Background Reconstructing large segmental tibial defects remains challenging for surgeons. When defects are extensive and involve soft tissue loss, the vascularized free fibular flap (VFFF) offers advantages, including shorter treatment duration and single-site harvest of bone and soft tissue. This study reviews long-term outcomes of VFFF in the reconstruction of segmental tibial defects performed by a single surgeon at our institution. Methods The surgical case log of the senior author was reviewed for all adult patients who underwent VFFF reconstruction for tibial defects between 2007 and 2023. Electronic health records were used to collect demographic, clinical, and surgical data, including age, sex, race, comorbidities, etiology of injury, defect size, ankle joint involvement, need for soft tissue coverage, fixation method, and duration of external fixation. Outcomes included ED visits; unplanned readmissions and reoperations; pin site infections; flap fractures; time to and achievement of full weight-bearing; ambulation without aids; NRS pain scores; time to return to work/avocation; flap success rate; conversion to amputation; and long-term donor/recipient site complications. Results Fifteen patients (80% male, mean age 41.4) met inclusion criteria. Most cases resulted from high-energy trauma complicated by nonunion and infection; three cases (20%) involved oncologic resection, and one case involved primary chronic osteomyelitis. The average tibial defect size was 10.91 cm (SD = 2.25), and ankle arthrodesis was performed in 4 patients (27%). Soft tissue reconstruction was required in 13 patients (87%), with an average defect size of 117 cm² (SD = 40.84). A VFFF skin paddle was used in 11 patients; 3 (20%) required an additional ALT flap. Fixation methods included internal or external fixation, with or without subsequent conversion to a Taylor spatial frame. The mean number of unplanned reoperations was 1.13. Pin site infections and flap fractures occurred in 3 patients each (20%). Full weight-bearing was achieved in 73% of patients, and 47% were able to ambulate without mobility aids, including orthotic braces. The mean NRS pain score at final follow-up was 1.64 (SD = 2.73), and time to return to work averaged 1.55 years (SD = 1.28). Flap success rate was 93%, with one additional patient electing amputation. Recipient site complications included lymphedema (N = 3), venous stasis (N = 1), and foot drop (N = 1). Donor site complications included one case of claw toe, which was surgically corrected. Conclusion Our study demonstrates that VFFF is an effective option for reconstructing large segmental tibial defects with associated soft tissue loss, achieving an 93% flap success rate and an acceptable complication profile.