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Aseptic avascular necrosis of the metacarpal head, or Dieterich disease, is a rare and painful condition of unknown etiology. There is no consensus regarding optimal treatment, although multiple surgical options have been described. Many cases are refractory to nonoperative management.We present a case of a young, active patient with avascular necrosis of the long finger metacarpal head that was treated surgically with osteochondral autograft transplantation. An osteochondral autograft system was used to remove a 10×13 mm core, which contained the entire osteochondral defect. An incision was made and the superior lateral aspect of the trochlea was exposed through a small fascial incision. A size-matched core was harvested from the lateral aspect of the trochlea proximal to the sulcus terminalis in the non–weight-bearing portion of the lateral condyle. The harvested osteochondral donor fragment was then transplanted into the defect in the metacarpal head and noted to be an excellent size match.At 2 weeks postoperative, the patient had nearly full range of motion of both the affected hand and the donor knee. Radiographs demonstrated a small intra-articular step-off of <1 mm, which was appreciated in the intraoperative fluoroscopic image and is within the acceptable limits for metacarpophalangeal joint step-off. At one year postoperative he was pain-free with a QuickDASH score of 2.3.Avascular necrosis of the metacarpal head in a young patient can be a challenging problem, especially when it is resistant to conservative therapy. Arthroplasty or arthrodesis could be reliable options in older, lower-demand patients, but are not appropriate for a young, high-demand patient.