Ankle osteoarthritis often presents in patients with a history of lower leg trauma. Hence, they are young with sportive demands and in the active labor phase, treatment must be adapted. Non-surgical treatment is based on corrective orthotics, supportive shoes, and intraarticular hyaluronic acid injections. Joint preserving surgery (JPS) represents a valid alternative to the traditional ankle fusion. JPS may restore normal biomechanics of the ankle joint, resulting in substantial postoperative pain relief, functional improvement, and slowing of the degeneration process. Overall, JPS defers the need for secondary surgeries in most of these young patients, making these patients suitable candidates for joint motion-preserving surgery, as is the case of ankle arthroplasty.