Revision and Salvage Management of Failed Osteochondral Lesions of the Talus: Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle

Background Management of failed osteochondral lesions of the talus (OLTs) remains challenging due to limited comparative evidence guiding revision and salvage treatment. This proceedings summary presents the conclusions reached during the International Congress on Cartilage Repair of the Ankle (ICCRA) meetings for evaluating failure and selecting subsequent treatment. Methods Two meetings used a modified Delphi process involving blinded electronic surveys, literature review, in-person discussion, and anonymous final voting. The 2017 panel comprised 75 experts from 25 countries and 1 territory, with the same panel participated in 2025. Eight revision and salvage statements developed in 2017 were ratified in 2025, and 6 statements addressing failed primary bone marrow stimulation (BMS) were developed in 2025. Consensus strength was classified by percentage agreement. Evidence was graded using a scale ranging from randomized controlled trials or meta-analyses (A1/A2) to expert opinion or basic science (E). Results Of 14 statements, 6 achieved unanimous agreement, 7 strong consensus, and 1 consensus. Evidence grades were B2 for 10 statements, C for 1, and E for 3. The statement identifying lesion size as the main treatment determinant when alignment and stability are maintained achieved 69% agreement, representing modest consensus. Revision recommendations emphasized identifying the lesion as the symptom source and a cause of failure. Salvage was supported when further cartilage revision was unrealistic or progressive osteoarthritis was present. Consideration to use orthobiologics received unanimous agreement, but Grade E evidence. Conclusion These statements provide an expert-consensus framework for managing failed OLT. Prospective comparative studies are needed to clarify treatment selection and outcomes. Level of Evidence: V, expert consensus