Abstract:[Objective] To compare the clinical outcomes of two sequences of open reduction and internal fixation (ORIF) of Pilon frac- ture accompanied with fibular fracture. [Methods] A retrospective study on 150 patients who underwent ORIF for OA/OTA type B and C Pi- lon fractures complicated with fibular fracture from January 2018 to January 2021. According to preoperative doctor-patient communica- tion, 74 patients had the fibula treated first, while the remaining 76 patients had the tibia treated first. The clinical and imaging data were compared between the two groups. [Results] All the patients in both groups were operated on successfully. The fibular group proved signifi- cantly superior to the tibial group in terms of the operation time, total incision length, times of fluoroscopy, intraoperative blood loss, and in- cision healing (P<0.05) . However, there was no significant difference in the time to resume full weight-bearing activity between the two groups (P>0.05) . The active ankle range of motion (aROM) and AOFAS scores significantly increased over time in both groups (P<0.05) , whereas no significant differences were noted in abovesaid items between the two groups at the matching time point (P>0.05) . Radiographi- cally, there were no significant differences in fracture reduction quality, fracture healing time, and changes of internal fixators at the last fol- low-up between the two groups (P>0.05) . [Conclusion] For open reduction and internal fixation of OA/OTA type B and C Pilon fractures accompanied by a fibular fracture, prioritizing the fibula can significantly reduce surgical trauma and improve surgical efficiency.