Objective To evaluate the effects of minimally invasive percutaneous plate osteosynthesis and open reduction and plate internal fixation in the treatment of Pilon fractures with distal fibula fractures. Methods The clinical data of 190 patients with Pilon fractures complicated with distal fibula fractures treated in the hospital were collected between April 2018 and June 2020, and the patients were divided into observation group (minimally invasive percutaneous plate osteosynthesis, 95 cases) and control group (traditional open reduction and plate internal fixation, 95 cases) based on two different surgical methods. The surgery-related indicators (intraoperative blood loss, surgical time, postoperative drainage volume, total hospital stay) were compared between the two groups. At 1 year of follow-up after surgery, the clinical efficacy of the two groups was compared according to the evaluation criteria of clinical treatment results of Tornetta tibial Pilno fracture. The knee function scoring system (Hospital for Special Surgery, HSS) and ankle function scoring system (Baird-Jackson Ankle Joint Scoring System) were used to compare the joint function recovery in the two groups. The incidence rates of postoperative complications (delayed union, incision infection, joint stiffness, bone nonunion) were compared between the two groups, and European Five-Dimensional Health Scale (EQ-5D) was applied to compare the quality of life of the two groups. Results In terms of surgery-related indicators and hospital stay, the intraoperative blood loss and postoperative drainage volume of observation group were less than those of control group, and the surgical time and hospital stay were shorter than those of control group (P＜0.05). As for clinical efficacy, the clinical effective rate of 94.74% in observation group was significantly higher than 86.32% in control group (P＜0.05). The Baird-Jackson score and HSS score of observation group were higher than those of control group at different time points after surgery, and there were differences in time-point effect, between-group effect and interaction effect (P＜0.05), and the Baird-Jackson score and HSS score of the two groups were significantly higher than those before surgery (P＜0.05). The incidence rate of postoperative complications was 8.42% in observation group, which was lower than 20.00% in the control group (P＜0.05). The scores of various dimensions of ED-5Q in observation group were improved compared with those in control group (P＜0.05). Conclusion Minimally invasive percutaneous plate osteosynthesis has smaller surgical trauma and better clinical efficacy and postoperative joint function recovery than traditional open reduction and internal fixation, and the former one has lower incidence rates of postoperative complications and can help improve the quality of life of patients, therefore it is worthy of clinical application and promotion.