Primary osteoarthritis of the ankle is a rare entity. Osteoarthritis of the ankle more commonly is seen secondary to trauma of the articular surface involving the normal biomechanics of the ankle. The causes are many and treatment consists of prevention of additional deterioration or treatment of that deterioration. The patient with osteoarthritis is plagued by chronic pain and decreased function. The surgical option for treatment includes soft tissue and bony debridement, ligamentous reconstruction, corrective osteotomy, arthrodesis, arthroplasty, or a combination of those treatments. The surgical treatment options are discussed and guidelines are provided for the treatment of ankle arthritis based on current concepts reported in the literature.