Bony defects involving the physis in skeletally immature patients present significant challenges in reconstructive surgery. Effective approaches require complex reconstructions that address the loss of the growing physis, articulating surfaces, and associated supporting ligaments. This chapter provides an in-depth discussion on the anatomical considerations, clinical indications, and surgical techniques for proximal fibular epiphyseal transfer, a method that has evolved greatly since its early experimental attempts in the late nineteenth century. Historically, nonvascularized growth plate transfers yielded variable results, leading to the exploration of vascularized transfer techniques. The first successful vascularized transfer of the proximal fibula was reported by Pho in 1979, although it did not include a growth plate. Subsequent advancements saw the introduction of vascularized growth plate transfers, but the initial technique using the peroneal vessels was insufficient for supporting the physis, prompting innovations such as bipedicled transfers to enhance vascular support with increased surgical complexity and complication risks. Recent anatomical studies have clarified the vascular supply of the proximal fibula, highlighting the role of the anterior tibial vessels and a rich anastomotic network of several arteries that includes the inferior lateral genicular artery and recurrent epiphyseal arteries. This detailed understanding allows for safer harvesting techniques while preserving critical neurovascular structures. The standard techniques of harvesting a vascularized epiphyseal transfer from the proximal fibula involve a meticulous dissection to ensure vascular integrity and the preservation of periosteal branches for maintaining the viability of the fibular shaft. The clinical implications are detailed through a case report of a 39-month-old boy who presented with massive bony loss at the left hip due to a type IV late sequela of infantile septic arthritis. The surgical approach, utilizing the proximal fibular epiphyseal transfer, successfully restored structural integrity and promoted healing. Postoperative follow-up demonstrated encouraging outcomes in terms of limb function and skeletal growth. In conclusion, proximal fibular epiphyseal transfer offers a valuable solution for reconstructing bony defects in skeletally immature patients. A comprehensive understanding of the vascular anatomy, along with refined surgical techniques, allows reconstructive surgeons to optimize outcomes in pediatric reconstruction. Further research is needed to explore its broader applications, expanding its therapeutic potential in managing bony defects in children.