Objective To explore the clinical efficacy of modified anteromedia approach with superior extensor retinaculars and traditional anteromedia combined with posterolateral approach in the treatment of Rüedi-Allg?wer type Ⅲ Pilon fractures. Methods In this study selected 56 patients with Rüedi-Allg?wer type Ⅲ Pilon fractures treated in our hospital from January 2020 to January 2022， all of whom met the inclusion and exclusion criteria， 27 in the experimental group and 29 in the control group. Both groups underwent open reduction and internal fixation of Pilon fractures. The experimental group used a modified anteromedial approach to preserve the supraspinatus， while the control group used a traditional anteromedial combined with posterolateral approach to cut off the supraspinatus. The general clinical data， operation time， intraoperative blood loss， postoperative drainage volume， fracture reduction quality， early pain VAS score， complications and ankle function evaluation of the experimental group and the control group were compared in detail， and the early clinical efficacy of the two surgical methods was analyzed and compared. Results There were no significant differences in age， gender， body mass index （BMI）， complications， injury mechanism and the time from admission to operation between the experimental group and the control group （P > 0.05）. Experimental group： operation time （115.92 ± 12.23）min， intraoperative blood loss（129.25 ± 16.15）mL， postoperative drainage volume （82.44 ± 25.57）mL， fracture healing time （17.89 ± 2.39）w；Control group： operation time （172.75 ± 15.09）min， intraoperative blood loss （177.24 ± 14.36）mL， postoperative drainage volume（115.06 ± 21.95）mL， fracture healing time（19.93 ± 3.75）w. The operative time and fracture healing time of the experimental group were less than those of the control group（P < 0.05）， and the intraoperative blood loss and postoperative drainage volume of the experimental group were less than those of the control group， the difference was statistically significant（P < 0.05）. The Buewell-Charnley fracture reduction radiological evaluation criteria were used to evaluate the fracture reduction， and the rate of good reduction was 96.29% in the experimental group and 93.10% in the control group. There was no statistical significance in the anatomical reduction between the two groups （P > 0.05）. Visual analog scale （VAS） was used to evaluate postoperative pain， and pain VAS scores of the experimental group were lower than those of the control group at 3 days， 1 week and 4 weeks after surgery （P <0.05）. Both groups were followed up for at least 12 months after surgery， and the incidence of postoperative complications in the experimental group was lower than that in the control group（P < 0.05）. The AOFAS score of the experimental group was higher than that of the control group at 3 months， 6 months and 12 months after surgery （P < 0.05）. Conclusion Improvement on the medial approach retains the superior extensor retinaculum， relative to the combined surgical approach to cut off the superior extensor retinaculum treatment Rüedi-Allg?wer Ⅲ Pilon fractures， with shorter operation time， less intraoperative blood loss， less postoperative complications and other advantages. The functional recovery of the ankle joint in the modified anteromedial approach preserving the superior extensor retinaculum was better than that in the combined approach cutting the superior extensor retinaculum.