Fresh osteochondral allograft transplantation is a technique with a long clinical history. In fresh allografting, diseased or damaged articular cartilage and bone are replaced with mature hyaline cartilage along with underlying bone. Fresh allografts can be used for a wide spectrum of knee joint pathology, ranging from isolated chondral lesions to posttraumatic arthrosis. The surgical technique involves fashioning the allograft tissue to fit into a prepared recipient site. Outcomes in the treatment of focal femoral condyle lesions are 75 to 90% successful, while in salvage situations the success ranges from 50 to 75% at follow-up intervals ranging from 2 to 10 years. There are many unique clinical issues with fresh osteochondral allograft transplantation that require further understanding; however, the clinical success to date does support the selected use of this procedure.