Abstract: [Objective] To analyze the safety and effectiveness of different surgical procedures in patients with Hawkins Ⅱ and Ⅲ talar neck fractures. [Methods] A retrospective analysis of 120 patients with Hawkins Ⅱ and Ⅲ talar neck fractures admitted to our hospital from July 2017 to July 2019. The osteotomy group was treated by transmedial malleolus osteotomy (62 cases) and the non-osteotomy group Non-osteotomy approach was performed (58 cases). Observation indicators include perioperative conditions, follow-up indicators and imaging evaluation. [Results] The perioperative indexes such as operation time, intraoperative blood loss, hospital stay and fracture healing time of the osteotomy group were significantly lower than those of the non-osteotomy group (P<0.05). At the last follow-up, the pain, function, alignment and other efficacy scores of the osteotomy group were significantly better than those of the non-osteotomy group (P<0.05); infection, talus avascular necrosis, and traumatic arthritis in the osteotomy group The incidence of adverse reactions such as malunion and malunion was significantly lower than that of the non-osteotomized group (P<0.05); the excellent and good rate of Hawkins evaluation criteria in the osteotomy group was significantly better than that of the non-osteotomized group (P<0.05). [Conclusion] The transmedial malleolus osteotomy approach in patients with Hawekins type Ⅱ and Ⅲ talar neck fractures has the advantages of safety, efficiency, and low invasiveness. It has satisfactory results in restoring ankle joint function, relieving pain symptoms and promoting fracture healing. In addition, the medial malleolus osteotomy approach can effectively avoid the impact of surgical trauma on rehabilitation and reduce the incidence of adverse events.