Background <p>This study systematically compares the efficacy of different adjunctive therapies in enhancing microfracture (MF) treatment for osteochondral lesions of the talus (OLT) through a network meta-analysis, aiming to identify the optimal adjunctive therapy for microfracture.</p> Methods <p>A systematic search of PubMed, Embase, Web of Science, Cochrane, and Scopus databases was conducted for relevant literature until October 1, 2024. Two researchers independently screened, extracted data, and assessed quality. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.</p> Results <p>A total of six randomized controlled trials were included, comprising 295 OLT patients and involving four adjunctive therapies: MF combined with platelet-rich plasma (MF_PRP), hyaluronic acid (MF_HA), collagen scaffold (MF_CS), and pulsed electromagnetic fields (MF_PEMF). The results of the network meta-analysis indicated that while HA is the most commonly used adjunctive therapy, PRP-assisted MF demonstrated the best improvement in AOFAS and VAS scores for OLT. The surface under the cumulative ranking curve (SUCRA) predictions also revealed that PRP has the greatest potential among the four adjunctive therapies, followed by HA. Conversely, MF_PEMF showed the least effectiveness in improving AOFAS and VAS scores. Additionally, only one study reported complications associated with MF_PEMF and MF, with no statistically significant differences between the two.</p> Conclusion <p>Among the MF adjunctive therapies validated by RCTs, HA is the most widely used; however, PRP-assisted MF provides the best outcomes for OLT patients, suggesting that its application should be emphasized in clinical practice.</p> PROSPERO <p>Registration No: CRD42024546984.</p> Clinical trial details <p>Not applicable.</p>