It is not rare for a patient to have disease of the ankle and one or more hindfoot joints. Arthritic degeneration is commonly seen as a late result of trauma, while major deformity may develop with neuromuscular disorders. When symptoms no longer respond to nonoperative measures, combined fusion of the ankle and hindfoot joints is often a good option. The goal of such surgery is to restore alignment and relieve pain. The multiply fused foot is far inferior to the normal condition, with stiffness and varying degrees of aching almost universal. Surgery is usually performed through a lateral transfibular approach. Alignment in the ankle, hindfoot, and forefoot must be precisely restored. Then rigid internal fixation with lag screws maintains the position until fusions have healed. Finally, muscle balance must be restored to prevent the development of deformity in the remaining joints. With good technique, high rates of union and patient satisfaction can be achieved. However, distal joint degeneration can be expected in long-term follow up. For this reason, we have begun performing total ankle replacement in extremities with multiple fusions.