Vascularized bone grafts serve an important role in bony reconstruction in the setting of not only large segmental bone loss, but also in smaller deficits recalcitrant to allograft or nonvascularized options, or in poorly vascularized environments such as radiation, infection, or avascular necrosis. They can be effectively utilized for bony deficits across the extremities from distal to proximal and can be transferred as free or pedicled transfers, along with as osteochondral and physeal transfers.