Autologous Osteochondral Transplantation in Large Osteochondral Defects—A Follow-Up of 40 Patients After Talus Re-Surfacing

<b>Background/Objectives</b>: Large osteochondral lesions of the talus (OLT) pose a major challenge because their size and depth often exceed the indications for bone marrow stimulation, and durable biological repair remains difficult to achieve. However, evidence for autologous osteochondral transplantation (AOT) in extensive talar defects is still limited. <b>Methods</b>: In this retrospective cohort, 40 consecutive patients ≥ 14 years with ICRS grade III-IV lesions of the talar dome were treated with AOT at a tertiary referral center. One to three overlapping cylindrical osteochondral grafts (mean diameter 0.9 cm) were harvested from non-weight-bearing regions of the ipsilateral patellofemoral groove using a water-cooled diamond trephine system and implanted press-fit into the talar dome. Donor sites were refilled with autologous iliac crest bone cylinders and hydroxyapatite substitute. Pain (Numeric Rating Scale, NRS) and function (AOFAS Ankle-Hindfoot Score) were recorded preoperatively and at 3, 6, 9, and 12 months, and changes over time were analyzed using generalized estimating equations. <b>Results</b>: Mean defect size was 137.4 ± 31.9 mm², and 82.5% of lesions were ICRS grade III. NRS pain improved from 5.69 ± 2.52 preoperatively to 0.53 ± 0.98 at 12 months (<i>p</i> < 0.001). AOFAS score increased from 63.79 ± 2.55 to 97.36 ± 2.49 (<i>p</i> < 0.001). Age and graft location significantly influenced postoperative pain, whereas graft size and sex did not. No infections, graft failures, conversions to arthrodesis or arthroplasty, or clinically relevant donor-site symptoms occurred. <b>Conclusions</b>: Multi-plug AOT using a diamond trephine system provides substantial and durable pain relief and functional improvement in patients with large OLT, with low complication and donor-site morbidity rates. These findings support AOT as a joint-preserving option for extensive talar defects and justify further prospective, comparative studies with long-term follow-up.