Introduction: Charcot neuroarthropathy (CN) of the foot and ankle presents significant challenges to the foot and ankle surgeon. Established practice focuses on conservative management during the acute phase with offloading followed by deformity correction during the chronic phase. However, if the deformity progresses in spite of optimal offloading, ulceration, infection, and limb loss are possible. Our aim was to assess the outcomes of primary surgical management with early reconstruction, even in the acute phase, when the foot is at risk of major amputation. Methods: This was a retrospective review of all cases of Charcot foot reconstruction done within our unit between 2011 and 2019. Only patients presenting with acute CN foot that required surgical reconstruction due to failure of nonoperative measures have been included in this study. A detailed assessment was then made for this subsets of patients, who underwent reconstruction while still within the acute CN phase. We reported on their clinical outcomes of mobility, ulcer healing, bone union, and need for repeat surgery. Results: A total of 92 Charcot reconstructions were done between 2011 and 2019, and there were 26 patients (27 feet) who had reconstruction during their acute phase; 15 in Eichenholtz stage I and 12 in stage II with instability due to non-union resulting in progressive deformity. All had peripheral neuropathy, and the majority were due to diabetes (96%). A total of 14 of these were performed as single-stage procedures, whereas 13 were as two-stage reconstructions. These included isolated hindfoot reconstructions in eight, midfoot in four, and combined in 15 feet. The mean age at the time of operation was 55 years (range 31–78). Preoperative ulceration was evident in 15 feet. Mean follow-up was 45 months (range 12–98). One patient died before completing a minimum follow-up. There was 100% limb salvage. Final ambulation outcomes demonstrated full-weight-bearing in 25 patients (96%), mobilizing in bespoke footwear in 18 and in an ankle foot orthosis (AFO), Charcot restraint orthotic walker (CROW) or bivalve cast in seven. All preoperative ulcerations had healed within 12 months of follow-up. Full bone union was seen in 19/22 hindfoot reconstructions and 7/19 midfoot reconstructions. There were nine episodes of return to theater, of which five were within the first 12 months. There was one episode of new ulceration. Conclusion: Early surgical management following acute and unstable CN of the foot provides functional limb salvage. In particular, hindfoot reconstruction shows better rates of bony union compared to midfoot reconstruction. It should be considered in stage I presentations and stage II with instability, if the nonoperative measures fail and there is a risk of limb loss due to progression of deformity, ulceration and infection.