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Abstract. Objectives:. Aims of the present study were to establish generalizable outcome data on long-term functional outcomes and health-related quality of life (HRQoL) after operative treatment of pilon fractures on a large scale. Second, it was aimed to examine factors associated with these outcomes. Design:. Retrospective cohort study with follow-up by questionnaire. Setting:. Two level 1 trauma centers. Patients:. Two hundred twenty-five of 480 eligible patients completed the survey (response rate 47%). Intervention:. Open reduction internal fixation for tibial pilon fracture. Main outcome measurements:. Ankle function measured using the Foot and Ankle Ability Measure, physical function using the Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire and HRQoL using the EuroQol 5-Dimensions 3-Level (EQ-5D-3L) questionnaire. Results:. At a medium follow-up of 82 months (82 (interquartile range (IQR), 45–120), median Foot and Ankle Ability Measure was 74 (IQR, 57–82), median PROMIS PF 49 (IQR, 44–57), median EQ-5D-3L 0.81 (IQR, 0.71–0.84). HRQoL was significantly lower compared to a reference population (P < .001). In multivariable regression analyses, smoking was associated with poorer HRQoL. Higher body mass index, deep infection, and lower HRQoL were associated with worse ankle function. Conclusions:. Long-term patient-reported outcomes after operative treatment of pilon fractures reveal impaired functionality and lower HRQoL compared to an uninjured reference population. As pilon fractures can have significant effects on a patient's life, patients should be counseled about the expected long-term outcomes to set realistic expectations. This study emphasizes the importance of obtaining both general and region-specific measures when evaluating outcomes after injury, in order to evaluate the injury of interest in the accurate context. Level of evidence:. Prognostic level III.