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A two-staged approach offers acceptable results for the treatment of severe pilon fractures. These results compare favorably with those of primary open reduction and of internal fixation and external fixation techniques. The major advantages include limited soft tissue complications and improved articular reconstruction.

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Significant innovations in the field of total ankle replacement surgery have occurred since the early disappointing experiences with first-generation devices. In recent years, total ankle arthroplasties are commonly placed in patients with end-stage ankle osteoarthrosis, supplanting ankle arthrodesis as the procedure of choice at some institutions. Careful clinical and preoperative radiographic evaluation is helpful to plan concomitant ligament release, ligament reconstruction, or osteotomy. Careful attention to radiographic signs of early hardware loosening or subsidence can prompt intervention while bone loss is still minimal, and computed tomography has an adjunct role in the evaluation of periprosthetic lucency and osteolysis.