Despite the lack of evidence-based standard guidelines to select the best surgical treatment option for end-stage ankle osteoarthritis, the rate of total ankle arthroplasty (TAA) is increasing rapidly relative to ankle arthrodesis (AA) with the development of implant designs and surgical techniques. Physicians and patients would benefit from a more comprehensive understanding of the differences in postoperative pain relief, functional improvement, the rates of complication or reoperation, and restoration of gait ability and sports activity. This paper overviews the current consensus on indications and contraindications for TAA and provides a literature review on a comparison of the clinical and functional results between TAA and AA.