Total ankle replacement is emerging as a viable treatment for symptomatic ankle arthritis that has not responded to nonoperative treatment. Most modern implant designs involve the use of a three-component, mobile-bearing implant. Although the results of the different design approaches are encouraging in limited clinical series, there is still the need for careful, long-term analyses to estimate to what extent the current designs are mimicking the biomechanics of the ankle joint. More attention must be paid to more accurate implantation techniques that result in a well-balanced ligament and allow the ligaments to act together with the replaced surfaces in a most physiologic manner. To improve the stability of the bone-implant interface over time, specific efforts should be made to better understand the extrinsic and intrinsic forces of the ankle joint, including the forces that are created by the prosthesis itself.