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Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up.Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate “normal” knee function at long-term follow-up.Case series; Level of evidence, 4.Twelve patients were identified who underwent ORIF of a knee OCD loose body into the grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm2 (mean, 3.5 cm2). After 12 weeks, hardware was removed, and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score.Arthroscopy for screw removal revealed stable healing in 92% (11 of 12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years' follow-up (range, 3.8–15.8 years), 83% (10 of 12) of patients completed the KOOS. The KOOS subscale scores for pain (mean, 87.8; range, 67–100), other symptoms (mean, 81.8; range, 61–96), function in activities of daily living (mean, 93.1; range, 72–100), and sports and recreation function (mean, 74.0; range, 40–100) were not significantly lower than those of published age-matched controls. However the KOOS subscale score for knee-related quality of life (mean, 61.9; range, 31–88) was significantly lower (P = .003).Operative fixation of grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee-related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.