The HINTEGRA ankle was developed as an attempt to specifically address the needs of minimal bone resection, extended bone support, proper ligament balancing, and minimal contact stresses within and around the prosthesis. The purpose of this article was to present the design and rationale of this prosthesis, and to analyze the clinical and radiological short- to mid-term results particularly with respect to the revisions and learning curve. Of the 278 total ankle replacements (between 2000 and 2004) with the HINTEGRA ankle, 271 ankles [patients: 261, males: 133, females: 128, age: 58.4 years (range: 25-90 years)] were clinically and radiographically assessed after 36.1 months (range: 12-64 months). The preoperative diagnosis was post-traumatic osteoarthrosis in 206 cases (76.0%), systemic arthritis in 34 cases (12.5%), and a primary osteoarthrosis in 31 cases (11.5%). Beside 4 perioperative and 19 early postoperative complications, a late complication occurred in 40 cases (14.8%). Of these, 22 complications (8.2%) were not related to implants, and 18 complications (6.6%) were related to implants. In all, 39 cases (14.4%) were revised; of these, 5 cases (1.8%) were revised to ankle arthrodesis. All other 34 revision arthroplasties were successful and did not evidence any differences in the outcome to the non-revised ankles. The AOFAS hindfoot score improved from 40.3 (range: 14-61) to 85.0 (range: 44-100) points at last follow-up. Radiographically, the tibial component was stable in all remaining 266 ankles, and no tilting of the component occurred since surgery. The talar component was positioned too posteriorly in 12 ankles (4.4%). The concept of minimal bone resection and wide bony support was shown to be successful on the tibial and talar sides. Most complications occurred in the early cases of this series, and the learning curve was found to be short and steep. Despite the high amount of post-traumatic cases with limited soft tissue quality, the obtained function, pain relief, and patient satisfaction were promising and, compared with other devices, the results mostly were superior. This may support the belief that anatomically shaped surfaces, as is the case in the HINTEGRA ankle, may advance success in total ankle replacement.