BACKGROUND: Total ankle replacement (TAR) has evolved in the last decade from a procedure rife with complication and failure to a promising alternative to arthrodesis. The ability to maintain ankle joint range of motion is showing great promise in patient-reported outcomes, postsurgical pain, as well as long-term sequalae of joint fusion. Although TAR can be performed via either an anterior or lateral approach both with their own sets of benefits and potential complications, the consensus seems to be that one is no better than the other when performed by high-volume surgeons. METHODS: Data were gathered over a 6-year period looking at an age- and gender-matched cohort of lateral approach TARs with either plate osteosynthesis or fibula nail fixation in the management of the fibula osteotomy and compared reoperation and infection rates with the working hypothesis that nail fixation would afford better outcomes. Secondary outcomes including rates of fibula union, tourniquet time as an adjunct to procedure length, and patient-reported outcome measures (PROMs) in the form of FAOS Quality scores were included. RESULTS: A total of 234 TARs were analyzed. Forty-five of these used intramedullary nail fixation (IM), and a control group of 45 plate osteosynthesis (PO) fixation cases was correlated. The CONCLUSION: Our results confirmed that the rates of reoperation and infection were statistically significantly improved with the use of nail fixation over plate fixation. This was tempered by a concerningly high nonunion rate. This article shows promising results for the use of a simple technique in improving long-term outcomes in ankle arthroplasty.