Because of the good functional results and satisfactory implant survival achieved with modern models, total ankle replacement (TAR) has become a legitimate alternative to ankle fusion. However, alignment and balance are mandatory for implant survival. Satisfactory results can be achieved in patients with significant preoperative deformity if alignment and balance were obtained. If not, a staged procedure involving deformity correction and secondary TAR is possible. The authors describe the principal aspects of this concept and illustrate their current approach to TAR in cavovarus deformity.