Evolving Management Strategies for Osteochondral Lesions of the Talus: A Contemporary Treatment Algorithm.

➢ Osteochondral lesions of the talus (OLT) are common injuries that remain difficult to treat because of the challenge of restoring durable hyaline cartilage. Surgical outcomes are influenced by lesion size and morphology, cartilage integrity, subchondral bone involvement, and ankle stability, all of which should be considered when evaluating operative strategies.➢ Fragment fixation preserves the native osteochondral unit in lesions with a viable fragment and is primarily indicated in acute OLT. Lift-drill-fill-fix is utilized in selected chronic lesions with a salvageable fragment and compromised subchondral bone, allowing restoration of the lesion bed and stable fixation.➢ Bone marrow stimulation techniques, including microfracture, antegrade drilling, and retrograde drilling, have demonstrated improvements in pain and functional outcomes in small and contained lesions, although the long-term durability of fibrocartilaginous repair tissue remains variable.➢ Replacement procedures such as autologous osteochondral transplantation and osteochondral allograft transplantation restore the osteochondral unit and have demonstrated favorable outcomes in larger or structurally complex lesions. Cell-based and matrix-assisted cartilage restoration strategies, such as autologous chondrocyte implantation, matrix-induced autologous chondrocyte implantation, and autologous matrix-induced chondrogenesis, have demonstrated improvements in clinical outcomes and cartilage repair in selected patients with OLT.➢ Emerging restorative approaches such as scaffold-based cartilage repair, osteoperiostic autografting techniques, and biologic adjuncts including concentrated bone marrow aspirate, platelet-rich plasma, and hyaluronic acid have demonstrated promising early clinical results, although current evidence remains limited.➢ Salvage procedures, including bulk allograft transplantation, metallic resurfacing, hemiarthroplasty, and arthrodesis, may be considered for extensive lesions or after failure of prior surgical management, although outcomes remain variable, with high complication and failure rates.