[Objective] To compare the clinical efficacy of anterolateral (AL) plate combined with medial minimal invasive plate osteo-synthesis (MIPO) versus anterolateral fixation alone for tibial Pilon fractures. [Methods] From March 2019 to May 2022, 115 patients withPilon fracture of distal tibia were randomly divided into two groups by drawing lots. Of them, 58 patients received AL plate combined withmedial MIPO (the combined group), while the remaining 57 patients received AL fixation alone (the AL group). The perioperative, followupand imaging documents of the two groups were compared. [Results] Although the combined group was inferior to the AL group in termsof operation time [(75.4±14.0) min vs (68.6±13.7) min, P=0.010], incision length [(7.0±0.5) cm vs (4.8±0.4) cm, P＜0.001], intraoperative flu-oroscopy times [(9.2±2.0) times vs (6.4±1.8) times, P＜0.001], the former proved significantly superior to the latter in terms of intraoperativeblood loss [(54.8±10.2) ml vs (60.5±10.5) ml, P=0.004], hospital stay [(8.5±2.4) days vs (10.3±3.1) days, P＜0.001], postoperative walkingtime [(11.0±2.5) days vs (16.5±3.0) days, P＜0.001] and time to resume full weight-bearing activity [(101.5±25.0) days vs (120.4±25.2) days,P＜0.001]. The VAS and AOFAS score, as well as dorsal extension-plantar flexion ROM in both groups were significantly improved overtime (P＜0.05). The combined group was significantly better than the AL group in terms of VAS score [(2.0±0.5) vs (2.7±0.8), P＜0.001], AO-FAS score [(68.8±12.6) vs (63.5 ±11.2), P=0.019] and ROM [(55.0±6.5)° vs (51.5±7.0)°, P=0.006] 3 months postoperatively, whereas whichbecame not statistically significant between the two groups at the latest follow-up (P＞0.05). Radiographically, the articular congruency, me-chanical lateral distal tibial angle (mLDTA) and anterior distal tibial angle (ADTA) significantly improved (P＜0.05), while K-L grade re-mained unchanged significantly (P＞0.05) at 3 months after surgery and the last follow-up compared with those preoperatively, which werenot statistically significant at any corresponding time points between the two groups (P＞0.05). [Conclusion] The anterolateral plate combined with medial MIPO for distal tibial Pilon fractures is beneficial to the early recovery of ankle joint function.