Among the various surgical techniques, arthroscopic microfracture is widely utilized and considered the primary treatment alternative for small to medium-sized osteochondral lesions of the talus (OLT). However, when OLT are accompanied by subchondral cysts, the optimal treatment approach is controversial. Medial malleolar osteotomy is often required to access and treat subchondral cysts. In some cases, a sizeable aperture must be created in the intact overlying cartilage and subchondral plate to adequately prepare the lesions. This case report presents a surgical approach involving fluoroscopy-guided retrograde core drilling and autologous bone grafting for medial OLT with subchondral cysts, performed without medial malleolar osteotomy or disruption of the intact subchondral plate.