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Osteochondral defects of the knee in young, active patients represent a challenge to the orthopaedic surgeon. Our study examined long-term outcomes of the use of fresh allograft for posttraumatic osteochondral and osteochondritis dissecans defects in the distal aspect of the femur.We reviewed the cases of sixty-three patients who underwent osteochondral allograft transplantation to the distal aspect of the femur between 1972 and 1995. Five patients who resided out of the country were lost to follow-up. Indications for the allograft procedure were an age of less than fifty years and a unipolar posttraumatic osteochondral or osteochondritis dissecans defect in the distal aspect of the femur that was larger than 3 cm in diameter and 1 cm in depth.Fifty-eight patients ages eleven to forty-eight years at the time of surgery (mean age, twenty-eight years) were followed for a mean of 21.8 years (range, fifteen to thirty-two years). Thirteen of the fifty-eight cases required further surgery; three underwent graft removal, nine were converted to total knee arthroplasty, and one underwent multiple debridements followed by above-the-knee amputation. Three patients died during the study due to unrelated causes. A Kaplan-Meier analysis of graft survival showed rates of 91%, 84%, 69%, and 59% at ten, fifteen, twenty, and twenty-five years, respectively. Patients with surviving grafts had good function, with a mean modified Hospital for Special Surgery (HSS) score of 86 at fifteen years or more following the allograft transplant surgery. Late osteoarthritic degeneration on radiographs was associated with lower HSS scores and poorer clinical outcomes.Fresh osteochondral allograft was found to provide a long-term solution for large articular cartilage defects in the distal aspect of the femur in young, active patients.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.