Prior to the need for arthroplasty, there are numerous surgical options for management of osteoarthritis. This chapter is aimed at addressing the current state of knowledge and practice regarding: (1) arthroscopic lavage and debridement; (2) articular surface stimulation by means of penetration or microfracture; (3) high tibial osteotomies; (4) preventative ligament stabilization and joint distraction; and (5) transplantation of soft tissue, osteochondral, chondrocyte and matrix implantation as well as use of growth factors. Evidence is reviewed regarding the outcomes and indications for each of these operations, and where evidence is lacking, needs for further research are indicated. Future directions building upon promising early results of articular surface regeneration are also described.