Surgical Intervention for Moderate-To-Large lesions (1-2.9 cm²): Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle

Background: Management of moderate-to-large (1-2.9 cm²) osteochondral lesions of the talus (OLT) remains challenging due to the transition from reparative to replacement surgical strategies and the absence of high-level comparative evidence guiding treatment selection. Methods: An international panel of experts participated in a modified Delphi consensus process during the International Congress on Cartilage Repair of the Ankle (ICCRA) meetings held in 2017 and 2025. Survey rounds and structured discussions were used to generate and refine consensus statements. Consensus strength was categorized as consensus (51%-74%), strong consensus (75%-99%), or unanimous (100%), and levels of evidence were graded according to established criteria. Results: Consensus statements were developed for autologous osteochondral transplantation (AOT), osteochondral allograft transplantation (OCA), scaffold-based cartilage restoration techniques, and emerging extracellular matrix and juvenile cartilage allograft strategies. Autologous osteochondral transplantation was supported as a primary treatment option for cystic, uncontained, and revision lesions, with emphasis on graft continuity and appropriate depth. Osteochondral allograft transplantation was recommended for larger or uncontained lesions and in cases where autograft is contraindicated, with preference for fresh, size-matched grafts used within 28 days. Scaffold-based techniques were identified as viable alternatives in select primary and revision settings, although not superior to AOT for larger lesions. Extracellular matrix cartilage allograft (ECMA) and particulate juvenile cartilage allograft transplantation (PJCAT) potentially enhance cartilage restoration. Conclusion: The ICCRA consensus provides a structured, evidence-informed framework for the surgical management of moderate-to-large OLT. Although multiple treatment strategies demonstrate clinical utility, the current literature remains heterogeneous with limited high-level evidence. Further prospective and comparative studies are warranted to better define optimal indications and long-term outcomes for each approach.