Ankle osteoarthritis (OA) is a painful debilitating condition that affects approximately 1% of the world’s adult population. 70-80% of ankle OA cases are posttraumatic with the three leading causes being malleolar fractures, intraarticular fractures of the distal tibia and ligamentous ankle injuries. On average it takes 21 years for end-stage ankle OA to develop after a malleolar fracture, and 25–38 years after an ankle ligament injury. The goals of treatment are pain management and reduction in disability in activities of daily living. Pain medication, orthotics and bracing, as well as physical therapy to improve muscle function and intraarticular injections are all part of conservative management. Surgical treatment aims at alleviation of symptoms either preserving the native joint via arthroscopic debridement or osteotomies, or sacrificing the joint with an ankle arthrodesis or a replacement. The search for the perfect treatment of end-stage ankle OA continues.