Although there exist general guidelines regarding which patients are “suitable” candidates for total ankle replacement, these guidelines tend to be very conservative, much like those of knee and hip replacement from decades ago. There are also no direct comparison studies of one total ankle replacement design with another. Because of the paucity of data, surgeons are left to surmise the opinion based on limited studies, as well as industry-sponsored data and advertising material. This article examines several key, controversial issues that apply to total ankle replacement. Recommendations and points for thought are provided.