Distal tibia fractures are difficult injuries to treat both in terms of articular injury as well as management of traumatized soft tissues. It is not uncommon for patients undergoing open reduction and internal fixation to have wound complications, develop post-traumatic arthritis, and proceed to have multiple unplanned surgeries on their ankle, occasionally even amputation. Primary fusion of the tibiotalar joint for highly comminuted, unreconstructable pilon fractures may give patients the best opportunity to obtain a functional limb while avoiding complications. A spanning external fixator is placed within the first 24 hours from injury. If primary arthrodesis is determined to be the correct treatment option it is performed when the soft tissue envelope allows. Primary fusion is indicated in the presence of an unreconstructable articular surface, either due to comminution or bone loss, or due to protracted untenable soft tissue condition. The patient is placed prone, the fixator prepped into the field, and a posterolateral approach to the ankle and distal tibia is made. The articular surfaces are prepared, bone graft obtained, and a 4.5-mm cannulated blade plate is used to secure and instrument the fusion. A retrospective case series was used to report the outcomes of this technique. Data regarding demographics, injury mechanism, fracture treatment, and socioeconomic factors were obtained from medical records, and contacted patients completed outcome scores. Twelve patients were identified and all had AO 43C.3 fractures. Eight fractures were open and of these, 7 were Gustilo-Anderson grade 3. Thirty-three percent (4 of 12) of the patients required acute, additional, unplanned procedures on the ankle. Six patients were contacted and completed outcome scores. The mean SF-36 physical component was 31.5 and the mental component was 47.6. The mean American Orthopaedic Foot and Ankle Society hindfoot score was 62.5 and the mean Foot Function Index was 52.6. Four of 12 patients had a complication. There were 3 metaphyseal nonunions, all of which healed after replating and bone grafting, and 1 infection where the patient elected for below knee amputation. We were able to provide a "one and done" surgery, after the initial external fixation staging, to two thirds of our patients inflicted with these devastatingly complex, complication-prone injuries. Primary blade plate fusion for unreconstructable pilon fractures may be a method of treating these injuries while minimizing complications. In the future we foresee its continued use in these very limited indications. © 2013 by Lippincott Williams and Wilkins.