Severe ankle degeneration can be a devastating problem for young adults. Although ankle fusion continues to be the gold standard, inherent long-term problems are related to this treatment option. Further advances in total ankle prosthetic arthroplasty are needed before this treatment option can be considered suitable in a younger population. The use of fresh osteochondral allograft transplantation can provide an alternative treatment option without precluding future salvage procedures. Future studies may further define the role immunosuppression can play in improving fresh osteochondral allograft viability.