Tibial metastatic lesions comprise a small proportion of metastatic disease to bone and often signify advanced metastatic disease. These lesions are regularly at risk for pathologic fracture, frequently necessitating operative intervention. Factors influencing decision for surgery include impending or pathological fracture, tumor histology, pain, patient comorbidities, and life expectancy. The goal of surgical treatment is to improve quality of life by improving pain and function and decreasing disease burden. Surgical treatment for tibial shaft metastasis ranges from curettage with or without adjuvants, open or closed reduction and internal fixation, resection with allograft or prosthetic reconstruction, or amputation. Postoperatively, multidisciplinary management is continued with systemic therapy and/or local radiation in addition to anticoagulation, infection prevention, nutritional optimization, and analgesia. This chapter will discuss the epidemiology of metastatic disease involving the tibial shaft and approach to treatment consisting of surgical and nonsurgical indications, preoperative planning, surgical options, and postoperative care.