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Background: Large-volume osteochondral lesions of the talus present a difficult dilemma for the treating physician. The purpose of this study was to evaluate the clinical outcomes of talar lesions with a volume of >3000 mm3 treated with fresh bulk osteochondral allograft transplantation.Methods: Fifteen patients (mean age, 41.9 years) who had symptomatic osteochondral lesions of the talus with a mean volume of 6059 mm3 underwent fresh matched osteochondral allograft transplantation. All patients were followed prospectively for a minimum of two years and were evaluated with use of the pain score on a visual analog scale, which ranged from 0 to 10, and the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, which had a maximum of 100 points. Patient satisfaction and radiographic stability of the graft were also assessed.Results: All patients were available for follow-up at an average fifty-four months after surgery. Two ankles subsequently underwent conversion to an ankle arthrodesis at thirty-two and seventy-six months, respectively. With the scores for these patients included (at the time of arthrodesis), the mean pain score had improved from 8.5 to 3.3 and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score had improved 45 points, from 38 to 83 points. Overall, five patients rated the result as excellent, six as good, two as fair, and two as poor.Conclusions: Bulk fresh osteochondral allograft transplantation to the talus is a viable reconstructive option for patients with large-volume cystic lesions of the talar dome. Graft stability and viability are maintained both structurally and functionally over a mean follow-up period of 4.5 years (minimum, two years).Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.