Background and purpose Total ankle replacement is an established surgical procedure in patients with end-stage ankle osteoarthritis. We analyzed complications and medium-term results in patients with simultaneous bilateral total ankle replacement. Patients and methods 10 women and 16 men, mean age 60 (SD 13) years, were followed for a median of 5 (2–10) years. Results There were no intraoperative or perioperative complications, with the exception of 1 patient with prolonged wound healing. Major revision surgery was necessary in 6 of the 52 ankles, including 4 revisions of prosthetic components. The average pain score decreased from 6.9 (4−10) to 1.8 (0−4) points. The American Orthopaedic Foot and Ankle Society hindfoot score increased from 32 (SD 14) points preoperatively to 74 (SD 12) points postoperatively. The average range of motion increased from 28° (SD 12) preoperatively to 38° (SD 9) postoperatively. All 8 categories of SF-36 score improved. Interpretation Simultaneous bilateral total ankle replacement is a suitable method for restoration of function and attainment of pain relief in patients with bilateral end-stage ankle osteoarthritis. The results of this procedure, including complication rates, revision rates, and functional outcome, are comparable to those reported in patients with unilateral total ankle replacement.