Because autogenous bone grafts are histocompatible by definition and because the hand does not require massive bone grafts, one may question the indications for using allogeneic bone in the hand. Although humans have been shown to develop donorgraft specific antibodies following large osteochondral allografts, these antibodies have not yet been noted after smaller bone grafts nor is the clinical significance of these antibodies clear. The use of allogeneic bone better satisfies the architectural and strength requirements for reconstruction when there is a need for osteochondral grafts, strong cortical grafts to allow secure fixation and early motion, and small tubular grafts that meet the demands of minimizing bulk in the hand. For the repair of osteochondral defects, autogenous grafts (ie, fibular head or metatarsal head) impose donor site deficits that can be clinically significant. In addition, grafts such as the fibular head do not provide reconstruction of a congruent joint surface. Strong cortical bone is an asset in metacarpal reconstruction; it enhances the quality of internal fixation, which in turn allows hand therapy to be started early, an essential treatment following hand injuries. A stiff hand after reconstruction will result despite excellent bony reconstruction if the fixation does not allow early motion. Autogenous cortical grafts donor sites (eg, ulna or tibia) can cause donor site morbidity, including fracture of weakened bone. The need for small tubular grafts is especially important in pediatric patients. Strong autogenous corticocancellous grafts are difficult to obtain in children, and these grafts are bulky and difficult to insert. In addition, for adults and children, the lack of a donor site means a much shorter hospital stay.