Management of symptomatic osteochondral lesions of the talus (OLTs) is challenging, given the poor healing potential of articular cartilage and limited access to the ankle joint. A wide variety of procedures, varying in complexity from simple débridement to osteochondral allograft reconstruction, has been described for the treatment of these lesions. Arthroscopic procedures (eg, débridement, drilling/microfracture) rely on marrow stimulation to fill the osteochondral defect with fibrocartilage that is not as durable as the native hyaline cartilage. However, these procedures are relatively simple and inexpensive, introduce no donor site morbidity, and do not preclude an open reconstructive salvage procedure at a later time. Open reconstructive procedures (ie, osteochondral autograft transfer [OAT], autologous chondrocyte implantation [ACI], structural allograft reconstruction) are techniques that fill the defect with near-normal hyaline cartilage. These operations are generally indicated for larger lesions or as secondary procedures when arthroscopic techniques have failed. However, they are technically demanding, require extensive exposure, and carry a risk of donor site morbidity (autograft) or disease transmission (allograft).