements have introduced more anatomic and pressfit techniques. Early results have been promising, with improved functional outcomes versus ankle arthrodesis. However, complication rates are still substantial, and the procedure should be restricted to properly indicated patients. Long-term follow-up studies are necessary, but total ankle arthroplasty has become a viable option for surgical treatment of ankle arthritis.