Research and development of total ankle replacement is a rapidly expanding field, but ankle fusion remains the “gold standard” in the treatment of ankle arthritis. The transfibular approach is one of the most popular techniques in clinical practice. It offers the advantages of excellent exposure, the ability to minimize wound problems by developing full thickness flaps, and the availability of the distal fibula for local bone graft. Either internal or external fixation may be used, and it has been shown to have a high rate of fusion with low complication rates. With proper alignment of the fusion, the long-term results have shown 80–100% success rate. Long-term studies have raised questions about development of osteoarthritis in adjacent joints (Saltzman) and this has stimulated more research into the field of joint arthroplasty.