The most important finding in this study was the satisfactory outcome of the Ilizarov method, independently of fracture pattern. Using an identical protocol for both intra- and extra-articular fractures, it was possible to operate on all patients without delay, regardless of the status of soft tissues, the size of the distal fragment, and the intra-articular fracture lines or whether a staged protocol should be used. This is also emphasised by the absence of clinically important differences in the present study in terms of the results between the intra- and extra-articular fractures.
In the present study there is a mixture of fractures and from a radiological point of view the treatment of many of these fractures might seem to be uncontroversial.
However, despite the fact that the trauma in a majority of the patients was classified as low energy, most of these patients had other complicating conditions, such as soft-tissue injuries, diaphyseal fracture extension etc. (Table1). In other words, several of the factors considered when choosing the method of treatment are difficult to evaluate.
Twenty-one of 39 patients in our study had extra-articular fractures, which could possibly have been treated with open reduction and internal fixation using intramedullary nails or plates. However, the use of intramedullary nails in extra-articular distal tibial fractures is technically demanding, because of the widening of the medullary canal in the metaphysis, which raises concern regarding the biomechanical stability and the subsequent increased risk of malunion . The more modern technique with percutaneous angle stable plate fixation is more reliable with a lower rate of complications than previous plate techniques [48–50]. However, until now, both superficial and deep infections have continued to be a problem and there is also a high rate of hardware complications requiring plate removal [51–56]. In this study, thirty patients had a significant diaphyseal extension of the fracture, indicating that a fairly long plate would have to be used.
One common problem with external fixators of all types is the risk of skin-penetrating infections (pin site and pin tract infections). The incidence of pin site infections reported in the literature varies from 4.5% to 71%  and pin tract infection varies from 10% to 50% . Parameswaran et al. , found that ring fixators had the lowest incidence of infection compared with unilateral and hybrid fixators. Pin site infections were frequent in the present study; however, they did not constitute a major problem, as all the infections healed following minor intervention. In the present study, 3.7% of the pin sites became infected, while only two patients had more severe pin tract infections.
Ristiniemi used hybrid ring fixators in different types of intra-articular fracture, with or without osteoinduction . In the group without osteoinduction, the healing period was 21 weeks, which compares favorably with the 15 weeks for similar fractures in our study.
The amount of residual deformity that can be accepted is still controversial . It is difficult to correlate the postoperative radiological findings to the clinical result and to use this as a prognostic factor. In a 10-year follow-up, Etter and Ganz  retrospectively examined how the fracture pattern and quality of reduction correlated to postoperative arthritis in 41 patients with plafond fractures treated with internal fixation. Anatomical reduction was correlated to a better prognosis in terms of a lower risk of post-traumatic osteoarthritis, but it did not guarantee a good clinical result. Severe osteoarthritis present at late follow-up did not correlate with poor subjective or objective function. DeCoster et al.  came to the same conclusions using the rank order method to assess the quality of articular reduction in the outcome of displaced intra-articular distal tibia fractures in 25 patients treated with articulated external fixation and limited internal fixation. With ten B3, three C1, ten C2 and twelve C3 fractures, Marsh et al.  rated the quality of reduction as good in 14 ankles, fair in 15 and poor in 6, using the same radiological evaluation method as in the present study. They did not find any association between the fracture type and the clinical outcome measures. In their study, the majority of the patients had some limitation with regard to recreational activities, with an inability to run as the most common complaint. Fourteen patients had to change jobs due to the ankle injury.
Williams et al.  determined which fracture- and patient-specific variables affected the outcome most in 29 patients with tibial plafond fractures. They evaluated their patients a minimum of two years from the time of the injury. Outcome was assessed by four independent measures; radiographic osteoarthritis score, subjective ankle score, the Short Form-36 (SF-36), and the patient’s ability to return to work. Interestingly, the four outcomes did not correlate with one another. They also found that the ability to return to work was affected by the patient’s level of education and highlighted the difficulties of predicting patient outcome in, these severe articular fractures.
Pollak et al.  evaluated eighty patients, treated with bridging external fixation and/or internal fixation, at a mean of 3.2 years after injury. They analysed general health, walking ability, range of motion, pain, and stair-climbing as well employment status. Their general conclusion was that pilon fractures could have persistent and devastating consequences for patient-health and well-being. In approximately 30% of their patients, the injury prevented a return to work.
In the present study, several self-appraisals were used in our study, both general (NHP and EQ-5D) and more specific (Pain in the affected limb -VAS and FAOS). The patients with metaphyseal fractures without joint engagement were in an almost normal situation at one year postoperatively, but the intra-articular fractures were also better than the reported by the patients in the above mentioned studies. Despite successful treatment and improvement in their outcomes, the FAOS subscores showed the lowest values for Sports and QoL activities especially in the C fractures. Apart from this, they did not differ significantly, compared with patients after operated ankle ligaments, trimalleolar or distal fibular fractures [42, 45, 46]. All the patients returned to work while sporting activities were severely restricted in both groups without significant differences, but we observed a trend towards more seriously affected Sports and QoL for the group with extra-articular fractures.
The results of the follow-up observed in this study might differ in the future in terms of functional outcome. Marsh et al.  claimed that, although tibial plafond fractures have a negative effect on ankle function and pain, at a minimum of five years after the injury, few patients required secondary reconstructive procedures because these symptoms tend to decrease during a long time period after the acute injury.