Coronal plane deformity has been found to be one of the main risk factors for poor clinical results, higher complication rates and failure of total ankle replacements. Initially, many authors considered a malalignment of more than 10° to be a contraindication for total ankle replacement, however, several publications later underlined the usefulness of the distinction of different etiologies of hindfoot malalignment. This subsequently led to suggestions for additional procedures in order to avoid early implant failure.The aim of the present article is to illustrate the different causes of varus malaligned arthritic ankles and to present procedures to balance these ankles at the time of replacement.