This study evaluates the reconstructive ladder of soft tissue reconstructive options in the setting of Ilizarov fixation for Charcot foot and ankle disorders. A retrospective study was conducted utilizing the Georgetown Limb Center Charcot database between 1997 and 2001. 64 patients who received Ilizarov fixators were available for review. In this series, plastic surgery closure was required for 33 patients. Among these patients, 76 procedures (range 1-9, average 2.3) were performed in an effort to achieve final wound closure. Of these, 35 were staged debridements. In 28 patients (85%), definitive closure was achieved without complication. Procedures utilized to achieve closure included: delayed primary closure with or without limited bone resection (12), skin graft alone (8), local flap closure +/- skin graft (7), pedicled flap +/- skin graft (5), and free tissue transfer +/- skin graft (2). Complications, including partial flap loss, dehiscence, and failure to heal occurred in 5 patients (15.2%). In these cases, secondary procedures were required to achieve final wound closure. Complete failure to heal occurred in 1 of 33 patients (3.0%). The authors found that the key to reconstruction around an Ilizarov fixator is to initially cover exposed bone with local tissue. Residual soft tissue defects can then be covered with a skin graft. Usually, an adjacent local or pedicled flap in the lower extremity can be found to cover bone exposure that measure less than 10cm2. For defects > 10cm2, more distal tissue is usually required (i.e. free flap). The VAC has proved to be a very useful device to prepare the wound prior to definitive reconstruction. Indeed it can decrease the size of the wound sufficiently so that a local or pedicled flap, rather than a free flap will close the defect. Given this approach, our ratio of local and pedicled flap to free flap was 6 to 1. In the past, the ration would have been the exact opposite. Space limitations imposed by the fixation device present significant challenges in selecting appropriate reconstructive options. Careful pre-operative planning is required with the orthopedic surgeon so that access for the planned reconstruction is possible. If a free flap is planned, then access to the recipient vessel must be maintained and definitive fixation may have to be delayed until after the free flap is done. With local or pedicled flaps, careful planning in pin placement usually provides sufficient access to the flap.