In advanced stages of ankle osteoarthritis (OA), ankle arthrodesis (AA) or total ankle arthroplasty (TAR) may be necessary. Our purpose is to compare AA and total ankle replacement for the surgical management of end stage ankle OA. We conducted a literature search of PubMed, Medline, CINAHL, Cochrane, Embase and Google Scholar databases using the terms 'ankle' in combination with 'OA', 'arthrodesis', 'arthroplasty', 'joint fusion', 'joint replacement'. Studies where treatment was exclusively total ankle replacement or AA were excluded. Treatment characteristics and outcome parameters (overall postoperative outcome and complication rate) were reviewed. When counseling patients who are considering their options with regard to ankle arthritis treatment, surgeons should determine on an individual basis which procedure is more suitable. TAR has become an accepted treatment for end-stage OA, but revision rates for TAR are significant higher than for AA (odds ratio 2.28 95% confidence interval CI, 1.63-3.19; P < 0.0001). The results of TAA are gradually improving, but the procedure cannot yet be recommended for the routine management of ankle OA. Although there is some evidence to support TAR to conserve ankle motion and offer improved function and decreased pain with high satisfaction rates, revision rates for TAR are significantly higher than revision rates for AA. Proper patient selection should be better addressed in future studies for successful treatment of end-stage ankle OA. Systematic review, level III.