Ankle arthrodesis and total ankle arthroplasty are the most common treatments for end-stage ankle osteoarthritis; however, these surgeries are not ideal for young, active patients because of the nature and long-term consequences of sacrificing the ankle joint. The concept of joint distraction was introduced in the 1970s but has only received clinical support in the past two decades as interest in joint preservation treatments has grown. Ankle distraction preserves the native joint and, thus, does not compromise any future arthroplasty or arthrodesis, if required. The main indication for ankle distraction is severe osteoarthritis, and, with encouraging data, the indications continue to expand. The early results of ankle distraction are promising; however, ankle function after joint distraction declines over time. Careful patient selection is necessary to optimize ankle distraction outcomes and avoid complications.