Recent advances in microvascular surgery have made it possible to reconstruct large skeletal defects with autogenous bone grafts on a vascular pedicle. Experimental studies have demonstrated that vascularized bone grafts have superior blood flow and osteocyte survival when compared with nonvascular grafts. This improves the union rate and allows full incorporation of cortical bone, remodeling, and graft hypertrophy. Clinical experience over the past decade demonstrates that 80% to 90% of these grafts are ultimately successful, allowing limb salvage in complex reconstructive cases. However, the technique is technically demanding, has a relatively high complication rate, and requires prolonged immobilization and rehabilitation. Thus, vascularized bone grafts should only be used when simpler reconstructive techniques are unlikely to succeed.