Joint preservation is the alternative to fusion or replacement. The strategy depends on the specific disease: realigning the joint to load it more evenly (a supramalleolar or fibular osteotomy), repairing or replacing the worn cartilage in a focal lesion (microfracture, AMIC, OATS, or MACI), or off-loading the joint temporarily with an external fixator to let inflamed cartilage recover (joint distraction). These are not procedures that suit every patient with ankle pain. They are right for a specific window: younger patients (broadly under fifty), with focal cartilage damage or asymmetric wear, in whom an aggressive operation now might delay or avoid an ankle replacement later. The work-up is therefore careful — weight-bearing CT, MRI, sometimes a diagnostic arthroscopy — and the conversation is honest. Preservation surgery is more demanding than its end-stage alternatives, recovery is longer, and outcomes are good in well-selected patients rather than universally excellent.