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BACKGROUND: Osteochondral grafting for the treatment of osteochondral lesions of the talus (OLT) usually requires a medial malleolar osteotomy (MMO) to achieve adequate intraarticular exposure. This study describes the technique used and the results obtained using a modified step-cut MMO for osteochondral grafting of talar dome lesions. MATERIALS AND METHOD: Eleven feet in ten patients underwent modified step-cut MMO prior to osteochondral grafting for OLT. The patients included three women and seven men with a mean age of 40 (range, 20 to 51) years. Modified step-cut MMO consisted of an oblique osteotomy, which was made at approximately 45 degrees to the transverse plane of the proposed traditional step-cut osteotomy, and a vertical osteotomy to the axilla on the medial tibial plafond. RESULTS: In all patients, modified step-cut MMO provided better perpendicular access to lesions than traditional step-cut osteotomy. In all cases, the osteochondral graft plug was accurately set perpendicular to the defect area, and all ten patients experienced uncomplicated osteotomy healing at a mean 8 weeks postoperatively without loss of reduction or malreduction. CONCLUSION: Modified step-cut MMO is an excellent, reproducible method for perpendicular access to a talar dome lesion. [ABSTRACT FROM AUTHOR]