Improved designs and surgical technique has led to much better mid-term and longer term outcomes than the first generation ankle replacements of the 1970's. However, there remains multiple recent papers discussing the many potential complications with total ankle replacement surgery. As we proceed into the future, one should be cognizant of the pitfalls and know how to deal with the difficult ankles, especially varus and valgus deformities. There should also be a clear understanding that the greater the varus or valgus, the more challenging the procedure, and the less predictable the outcome of a total ankle replacement.