The purpose of this study was to report the clinical outcomes of wrist arthroplasty with a free vascularized fibular head graft (FVFHG) and to highlight some considerations that may affect outcomes. FVFHG was performed on 12 patients with giant cell tumors of the distal radius between April 1984 and July 2005. The mean age of patients was 33 years. All 12 patients were classified as Enneking stage 2. Outcomes were evaluated with radiographic and functional assessments, including the scale of Enneking. The mean follow-up period was 6.26 years. Bone union was achieved in all patients at a mean of 15.7 weeks after surgery. Skin grafting was performed at the recipient site in 5 patients and had good skin healing. Subluxation in the wrist joint was observed in 5 patients and was related to the length of the transplanted fibula. The 5 patients with subluxation experienced considerable osteoarthritic change. The mean arc of flexion-extension and rotation of the wrist joint was 73.1° and 102.9°, respectively. The mean grip strength was 57.25% of the contralateral side. The mean functional score was 26.4 points. Wrist arthroplasty with a FVFHG is a useful option to treat Enneking stage 2 giant cell tumors of the distal radius. We believe that wrist instability is not determined by the choice of laterality of the fibula, which can be minimized by transplanting a short fibula with the anterior tibial artery as a donor artery. The recipient sites can be successfully resurfaced by skin grafting. © 2012 Wiley Periodicals, Inc., Microsurgery, 2013.