Objective to investigate the clinical effect of open reduction and osteotomy reconstruction in the treatment of old posterior Pilon fractures. Methods: From March 2015 to October 2018, 22 cases of old posterior Pilon fractures were treated, including 15 males and 7 females, aged 20-62 years, with an average age of 38.4 years. According to Klammer's classification of the first injured fracture: 8 cases of type I, 7 cases of type II, 6 cases of type III, all of them were closed fractures. Among them, 9 cases were treated conservatively, 13 cases were treated surgically, and all patients were treated surgically. Result: All patients were followed up for 16-53months, with an average of 35.2 months. Fracture healing time was 3-6 months, with an average of 4.4 months. At the last follow-up, ankle metatarsal flexion, dorsal extension ,VAS and AOFAS scores were significantly different from those before operation. [(31.4 ± 4.0); (15.4 ± 2.6); (6.5 ± 1.3); (43.7 ± 6.4); (41.5 ± 4.1); (26.8 ± 2.5); (1.9 ± 0.9); (83.0 ± 4.9); (P < 0.05)].Conclusion: Open reduction and osteotomy reconstruction can effectively relieve the symptoms of old posterior Pilon fractures and improve the quality of life of patients. It is a good treatment plan, but the indications of operation should be strictly controlled.